Ethical Question About Pacemaker

[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?

[funfunfun550, BSN, RN]

Wow...I don't know what to say. I do not think I ever saw that happening..I would feel very uncomfortable also

[limaRN, BSN, RN]

We do this sometime for pts with pacemakers that wish or whose families wish to withdraw care. It is a medical device that can prolong life in situations like these by continuously shocking them out of vtach or by pacing them to keep them alive. In someone that wishes to have care withdrawn or wishes to be made a DNR I think it is unethical NOT to discuss turning off a pacemaker/ AICD. I think you did the right thing. I understand why it makes you feel uncomfortable. I still feel uncomfortable when turning off meds/ extubating a pt to discontinue care. However, this pt expressed a wish to stop treatments and medical devices/ procedures that were keeping him alive. He has a right to make that choice. I think you should feel good about following through with his wishes and helping him have a comfortable death as possible with dignity. :)

[breaktime]

I agree with limaRN. I see this as no different than extubating a pt when withdrawing care. You are stopping a medical treatment/intervention that a pt no longer wants. It's not like you are smothering a pt with a pillow (in the case of extubation). In the case of stopping a pacemaker, you are not stopping the pts heart, you are stopping the device (read as treatment/intervention, that the pt expressed they do not want) that is keeping the heart going. In my mind their is a big difference. I think you did the right thing.

[VeniceMaylea]

This is observed and you did the right thing, I'm glad the patient had his wishes granted :)

[dah doh, BSN, RN]

Sometimes nursing is about supporting the patient's right to die with dignity and comfort. It can be uncomfortable for you as you feel you contributed to his death, but you honestly just need to change your way of thinking about it to "honoring the patient's wishes". As you do it more often, it will get easier for you.

[netglow, ASN, RN]

Spectacular care you gave OP. This is what a nurse does.

[FurBabyMom, MSN, RN]

You guys did the right thing - pacers/AICDs are really no different than vents, pressors, or even feeding tubes. Though, I will say, just because it is the right thing to do doesn't automatically make it easy...

[somenurse]

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.

[Sun0408, ASN, RN]

The pacer was overlooked. Once the pt is made comfort care only or to withdraw care, the pacer is usually turned off. I have turned off many. The pts usually don't pass immediately after turning it off, sounds as though the pacer was the only thing giving him a beat. His own heart was too damaged to do any work on its own.

Extubating pts, turning off pacers is all the same.. It is a machine/medical device that is keeping them alive. Keeping both just prolong the death and leave the pt in limbo as well as the families. You did nothing wrong.

[netglow, ASN, RN]

Yes exactly, I view vents/pacers etc. as only serving to make the patient a lab rat when wishes to just be done with it all have been expressed. To me it's gross to keep tweaking the body into doing tricks when the person living in that body wants off that ride.

[Nursingbride12]

Thanks for all the replies :) I'm glad did the right thing but for me this feels like the hardest part of our job.

I did give them 4mg of morphine before the tech got there so I'm confident they slipped away in peace.