Pacemaker deactivation: withdrawal of support or active ending of life?

Abstract

In spite of ethical analyses assimilating the palliative deactivation of pacemakers to commonly accepted withdrawings of life-sustaining therapy, many clinicians remain ethically uncomfortable with pacemaker deactivation at the end of life. Various reasons have been posited for this discomfort. Some cardiologists have suggested that reluctance to deactivate pacemakers may stem from a sense that the pacemaker has become part of the patient’s “self.” The authors suggest that Daniel Sulmasy is correct to contend that any such identification of the pacemaker is misguided. The authors argue that clinicians uncomfortable with pacemaker deactivation are nevertheless correct to see it as incompatible with the traditional medical ethics of withdrawal of support. Traditional medical ethics is presently taken by many to sanction pacemaker deactivation when such deactivation honors the patient’s right to refuse treatment. The authors suggest that the right to refuse treatment applies to treatments involving ongoing physician agency. This right cannot underwrite patient demands that physicians reverse the effects of treatments previously administered, in which ongoing physician agency is no longer implicated. The permanently indwelling pacemaker is best seen as such a treatment. As such, its deactivation in the pacemaker-dependent patient is best seen not as withdrawal of support but as active ending of life. That being the case, clinicians adhering to the usual ethical analysis of withdrawal of support are correct to be uncomfortable with pacemaker deactivation at the end of life.

This is a preview of subscription content, access via your institution.

Notes

  1. 1.

    ICDs are implanted devices that terminate lethal cardiac rhythm disturbances by automatically detecting them and administering an electric shock. Pacemakers are implanted devices that sense the electrical function of the heart and provide pacing impulses if those provided by the native cardiac electrical system are insufficient for normal cardiac function. Many pacemakers are not life-sustaining or are only so intermittently. Our argument in this paper is in regard to pacemakers that serve a life-sustaining function, such that a patient’s death might be reasonably anticipated after deactivation.

  2. 2.

    Kraemer’s suggested solution to the problem, which we shall not address here, is to posit that the patient’s perception of the device can guide our thinking as to whether the device is part of him/her or not and, hence, as to whether device deactivation is active or passive euthanasia in a given case. We suspect that this approach to the problem is too subjective to be satisfactory.

References

  1. 1.

    Mueller, P.S., C.C. Hook, and D.L. Hayes. 2003. Ethical analysis of withdrawal of pacemaker or implantable cardioverter-defibrillator support at the end of life. Mayo Clinic Proceedings 78: 959–963.

    Google Scholar 

  2. 2.

    Mueller, P.S., S.M. Jenkins, K.A. Bramstedt, and D.L. Hayes. 2008. Deactivating implanted cardiac devices in terminally ill patients: Practices and attitudes. Pacing and Clinical Electrophysiology 31: 560–568.

    Article  Google Scholar 

  3. 3.

    Kapa, S., P.S. Mueller, D.L. Hayes, and S.J. Asirvatham. 2010. Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: Results of a survey of medical and legal professionals and patients. Mayo Clinic Proceedings 85: 981–990.

    Article  Google Scholar 

  4. 4.

    Goldstein, N.E., D. Mehta, E. Teitlbaum, E.H. Bradley, and R.S. Morrison. 2007. “Its like crossing a bridge” complexities preventing physicians from discussing deactivation of implantable defibrillators at the end of life. Journal of General Internal Medicine 23(Suppl. 1): 2–6.

    Google Scholar 

  5. 5.

    Lambert, R.L., D.L. Hayes, G.J. Annas, et al. 2010. HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm 7: 1008–1026.

    Article  Google Scholar 

  6. 6.

    Kay, G.N., and G.T. Bittner. 2009. Should implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated? An ethical distinction. Circulation Arrhythmia and Electrophysiology 2: 336–339.

    Article  Google Scholar 

  7. 7.

    Sulmasy, D.P. 2007. Within you/without you: Biotechnology, ontology, and ethics. Journal of General Internal Medicine 23(Suppl 1): 69–72.

    Google Scholar 

  8. 8.

    Cruzan v. Director, Missouri Department of Health. 1990. 497 U.S. 261.

  9. 9.

    Sulmasy, D.P., and E.D. Pellegrino. 1999. The rule of double effect: Clearing up the double talk. Archives of Internal Medicine 159: 545–550.

    Article  Google Scholar 

  10. 10.

    Miller, F.G., R.D. Truog, and D. Brock. 2010. Moral fictions and medical ethics. Bioethics 24: 453–460.

    Article  Google Scholar 

  11. 11.

    Anscombe, G.E.M. 1961. War and murder. In Nuclear weapons: A catholic response, ed. W. Stein. London and New York: Sheed and Ward.

  12. 12.

    Bone, R.C., E.C. Rackow, and J.G. Weg. 1990. Ethical and moral guidelines for the initiation, continuation, and withdrawal of intensive care. Chest 97: 949–958.

    Article  Google Scholar 

  13. 13.

    American Thoracic Society. 1991. Withholding and withdrawing life-sustaining therapy. Annals of Internal Medicine 115: 478–485.

    Google Scholar 

  14. 14.

    Solomon, M.Z., L. O’Donnell, B. Jennings, et al. 1993. Decisions near the end of life: Professional views on life-sustaining treatments. American Journal of Public Health 83: 14–23.

    Article  Google Scholar 

  15. 15.

    Truog, R.D., M.L. Campbell, J.R. Curtis, et al. 2008. Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American Academy of Critical Care Medicine. Critical Care Medicine 36: 953–963.

    Article  Google Scholar 

  16. 16.

    Simon, J.R., and R.L. Fischbach. 2008. LVADs and the limits of autonomy. Hastings Center Report 38(3): 4–5.

    Google Scholar 

  17. 17.

    Simon, J.R., and R.L. Fischbach. 2008. Case study: “Doctor, will you turn off my LVAD?”. Hastings Center Report 38(1): 14–15.

    Article  Google Scholar 

  18. 18.

    Bramstedt, K. 2003. Contemplating total artificial heart inactivation in cases of futility. Death Studies 27: 295–304.

    Article  Google Scholar 

  19. 19.

    Kraemer, F. 2011. Ontology or phenomenology? How the LVAD challenges the euthanasia debate. Bioethics. doi:10.1111/j.1467-8519.2011.01900.x. Accessed Oct 27, 2011.

  20. 20.

    Brock, D. 1992. Voluntary active euthanasia. Hastings Center Report 22(2): 10–22.

    Article  Google Scholar 

  21. 21.

    Hamric, A.B., and L.J. Blackhall. 2007. Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine 35: 422–429.

    Article  Google Scholar 

Download references

Conflict of interest

None.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Thomas S. Huddle.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Huddle, T.S., Amos Bailey, F. Pacemaker deactivation: withdrawal of support or active ending of life?. Theor Med Bioeth 33, 421–433 (2012). https://doi.org/10.1007/s11017-012-9213-5

Download citation

Keywords

  • Pacemaker deactivation
  • Withdrawal of support
  • End of life care
  • Medical ethics
  • Physician assisted suicide