Posted on June 6, 2017 at 10:52 AM
The Case of Mr. Perry and his Pacemaker
Tarris Rosell, PhD, DMin
Rosemary Flanigan Chair at the Center for Practical Bioethics
NOTE: Dr. Rosell, a bioethics consultant and educator, will present the case of Mr. Perry for ethics discussion and likely debate on Thursday, June 22, 2017 at 7:00 PM in the artfully rebuilt Westport Presbyterian Church, 201 Westport Rd, Kansas City, MO. Bring your perspectives, arguments, and personal stories of moral medical dilemma. Admission is free. All are invited and welcome.
Mr. Perry (not his real name) was 83 years old and had several medical problems. He had spent the past several months in and out of hospitals and rehab. Prior to that, he lived independently in a small Midwestern town. Widowed many years ago, he subsequently enjoyed the company of a lovely lady friend who lived down the street from the Perry home. He had five adult children and numerous grandchildren.
Life should have been relatively good for this octogenarian. But life was not good. Not anymore. “My body is all worn out. I’m worn out. Don’t want to do this anymore, Doc. They say I can’t go home and be safe. And I’m NOT going to a nursing home. No way! Just stop that little gadget that shocks me and the part that keeps my heart going. I want them stopped. Yes, the pacemaker, too. A magnet will stop it, right? Just do it. Please.”
Tired of Fighting
Mr. Perry had a cardiac resynchronization therapy defibrillator (CRT-D) implanted a few years ago. It included an electrical pacing component for heart rhythms, on which the patient was 100% dependent. The defibrillator had shocked him, more than once, just before he came to the hospital E.R. with this request. That was the last straw for Mr. Perry. No more shocks for him. No nursing home or rehab or hospitalizations or medications. And no more mechanical pacing either. “I’m tired of fighting.”
Deactivating an internal defibrillator is one thing. The patient’s cardiologist didn’t need an ethics consultation for that decision. “If he doesn’t want to be shocked again, that’s his decision. And if it went off again after he’d requested it stopped, that could be a kind of torture,” she reasoned. Deactivation happened quickly after admission from the Emergency Department. A “Do Not Attempt Resuscitation” order was placed in the chart.
But the pacemaker, also? He wanted it stopped. Ought we do so? Would that be ethically respectful of this patient’s autonomy? Or would it be physician-technician assisted suicide?
“If we stop the pacemaker, Mr. Perry, you will die within a few minutes.”
“Yes, I know. I’m tired of fighting. Please.”
There are at least three ethics “take-aways” from pondering this situation:
1) Although most clinical ethicists and cardiologists will argue that stopping Mr. Perry’s pacemaker is ethically and medically permissible, there is a significant minority opinion that it is not. Other thoughtful people will see this as troubling, too close to the gray line between suicidality and permissible refusal of life-sustaining treatment. One survey of cardiologists indicated that 77.6% (n=787) had been involved in pacemaker deactivation. Only 34.4% reported being comfortable doing so. Anecdotally, a pacemaker manufacturer’s technician told me that neither he nor any of a dozen colleagues would agree to participate in turning off (or down to sub-therapeutic level) a pacemaker on which the patient was dependent. Two bioethicist-physicians debate the issue in a case review published as an article titled, “Is it permissible to shut off this pacemaker?” The one dissenting from pacemaker deactivation in a case like that of Mr. Perry claims that doing so would be assisted suicide, which he claims is wrong. Would it? Is it? We do not all agree.
2) Informed consent process, both oral and written, for cardiovascular implantable electronic devices (CIEDs) ought to include discussion of deactivation and end-of-life decisions. Clinical colleagues and I published a review of consent forms and patient charts for 91 patients who had received an implantable cardioverter defibrillator (ICD). Only one of those records gave evidence of end-of-life discussion, which could involve device deactivation. This paucity of information provided patients regarding deactivation ought to change.
3) One might reasonably ask whether Mr. Perry chose rightly. Even if we were to conclude that it was right of his cardiologist to respect her patient’s autonomous decision, is it possible that Mr. Perry himself acted wrongly? He had grandchildren, one of whom was in the room when Grandpa died. Ought he have been willing to accept lesser independence, to endure suffering awhile longer, to rethink what matters for an acceptable quality of life—if only to spend more time with his grandchildren? Were his values ordered rightly? One need not judge by simply raising the question. I am not yet a grandfather, nor do I physically or emotionally suffer very much right now, but I think that in Mr. Perry’s situation, I would hope to value and choose differently.
1) Mueller PS, Jenkins SM, Bramstedt KA, Hayes DL. “Deactivating implanted cardiac devices in terminally ill patients: practices and attitudes,” Pacing Clin Electrophysiol 2008 May; 31(5):560-8.
2) Yates, FD and RD Orr, Ethics & Medicine 24, 1 (Spr 2008): www.cbhd.org .
3) Niewald, Broxterman, Rosell and Rigler, “Documented consent process for implantable cardioverter-defibrillators and implications for end-of-life care in older adults,” Journal of Medical Ethics 2013; 39:94-97.
A hospital ethics consultation landed on the side of permissibility and respect for a capacitated patient’s autonomy. Subsequently, Mr. Perry had his wishes respected, and he died peacefully surrounded by family and a family friend, who read scripture and offered prayer. A priest chaplain had previously given last rites. His lady friend sat by his side, held his hand, stroked his arm and said, “We’ve had good years together, but you’ve suffered enough. I’ll let you go.” Mr. Perry’s last words were, “Thank you.”
Bioethics Case Studies
Case studies are an important tool in bioethics, especially in practical bioethics where the focus is on real issues in real life and real time. Case studies provide a roadmap for decision-making in future cases, help drive the development of new analysis and thought about complex medical and moral dilemmas, and are an effective way to bring bioethics alive for students, healthcare providers, administrators, attorneys and, even in some situations, patients and families. (Read More)