Case Scenario

I had a 90-year-old patient with a diagnosis of end-stage congestive heart failure who was receiving hospice care. He had a pacemaker implanted seven years earlier for complete heart block. During my most recent visit to his home, I found him to be weak and barely responsive to verbal stimuli. He had stopped eating and drinking a few days earlier. His wife told me that he never wanted to exist in this condition. He had spoken with her in detail about his wishes at the end of his life, which included forgoing any medical intervention or therapy that would prolong the dying process. She asked me if I thought his pacemaker was prolonging his dying process. She had spoken with his cardiologist about this issue and requested that the pacemaker be deactivated, but the cardiologist told her that turning off his pacemaker might be illegal and was equivalent to committing murder. I called the technician from the company that maintained the pacemaker to find out if they would deactivate the pacemaker, but he refused and stated that it would be unethical. The patient died before I was able to find another cardiologist or technician to help me carry out his wishes.

What are the ethical considerations surrounding pacemakers at the end of life? How are pacemakers typically deactivated, and by whom?

Commentary

Modern medicine has increasingly become infused with technology intended to extend a person's quantity and quality of life. More than 1 million persons in the United States have implantable pacemakers and the majority of this population is older than 65 years.¹ Physicians will care for an increasing number of older patients with pacemakers; therefore, physicians should become familiar with the ethics of dealing with pacemakers in the setting of terminal disease.

This case asks whether a pacemaker can be deactivated to prevent unnecessary prolongation of life. Every person has the right to refuse medical interventions or to request their withdrawal, and this right extends to pacemakers and other technological interventions. There is no ethical or legal distinction between withholding a pacemaker and deactivating one after it has been initiated.^2–4 In general, there is a widespread and accepted practice of withdrawing life-sustaining interventions (e.g., mechanical ventilation, hemodialysis, artificial hydration, nutrition) from patients who are terminally ill.⁵ Although the deactivation of devices such as pacemakers occurs with less frequency, the ethics surrounding the decision remain the same. The need to respect the patient's autonomy applies whether a life-sustaining device is internal or external to the body.

Typically, pacemakers do not need to be deactivated in end-of-life situations unless the patient or family requests it, which typically happens if they feel the device is prolonging the dying process. Primary care physicians can deactivate older pacemakers with a magnet. However, newer pacemakers have been designed to withstand magnetic fields and need the intervention of a cardiologist or technician to be deactivated. Therefore, the primary care physician and patient-family relationship is not enough to make the decision to withdraw pacemaker support. In addition, many physicians—like the cardiologist who was consulted in this case—are hesitant to deactivate pacemakers, despite patient or surrogate requests for withdrawal, because of a fear of litigation or because of misperceptions of the ethical and legal acceptability.^6–7

In the above case, the pacemaker was placed for complete heart block and was prolonging the dying process. There may be other reasons for pacemaker placement that may not necessarily be prolonging the dying process (e.g., bradycardia). The easiest way to determine this would be to interrogate the device, which would show if the patient's cardiac rhythm is completely or partially dependent on the pacemaker. If the rhythm is completely dependent upon the pacemaker, it is considered to be life prolonging. If the rhythm is partially dependent on the device, it may not be life prolonging and may not need to be deactivated. This patient had clearly conveyed his wishes to his surrogate regarding the removal of any therapies that could prolong his dying process. As physicians, we should recognize and remove medical interventions that are perceived as burdensome to the patient who is terminal, as illustrated in the above case.²

To address the cardiologist's claim that disabling the pacemaker was equivalent to committing murder, it should be noted that the law clearly protects physicians who are acting with the purpose of controlling pain and suffering or relieving anxiety in patients who are terminally ill. No U.S. court has found a physician liable for wrongful death for honoring a patient's or surrogate's request to refuse or withdraw life-sustaining treatments.³

At times, a patient's goals may conflict with a physician's. Patients may refuse treatment (in this case, the ongoing support of the pacing device), but physicians must remain engaged and supportive of the patient, even though there may be conflict. If granting the request violates the physician's conscience, the physician should arrange for the transfer of the patient's care to another physician, in accordance with the principle of nonaban-donment.⁸ In the case scenario, the primary care physician should refer the patient to a cardiologist or technician who would be willing to deactivate the pacemaker.

Ultimately, the cardiologist is a consultant and brings expertise to the management of that specialty, which is often narrow in scope. On the other hand, the primary care physician frequently has a more holistic approach to the patient, which is crucial in the management of the quality of life and in end-of-life issues.

The discussion about what to do with pacemakers (and other technological interventions) when a patient becomes terminal should be part of the informed consent process before the insertion of the device, rather than waiting until the dying process is underway. This may help alleviate unnecessary suffering by the patient and the patient's surrogate decision-maker. However, given that health conditions change over time and patient's wishes may change accordingly, it is important to know consultants who are comfortable and educated in such end-of-life issues.