Pacemaker deactivation

When you least expect it, some moral dilemma may strike in the wards. I have been taking care of a young 46-year-old man. He, unfortunately, has a very bad heart.  It only pumps at about 20%. This bad pump function causes fluid to back up into his lungs and legs, making anything strenuous just impossible.  He even had a pacemaker and a “shocker” put into his heart. The pacer helps the heart pump and the defibrillator shocks his heart back into life if it stops- which it has done on occasion.  While in the hospital, we've been walking a fine line with him, of getting the extra backed up fluid off of him (we give him medicines to pee it off) while making sure his kidneys don’t stop working from the medicines we give.  There have been multiple specialists involved. He actually could have a better life- and longer life- if he took the initiative to loose about 50 lbs AND if he could tolerate some of the heart medicines.  Unfortunately, he feels that both of these options are impossible for him.  So we kind of limp on, with our meager medical tools- trying to keep him going. 

Yesterday he was to his baseline- his usual semi-short of breath, somewhat fluid overloaded state.  We had reached our medical end and were ready to send him home.  Things changed when he made an unseemly request.  “Doctor, Just turn it off”.  I stopped to clarify, “Mr. R, what are you asking?”  “Just turn the pacemaker off, I have thought about this for a long time. If there is nothing else medical to do, I just want the machine off and let me die” At first I thought he was just angry about being discharged from the hospital, trying to shock us into keeping him longer.  However as the day went on, and more and more doctors became involved it became clear- he was ready to die.

With the Shiavo case fresh in all of our minds, it’s interesting to revisit this area of medicine.  Very often we as doctors are confronted with prolonging and shortening life. It is not unusual for a family, gathered around an aged grandmother on a ventilator, after a stroke has left nothing but a shell, to request that the breathing machine be turned off.  Most of us wouldn’t hesitate to honor the family’s wishes, especially when convinced that the grandmother wished that they never wanted a machine to keep them alive. But when a living, talking, walking, laughing, man says he wants the device keeping him alive to be stopped- what then?  It’s the same scenario – a man-made machine is being withdrawn…without it in place Mr. R wouldn’t still be alive anyway.  So why does it feel so different than the old lady in the ICU?  The difference medically is non-existant, but perceptively the difference is drastic.  One situation feels generous and natural, the other feels like assisted suicide.

We stalled all day today trying to prepare ourselves as doctors, and as humans, to be okay with his request, as the patient was already okay with it.  We had psychologists, ethicists, cardiologists, and palliative care doctors (end of life docs) all come and comment on this unusual request.  All came to the same conclusion. It was okay- he was rational and competent enough to make this decision, and we, as physicians were required to follow through. 

So tomorrow morning, if things continue as planned, the nurse cardiologist in charge of these medical devices will come and turn this pacemaker/defibrillator off. His family will be there, all the doctors will be there, and we, with heavy hearts, will say goodbye.