AACN News—January 2009

Vol. 26, No. 1, JANUARY 2009

Practice Resource Network

Q We’ve had families ask about deactivating permanent pacemakers for their loved ones who are in the process of dying. Some of the physicians and staff are uncomfortable with doing this. What are the ethical considerations surrounding this practice?

A On a clinical note, there is no indication to deactivate a pacemaker at the end of life. Pacing will neither hasten nor prolong the dying process. Deactivation of implantable cardioverter defibrillator (ICD) tachycardia or shock therapies, however, may be done so that patients do not feel a shock in the event that they have ventricular tachycardia or ventricular fibrillation.

A brief review of the literature and Internet resources reveals a general consensus that ethical tenets are no different for the deactivation of implanted cardiac devices than for other life-sustaining treatments, such as mechanical ventilation. Pacemakers and implantable defibrillators are a supportive therapy. One fundamental absolute each patient has is the right to say no to medical treatments, or to reject or withdraw medical treatments that are not meeting a meaningful goal, even if the treatment is life prolonging.
If the request is made by a competent patient or authorized surrogate, the deactivation of the tachy-therapies of an ICD is, on the basis of autonomy alone, ethically sound and legal.

There are several indications for deactivation of ICD tachy-therapies. These can include but are not limited to a patient’s preference when the patient is in an advanced disease state; irreversible cognitive failure, such as Alzheimer’s disease; when activation would be inappropriate in the dying phase, such as a shock from an ICD; following withdrawal of other life-sustaining therapies; and while an active DNR order is in place.

Decisions on deactivation should include open discussion with the patient and family or patient advocate if the patient is unable to participate.

Points of discussion may include:

• ICD deactivation is integral to the general decision about
resuscitation.
• Withdrawal will not result in immediate death, but the safety net provided by the ICD will no longer apply. However, even when the tachy-therapies of an ICD are turned off, the pacemaker feature of the device remains fully functional.
• Deactivation is achieved using an external programmer, is not painful, takes about 10 minutes and can be done with family and significant others present.Multi-organ failure associated with electrolyte disturbance may be pro-arrhythmic and result in ICD discharge (aka shocks).
• Inappropriate shocks are uncomfortable and inconsistent with symptomatic or palliative care.
• After death, both pacemaker and ICD generators may need to be explanted if cremation is being considered. ICD tachy-therapies would need to be deactivated if an autopsy is performed.
• A pacemaker will not keep the patient alive beyond the point of clinically apparent death.
• At the end of life due to cardiac disease or unrelated conditions, the heart tends to be refractory to pacing activity, and death can be assumed if there is pulseless electrical activity. If a monitor is being used this may show continued pacing spikes, but no cardiac muscle response (aka P or R waves).

“AACN Procedure Manual for Critical Care” (5th ed.) and “AACN Protocols for Practice: Palliative Care and End-of-Life Issues in Critical Care” both support the patient’s right to withhold and withdraw life-sustaining therapies when the patient’s goals are no longer being met or there is no longer hope for a meaningful recovery.

Bibliography/Resources

Ballentine, Jennifer M. Pacemaker and defibrillator deactivation in competent hospice patients: An ethical consideration. American Journal of Hospice and Palliative Medicine 2005 22: 14-19.

Bharadwaj P, Ward KT. Ethical considerations of patients with pacemakers. American Family Physician, August 1, 2008 Vol. 78 No. 3.

Mueller PS, Hook CC, Hayes, DL. Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life. Mayo Clin Proc 2003; 78:959-963.

Ng, T. Virtual Mentor. Ethics in the age of medical device technologies. American Medical Association Journal of Ethics. February 2007, Volume 9, Number 2: 83-85.

Code of ethics. E-2.20: Withholding or withdrawing life-sustaining medical treatment. American Medical Association Web site. Available at

http://blog.cleveland.com/health/2008/10/as_the_end_of_life_nears_do_yo.html

http://www.eperc.mcw.edu/fastFact/ff_111.htm

AACN News—January 2009—Practice

Vol. 26, No. 1, JANUARY 2009

Practice Resource Network