Monday, May 18, 2009

The Confrontation

“You’re not going to kill me, are you?”

“No sir, we’ll take good care of you.”


I shouted: “We’ll take good care of you!”

“Good. How many of these have you done?”

“At least two,” I shouted jokingly. “No, seriously, I’ve been doing lots of these since 1991. I honestly have no idea how many I have done.”

He smiled as he peered from behind the bed linens with warm, welcoming eyes. I could see his relatively thin chest and quietly wondered how large his vessel might be to accommodate the pacing lead.

“You better do a good job, you know I’d like to get home soon, not sure how much longer my caretaker’s going to want to feed the cat, and I have to make sure the company’s doing well.”

“If all goes well, from my standpoint you should be able to head home tomorrow.”

“Good. Now let’s get this done.”

And so, relucatantly, we did. What choice did I have? Gratefully, all went well.

In retrospect, this really isn’t much of a story …

… until you realize he was 101 years old.



Josh said...

Why are you putting a pacer in a 101 year old?!?!?!

OHN said...

That one made me smile :)

DrWes said...


How DO we decide who gets therapy and who doesn't in circumstances like this? Where's the legal precedent? Are you going to deny a patient who is functional and still working, living independently and capable of making his own decisions therapy on the basis of age alone? Can we predict this person's age of death? Will it be in 1 month, one year, or several years? What "Comparative Effectiveness Reasearch" has ever been done on centurians? Finally, how big's your checkbook?

Rogue Medic said...

Since he is 101 years old, you might suggest that he may have had more pacers implants than you. I suppose this was his first. Every hundred years, or so, he gets a pacemaker. :-)

When people ask me how many, there are so many responses, but the hearing difficulty makes the delivery of the punchline so much more difficult. :-(


He may live, with a fully functional brain, for another 20 years. A pacemaker is not a major surgical intervention.

Anonymous said...

Wait until universal healthcare takes over. :)
Honestly, Dr Wes, Methuselah could have had a pacemaker, it was his right. He should have paid for it out of pocket, that's all. Especially if he can afford to pay a caretaker to feed a cat.

roger said...

One way that I've thought about the question of the devices in older persons is a bit different. It's not so much that the person doesn't "deserve" the device at 100 years of age, as much as the fact that one thing in the discussion could include how the patient would like to continue to live, and how they would like to pass away (die).

For example, many people, when asked, say they would live to pass away "quietly in their sleep." They also say they would prefer not to have pain or suffering. Sudden cardiac death due to a fatal arrhythmia may be one of the few most painless and peaceful ways to die. That is, if you don't receive a shock or CPR immediately afterwards. That's not to say that this should override the patients desire for life-prolonging therapy like AICD (and certainly life-improving therapy like pacemakers), but that perhaps a discussion of life and death goals could be included in the discussion on "risks and benefits" before its placed. Of course, this may have happened, or may have been inappropriate in this patient, but it's something I've thought about in my limited experiences in similar situations.

Of course, this story appears to be about a pacemaker, rather than just an AICD, so the above comment may not completely apply to this case.

Rogue Medic said...


You make some excellent points. I believe these are covered with the patient when considering AICD implantation.

My father had an AICD. When he decided that his quality of life was not worth repeated ICU admissions following AICD shocks (his arrhythmias were secondary to other problems that required ICU admission), he had the AICD turned off. It still functioned as a pacemaker. He had 2 weeks to make his farewells before he experienced a fatal arrhythmia.

For my father, he could not have planned things better. Not all refusal of an AICD will work out that well for the patient. I was at work, when my mother called to tell me that my father had collapsed. I talked her through confirming pulselessness.

Some of the complications that can arise if someone calls 911 or if the problem is not an arrhythmia and nobody calls 911.