Without a doubt, pacemakers save lives. But there may come a time when it’s best to turn off the pacemaker. When is the right time? Who will make the decision? What are the guidelines?
More than one million pacemakers have been implanted in patients in the U. S. The majority of these patients are age 65 and older. With numbers like these, it’s safe to say that health care providers will be caring for an ever-increasing number of patients who may decide that it’s time to turn off the pacemaker. It’s a decision that will probably be made at end-of-life in the hope of not prolonging the dying process.
To improve the understanding of this issue, a recently published study reviewed the health records of 150 patients, the largest group of such patients examined to date, at Mayo Clinic. Of this group, 118 patients (79%) had undergone deactivation of a cardiovascular implantable electronic device. The study went on to note that half of the deactivation requests (51%) had been made by surrogates and that nurses had performed a majority (55%) of the deactivations. Palliative medicine consultations were called for 64 (43%) patients; ethics consultations were conducted for three of the patients. Most of the patients in the study died soon after the device was deactivated, reflecting the patients’ end-of-life status.
The study highlights the fact that patients who are faced with a decision to deactivate a pacemaker are elderly, very sick, and unprepared to deal with this issue. When patients can’t speak for themselves, family members and health care providers rely on the patient’s advance directives to determine the patient’s wishes. However, in this matter, the study found advance directives to be of little help. Although 85 patients in the study had prepared advance directives, only one mentioned the pacemaker. Advance directives commonly include the patient’s wishes regarding the use of resuscitation, ventilators, and feeding tubes, but few patients with pacemakers ever mention the choice to deactivate them. They may not even be aware that deactivation is a possibility. What this means, in effect, is that a family member or other surrogate is making this end-of-life decision and, most likely, struggling to decide what the patient might want.
These findings clearly point to a need for early discussions between the patient and health care provider—perhaps as part of the informed consent process before the pacemaker is inserted rather than leaving family members to face the decision when the patient is dying. Patients need to be better informed early on to become more proactive about making this decision and to include instructions in their advance directives.
The Ethical Implications
Even after the decision to deactivate is made, some health care providers may be hesitant to carry out the deactivation because of ethical or legal concerns. To provide guidance, several medical groups issued a consensus statement, affirming that it is both legal and ethical to turn off a pacemaker at the request of a patient or family member. The withdrawal of life-sustaining interventions, such as mechanical ventilation, hemodialysis, and artificial hydration, from patients who are terminally ill has become accepted practice. Pacemaker deactivation may occur less frequently, but the same guidelines apply. Patients have the legal right to refuse medical interventions or request their withdrawal. This right applies to pacemakers as well.