Ethical Question About Pacemaker

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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?

Specializes in Pedi.

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.

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?" :confused:

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. :twocents:

Specializes in PICU, NICU, L&D, Public Health, Hospice.

We rarely have to DC pacers in hospice...defibrillators are quite a different matter as has been addressed in earlier comments.

Most of the time, our patients will die regardless of pacing and it is typically not necessary to DC the device.

Some hospices consider discontinuation of a pacemaker as an action intended to shorten the lifespan and refuse to participate...

Who gives a rat's behind about what the hospice wants.

It's never about the hospice, or the nurse. It's always exactly what the patient wants.

I dealt with the same issue on a personal level. My grandmother had an AICD, and when we put her on hospice, the MD ordered the pacemaker rep out to "d/c" it. But he didn't write whether to d/c the pacer, the defibrilator, or both. The pacemaker rep disabled the defib but refused to stop the pacer itself, citing that a pacer will not keep a dying heart from dying. I argued that there was no need to have the pacer in a woman who was in MODS and expected to pass at any given moment, completely unresponsive (for days), DNR in place, literally with her family surrounding her, ready to go.

I should back up a bit and say that the pacemaker rep took forever to get there to turn the AICD off--12 hours in a patient who wasn't expected to even live another 12 hours. I had already had my brother go to the local Tractor Supply and buy me a big magnet. (I found it odd that the hospice nurse didn't have one? Is this not something they deal with on a fairly regular basis? Maybe not.) I refused to let my mom and her siblings see their mother being shocked just because the pacemaker chick couldn't find it in her busy schedule to get there and turn it off.

Anyway, to the OP, I think it was a huge oversight that the MD didn't write to have the pacer d/c'd in the patient. It was cruel and awful that the patient suffered and wasn't allowed to die as a result of this MD's negligence. You did the right thing. In my experience with dying patients, sometimes it takes a bit to begin to feel like you did the right thing.

And, yes, 20 mg of Morphine, not 4 mg. Everytime.

Specializes in ICU/CCU/CVICU.
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

The ethics committee does not need to be involved. The OP did not kill a pt they removed/ stopped a medical device which was keeping the pt alive. They followed the pts wishes and did the right thing.

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

I do not think an ethics committee needs to be involved to remove a tube feeding, an IV, a vent, or to turn off a pace-maker, or any other similar mad made devices.

Removing heroic efforts, or man-made devices, does not equate to "murder", if if if if IF that is what you are suggesting.

(if i am misunderstanding your post, i apologize).

some of the cruelest of all deaths i've ever witnessed, were those when we kept some dying suffering human alive at all costs, oh my, those do break my heart, to see such suffering, and the extended suffering of the family nearby, as the person dies an inch at a time, thanks to all the technology.

Specializes in PICU, NICU, L&D, Public Health, Hospice.

Again, it is rare that a pacemaker will prevent a person from dying a "natural" death. Hospice rarely requests that pacers be DC'd.

Implanted defibrillators are an entirely different story and they should be DC'd as soon as the person elects a palliative rather than a curative approach to their terminal illness.

Hospices are charged with palliating symptoms to provide for a comfortable and dignified death. If discontinuing a pacemaker could be seen to hasten the death many hospices will defer that judgement to the family and will not participate in the process...to avoid any appearance of ethical conflict.

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.

YES to this! My first code in my pedi cardiac ICU was a kiddo who was being internally paced, luckily (?) he was going down hill and I had the docs in my room already, one was already listening to him prior to his heart stopping and compressions were initiated as soon as the heart stopped. Meanwhile his moniter showed a beautiful 90bpm QRS

Specializes in ICU.

Think about it this way, the pacemaker is an artificial device. That device is prolonging their suffering, the patient was ready, by all means turn it off. It should have been addressed way earlier in this decision making progress.

Specializes in PICU, NICU, L&D, Public Health, Hospice.
Think about it this way, the pacemaker is an artificial device. That device is prolonging their suffering, the patient was ready, by all means turn it off. It should have been addressed way earlier in this decision making progress.

Welcome to the world of hospice where death, dying, and issues related to end of life are largely ignored by hcp's who are uncomfortable with the discussion. It is widespread and is in large part responsible for the vast amounts of money spent in the last 6 months of a persons life.

Specializes in Cardiac, Transplant, Vascular, NICU.
[COLOR=#003366]Quote from classicdame

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

I understand that way of thinking, but if it was the only thing keeping him alive when everything else had stopped working? I mean, his blood pressure was falling, he hadn't eaten in days, his kidneys had failed... I just felt like it was a way to let him go in peace in stead of forcing him to go through all of the pain and hurt of infection or some other problem.

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