Pacemakers and DNR's

[becca001]

As a new nurse on a step down unit, I was assigned a little lady that had a massive CVA. The family had decided comfort measures only (pt was 92). The family had many questions about her and was very caring, truly appreciative of my efforts to make the patient as comfortable as possible. On the last day, the family became very concerned about the pacemaker and it's role in the DNR and dying process. They wanted to know if her heart would continue beating for any length of time after she stopped breathing, and if so, could we just turn it off. I was able to fumble my way around the first part of the question although I still don't know how long a pacemaker might keep the heart functioning before it can no longer fire any impulses. The latter part was answered by the PCP (bless his heart, he was wonderful with the family) when he said he didn't think it would make any difference. Pacemaker dx was heart block. Question I have is, if it had been a different dx for the pacer, would it then become more of an ethics question? Such as Sick Sinus or something else that might have had an impact on the length of life? Any input is greatly appreciated.

[TampaTech]

Well as a monitor tech i have seen many different types of pacer rythms. If a pt is dying and they have a pacemaker (atleast in MY experience) the pacer will fire and you will have an odd looking iso-electric line, for being non conductive. It will continue to fire until it is physically shut of by some mechanical means like a magnet or computer. But if the heart is dead nothing will happen.

[leslie :-D]

i am not totally clear on what you're asking...

but when a person dies, the icd/pacemaker will not respond.

even during imminent death, you will often notice a symptomatic bradycardia.

some folks choose to have their devices deactivated, while others do not.

if they are deactivated, it is legal, ethical, and NOT pas or euthanasia...

although there are docs who say it is.

you also don't want the icd discharging during the dying process, so there are all sorts of things the doctor should be discussing with the pt.

when in doubt, up the morphine.

leslie

[becca001]

Thanks for both replies. I guess what I'm asking is, if the pacer is there to prevent an arrythmia from occuring that will be fatal, is turning it off a way of 'hurrying' the dying process along?

[leslie :-D]

Thanks for both replies. I guess what I'm asking is, if the pacer is there to prevent an arrythmia from occuring that will be fatal, is turning it off a way of 'hurrying' the dying process along?

yes, it does hasten death.

and even then, response will vary, contingent on how dependent they are on the icd.

if nothing is touched, then the pt will often be vulnerable to new onset of add'l firings.

this does nothing for their comfort level.

leslie

[scoochy]

When respirations cease, soon the heart will no longer be oxygenated. No matter how hard the PM works, no oxygen = cellular death. Their will be pacemaker spikes, but no capture (no impulse conduction to the atria or ventricle depending on the type of PM it is) if you were looking at a monitor.

[nursej22, MSN, RN]

The only fatal arrhythmia that I can think of that a pacemaker would prevent is ventricular standstill; even with a third degree heart block you can have a pulse albeit a very slow one. I would think that continuing pacing might provide comfort by preventing hypotension resulting from a bradycardia. Now an ICD is a totally different matter. When that thing discharges, and it will if a person is dying, it is very uncomfortable.

But as previous posters stated, when respirations cease, the body becomes acidotic and the heart muscle will not depolarize.

[StayLost, BSN, RN]

This is a really interesting post. I never thought about these scenarios.

[Tait, MSN, RN]

I would want my AICD off if I were comfort measures. Nothing speaks the anti of "comfort" as worthless, painful, stressful shocks. I don't care what part of you is already in the netherworld.

And to the doc that believes it is euthanasia, does he say that to people who decide not to have them at all too?

Tait

[ellakate]

After Dad died, his icd fired twice. I wish I had known how to disable it.