Q: Hospice patients or family members sometimes ask about deactivating the patient's pacemaker when the patient nears end of life. What factors should be considered?

There is an ethical debate regarding whether or not a patient has the right to have their pacemaker disabled when they are nearing end of life. The literature suggests that few patients discuss deactivation with their providers or even know it is an option, and clinicians do not readily discuss this option (Karches & Sulmasy, 2015). Pacemakers safely and effectively treat rhythm disorders, but are not usually life-supporting and do not resuscitate patients. Pacemakers do keep patients with complete heart block alive, so they are subject to the same ethical implications as other medical devices (Padeletti et al., 2010).

The Heart Rhythm Society released guidelines for deactivation. A patient or their legal surrogate has the right to refuse or request withdrawal of any medical treatment (Lampert et al., 2010). Timely communication between the patient, family, and healthcare team is necessary to clarify the patient's goals of care (Lampert et al.). Conversations should focus on how to support the patient who has made the decision (Gordon & Grossman, 2015). Patients and families should be educated on the physical and psychological aftereffects that result from deactivating pacemakers. The process of deactivation should include all team member in order to fully support the patient. The environment in which deactivation is elected should align with the patient's and caregiver's wishes in order to provide comfort and serenity. Additionally, social workers who can best support the complex emotional dynamics that may arise, should be consulted (Lampert et al.).

The decision as to how and when deactivation is to take place should be documented with the approval of the hospice care team and the patient's family. The patient and family need to be informed that deactivation of a pacemaker does not necessarily mean a quick and painless death, as the majority of the patients are not pacemaker-dependent. However, when a patient is dependent on pacing therapy, deactivation can lead to asystole and death, or it can lead to slow failure of organs, known as symptomatic bradycardia, which can cause a slower death. A provider who knows how to turn the device off (a nurse, nurse practitioner, or a technician) will be needed. Spiritual or religious support should be offered based on the patient and family's religious beliefs to help the patient and/or family process their decision (Karches & Sulmasy, 2015). The guidelines set forth by the Heart Rhythm Society aid the team to provide compassionate and effective care when withdrawing pacemaker therapy in order to honor a patient's decision.

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