Sunday, July 29, 2018

Saying “Turn it off” after a pacemaker or implanted defibrillator is in place

Ed note: With technology it’s often easier to say “yes” rather than “no” – or worse, saying “stop” after you said “yes.” As an ethics committee consultant, I was asked to see a dying patient on hospice who wanted his pacemaker turned off. His cardiologist refused saying, “I can’t be involved in killing people.” But the ethics committee felt that the patient had a right to refuse further treatment with this implanted device. Eventually, the manufacturer helped supervise our staff in turning the pacemaker off after considerable turmoil about patient autonomy. Another issue is the implantable defibrillator – essentially a built in AED to shock your heart when a lethal arrhythmia occurs. The following article shows how hard it can be for a doctor to deal with the patient who wants “everything done” even if it may give a more uncomfortable death. 
From the NYT: “Like most patients, mine wanted to live as long as possible. So when I brought up the option of a small implantable defibrillator for his failing heart, he immediately said yes. The device would be inserted in his chest to monitor his heartbeat and apply an electrical shock if the rhythm turned into something dangerous. It was like the paddles in the emergency room, I told him, but it would always be inside him.
In truth I wasn’t sure if a defibrillator was really such a good idea. My patient was near the end of his life. He might live longer than a year, but certainly no more than five. Patients with heart failure mostly die in one of two ways: either from a sudden, “lights-out” arrhythmia that stops the heart, or from insidious pump failure, in which the heart increasingly fails to meet the metabolic demands of the body. The former, which the defibrillator would help prevent, is quick and relatively painless. The latter, which the defibrillator would make more likely, is protracted and physically agonizing.
When the time came, wouldn’t it be better for my patient to die suddenly than to struggle for breath as congestive heart failure filled his lungs with fluid?

The funeral as we know it is becoming a relic — just in time for a death boom

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