Consent - Research – Pacemaker or Implantable Cardioverter Defibrillator (ICD)
– Deceased Donor
Each year, hundreds of thousands of patients with pacemakers or implantable cardioverter
defibrillators (ICDs) pass away and are buried with these devices. It is routine for the deceased who
choose cremation to have the devices removed. Your loved one’s pacemaker or ICD may still work
and could be donated to a patient in need. There are patients throughout the world, mostly in poorer
countries, that cannot afford pacemakers or ICDs. These patients do not have access to these same
life-saving devices.
The University of Michigan is working with World Medical Relief and with the support of citizens,
physicians, and funeral directors across the United States to help these patients in need.
Project My Heart - Your Heart is collecting pacemakers and ICDs for potential use in a research
study to determine if reusing these devices is safe and effective. You may be able to help save a life
by donating your loved one’s device to our project. A funeral director will respectfully remove the
device and send it to the University of Michigan Hospital. There is no cost to you or your loved one’s
estate or insurance company. You do not have to donate your loved one’s device.
If you have any questions about Project My Heart - Your Heart please ask your health care
provider, visit www.myheartyourheart.org, or contact:
Thomas Crawford, M.D. (University of Michigan Frankel Cardiovascular Center)
Email address: thomcraw@med.umich.edu Phone number: (734) 936-6858
I am the closest adult relative of the deceased. I agree to donate my loved one’s pacemaker
or ICD to the University of Michigan for Project My Heart - Your Heart. At this time, I
understand that the device will only be used for research. My loved one’s device will not be
delivered to another country or implanted into another person unless The U.S. Food and Drug
Administration (FDA) approves a clinical trial for the reuse of pacemakers and/or ICDs.
I HAVE READ AND UNDERSTAND THE INFORMATION ON THIS FORM BEFORE I SIGNED IT.
_____________________________________________________________________________
Signature of Legally Authorized Representative
Date: __________________
(mm/dd/yyyy)
_____________________________________________________________________________
Printed Name of Legally Authorized Representative
Relationship:
Spouse
Parent
Next-of-Kin
Other (specify): _____________________
VER: A/14 HIM: 10/14
The content of this form can be altered for reformatting purposes but text should not be edited for content without express
permission from Thomas Crawford, M.D. (University of Michigan Frankel Cardiovascular Center).
Email: thomcraw@med.umich.edu
Phone number: (734) 936-6858
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