Ethical Question About Pacemaker - page 2

Hi all! I have an ethical/end of life question for you. I had a patient who had a pacemaker placed in the 90s as well as an AVR a couple years previous to this visit. The patient was a young patient... Read More

  1. Visit  Sun0408 profile page
    5
    In time allowing for a peaceful, comfortable death will become one the best parts of your job. You will be sad a life is lost but the peace that comes over the pt because they are no longer suffering will be victorious. We can't save them all, the body can only take so much. Once they are terminal, letting go is the best. You will see many pts suffer as families try to keep them here when the body is done.. This gentlemen,you and his family, while hard did the best thing.
    Sugarcoma, merlee, KelRN215, and 2 others like this.
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  3. Visit  Roseyposey profile page
    3
    You saw something the rest of the team had overlooked, and you were not afraid to advocate for your patient. You sound like a great nurse, and if I would want you taking care of me.
    merlee, FecesOccurs, and somenurse like this.
  4. Visit  GrnTea profile page
    7
    They? There were more than one of these patients in your care? Please use singulars for one person; I thought "they" referred to his family or his caregivers and had to read this about three times to get it straight. Sorry to be so dense.

    I did find this a little confusing to read, but once I figured it out, I was so glad that the patient was able to express his wishes and say he was ready to die. A pacemaker isn't any more magical than any other piece of medical equipment, as others have so ably described above. Anyone can refuse care of any kind at any time. It that patient had been me or a loved one, I'd have said, "20mg of MS push(4mg is almost homeopathic), count to ten, and turn it off."
    Sugarcoma, Altra, tewdles, and 4 others like this.
  5. Visit  umcRN profile page
    2
    Agree with what the other posters have stated. It is very similar to extubating or withdrawing other kids of external support. A place I worked at a few years ago had a patient who was the very first one to have their LVAD turned off. In time pt had become no longer a transplant candidate and the LVAD was the only thing keeping her in a very painful life, she also had an ICD which gave frequent shocks through the day. She was in daily misery and with the LVAD and ICD off, was finally able to go in peace.
    somenurse and
  6. Visit  Nursingbride12 profile page
    1
    Sorry for the confusion! I just had 1 patient in this particular situation. It was my first case where I was the primary RN so I was trying to sort it all out mysel.
    somenurse likes this.
  7. Visit  OCNRN63 profile page
    0
    I don't see this as any different from removing a vent; the circumstances are a bit more unusual, but the bottom line remains the same. Turning it off honored the patient's wishes.
  8. Visit  twinmommy+2 profile page
    2
    Quote from Nursingbride12
    Hi all! I have an ethical/end of life question for you. I had a patient who had a pacemaker placed in the 90s as well as an AVR a couple years previous to this visit. The patient was a young patient in the 50's and just had a "bad" heart. Trouble with arrhythmias and all other sorts or problems. Well a couple of years ago they found out their new valve was dehissing. They needed surgery to replace it but he had already gone into kidney failure and bad heart failure and was refusing surgery due to unwanted more stress on their already fragile body not to mention family. So this visit they came in with shortness of breath and a DNR. Specifically no shock and no intubation. They were put on BiPAP, Levophed, epinephrine, dopamine, and Milrinone. About the third day of inpatient with the pt no longer responding to stimuli and having to keep titrating drips up and up the family decided enough was enough and that's not what the pt would want. So they decided to completely withdraw care. The pt was taken off BiPAP and was weaned down on all of the drips. I come in the next morning and come to learn that the pt is still alive. I get report from a newer nurse and something stands out to me. She is telling me the pt woke up and tearfully told their family member they was ready to go and wanted to go to heaven. The nurse said she had been pushing morphine to keep the pt comfortable etc. but then the nurse told me that his HR was PACED at 70. Well, he had an internal pacemaker/defib. My charge asked if it had been talked about if they had discussed turning off the pacemaker... Considering that was the only thing keeping them alive. When I discussed with the family, no one had brought it up before, and within 2 hours we had a dr order, the electronic company who had placed device up there, IOPO called, and the device off. The pt had no underlying rhythm and respiration a ceased immediately.

    My question is, I felt incredibly uncomfortable that turning off the pacemaker was an option. I felt that considering it was a device keeping them alive, that turning it off would force them to go instead of weaning down a drip or w/e. Older nurses have compared it to pulling the patient off a ventilator... its a machine coming off when the body is no longer working.
    Am I being too emotional?
    I work in the ER of a VA hospital, had a patient come in from the hospital's nursing home, they called ahead of time saying they just wanted an EKG to make sure the pacer/defib was off. He had been trying to pass on for weeks, but this past day he was continusly being shocked by the interna defib. They only had to pass a magnet over him, did an ekg, no paced rhythm, and they were back on their way and he was much more comfortable. That has to be uncomfortable to be shocked like that.
    GrnTea and merlee like this.
  9. Visit  malenurse354 profile page
    0
    As a new nurse, I know it will be hard for me to face situation similar to this in the future! I find this thread very helpful as I already have the idea how to deal with it if my time comes!
  10. Visit  qdiva411 profile page
    3
    Just a little disclaimer, a person can still die while a pacemaker is active. I have looked up many a time and seen only pacer spikes only to be coding seconds later. Just for those who may not know.


    I believe you did right as well. To me, it's about the patient. If he expressed his readiness to go and was in his right mind, let him go. Bravo to you! I know that had to be hard.
    Last edit by qdiva411 on Feb 4, '13
    umcRN, somenurse, and fromtheseaRN like this.
  11. Visit  classicdame profile page
    0
    Allowing someone to die is part of nursing (palliative care when ordered).

    Making someone die is murder.

    Sounds like the ethics committee needs to be involved
  12. Visit  classicdame profile page
    1
    OP: You keep referring to the patient as "them". Is this a subconscious referral to the entire family and their wishes?
    KelRN215 likes this.
  13. Visit  KelRN215 profile page
    2
    There are a lot of things we do to/for dying patients that are difficult for new nurses and the outside world to grasp. It can feel like you're doing more than just allowing a terminally ill person to die. Personally, I agree with turning off the pacemaker and view it as similar to turning off a vent. When I worked in the hospital, I worked in neurosurgery and recall a handful of times where we had patients who were dying but had EVDs in place. The EVD was draining their excess CSF and therefore keeping their ICP from rising to dangerous levels. There were a few times when the decision was made to pull the EVD and allow the patient to herniate resulting in immediate death. I recall two cases where the patient was vented in the ICU with EVDs and countless other lines in place... the parents chose to end treatment and bring their children home. In both cases, Palliative Care and ICU MDs as well as nurses accompanied the patient home, the lines/tubes were all dc'd and the patient passed in his/her own bed within a matter of minutes.
    Sugarcoma and Altra like this.
  14. Visit  GrnTea profile page
    2
    Quote from classicdame
    OP: You keep referring to the patient as "them". Is this a subconscious referral to the entire family and their wishes?

    No, this common verbal/written quirk is because many people think "they/them/their" are more all-inclusive words than they are.

    For example: "I gave my patient a bath and they told me it was the best bed bath they'd ever had. I thanked them." My internal response is always, "They who? And what are they all doing in that poor man's bed?"

    The correct pronouns to use about a single individual are "he" or "she," and "him" or "her." The adjectives are "his" and "hers."

    "Them," "they," and "theirs" are for the plural-- people.

    If you don't want to indicate gender here, say, "the patient," use a neologism like "s/he," or recast your sentence so it's all plurals. "My patients always tell me how much they love their bed baths. I thank them."

    Thus endeth today's lesson. We return to your regularly scheduled thread.


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