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 so agree with others above, who view this is as an end-of-life comfort measure, to prevent prolonged suffering by turning off a manmade device interfering with this patient's right to a peaceful death.
Our goals when caring for terminally ill, end-stage patients, can and should shift to comfort/preventing suffering/reducing any loss of dignity as we can/honoring that individual's wishes. A 'good' death is not necessarily one marked by the most heartbeats preceding it,
but instead, marked by the most peaceful, least painful death we can help our patient have.
I have also seen pacemakers turned off in end-stage patients, too.
Also, i do not view extubating a patient as "smothering them with a pillow" (an earlier remark) as every time i have ever assisted in extubation of a terminally ill patient, the patient was invariably given morphine, and it was peaceful--- not a horrific gasping or struggling thing, nothing like "smothering with a pillow". Usually, most typically, this was done on brain-dead people, still, morphine was given.
Last edit by somenurse on Feb 3, '13