Tuesday, August 03, 2010

Al Fine

“The family wants the pacemaker turned off.”

“We don’t typically turn them off.”

“They want it off.”

“It’s 2 am, can it wait?”

“I don’t think so.”

“I’ll head in.”

Bleary-eyed, I rose from bed, dressed, and was out the door. The cool air from the car window served as nature's wake-up call. The sky was clear, the moon hung brightly on the horizon and the cicadas’ shrill songs undulating high above. Driving in, the tires clapped rhythmically from one pavement segment to the next.

* Kla-lup, kal-lup, kal-lup *

For some reason the Emergency Room seemed farther away this night – perhaps because of my reluctance to go there. If the patient was pacemaker dependent, yet alive with a pulse and neurologic signs, the ethical dilemma was a real one: should I be responsible for stopping the patient's heart? Did the family really understand the implications of these actions?

* Kla-lup, kal-lup, kal-lup *

I turned the final time. The ER sign disrupted the dark sky. I parked and fumbled for my ID. The security guard looked remarkably cheery for that time of night.

Reviewing the case, it was a horrible fall, cerebral hemorrhage, neurosurgeon empathically discussed the prognosis with the family and me – little could be done.

On entering the room, what seemed like twenty pairs of eyes were upon me. Some older, some younger, older kids too. Questioning at first. Tearful. Some closed. It had been a long day. So glad I came. Others pointing the way to her, quietly huddled by his side, clutching his hand. She turn her gaze from him for a moment, offered a brief smile, then back to him again. "He was a great man," she said.

Except for the c-collar in place, he looked regal - staring up without movement. He looked younger than his age, an active lifestyle I guessed. His endotrachial tube had already been removed. "We don't want him to suffer."

I glanced at the monitor. 100% ventricular pacing.


"We'd like the pacemaker turned off," they reinforced.

"You understand that he might die as a result."


"There's a chance his heart could slow significantly, and not stop."

"We understand. If that's God's will."

I turned to his wife. She seemed at peace. I asked her:

"Are you sure this is how he'd want it?"


"And you understand what we're doing?"


"Would you like to be the one to turn off his pacemaker?"

"Honestly, no. But I'm his wife. This is how he'd want it."

"I'll grab the programmer and be right back. I'm so sorry."

I left the room, wrote a thorough note and pondered the situation as I walked to get the programmer. Usually some other metabolic derangement assists us in stopping the heart of patients with pacemakers - we don't usually turn them "off." The natural consequence of other confounding diseases work to cause a lack of oxygen, too much potassium, or another metabolic problem that disconnects the electrical activity from the mechanical. When the mechanical stops, it really doesn't matter what the electrical system does, since the pumping stops irrespective of the electrical impulses applied to the heart.

* sigh *

I returned and checked the device. Naturally, there was still plenty of battery life left. The rhythmic sound of the monitor was heard in the background as I noted his underlying atrial fibrillation with ventricular pacing.

Da Capo

The family huddled together. They gave Grampa a kiss. More tears. What was I doing? She held his hand, leaned forward, and whispered something in his ear. She did not cry. She was turned and shuffled to the programmer, assisted by her daughter. They stood together, arms entwined. The monitor was hushed, the waveform still visible.


I handed her the pen and pointed to the spot to touch to program his pacemaker to "off." She looked at the others. They stood together, resolute, tears flowing. She touched the screen. The programmer responded to make sure that this is what she wanted. She confirmed, "Yes."

The pacemaker responded in kind. A long pause, then a slow escape rhythm.


We were all granted a reprieve. It was not time. A few more notes of the concert called life were still to be played. They thanked me. "Would you mind if we were alone with him?"

"No. Not at all."

I packed up the programmer and pulled the curtain to provide privacy. The monitor out side the room showed an escape rhythm just faster than before. I appended my note with the recent events, spoke with the ER staff, returned the programmer, and headed home.

D.C. al fine.

I was grateful that I could not predict the tempo of death. It was His concerto, not mine after all. As I drove home I noticed the moon was no longer visible on the horizon and in its place were millions of radiant stars.

His metaphor, too.



Anonymous said...

Beautifully written.

Not sure why you found it so hard, though.

It needed to be done.

Unknown said...

A very beautiful piece of writing. It matters not whether something NEEDED to be done, these situations are never easy to go through. Middle of the night doesn't make it any easier, I suppose. From the heart of a JMS, thanks for the honesty and transparency.

Anonymous, two things: 1, these things are difficult because we humans are naturally wired to resist death, in ourselves and in others. Working as a doctor only emphasizes that desire. 2. If this situation weren't so hard, this piece would have never been "beautifully written."

Thanks Dr. Wes!

Daniel F. Kane said...

There is a particular form of humble wisdom that understands the difference between letting die and making dead. Once the circumstances manifest themselves such that recovery is hopeless, pacemakers, rather ordinary components of cardiac care become extra-ordinary and thus serve only to prolong dying instead of enhance health.

It was right and just to shut it off and it is the reflection of a very well formed and wise family to understand the transition from ordinary to extra ordinary and properly reject the extraordinary it in a hopeless case.

It was courageous, humble and merciful of you to acquiesce to that request.

When people speak of death with dignity, the speak of deaths such as this.

Sarada Kakinada said...

There's actually a NY Times Magazine article about this, but more from the patient's family perspective. Here's the link, in case you're curious: http://www.nytimes.com/2010/06/20/magazine/20pacemaker-t.html

DrJohnM said...


This was a brilliant piece.


You continually raise the bar.


Marco said...

Welcome back, Wes. A beautiful, thoughtful post.


#1 Dinosaur said...


Lilian said...

Thank you for this post.

Jodi said...

Wow, powerful stuff.

Anonymous said...

I have a pacemaker and have struggled with the issues this may present to my family and loved ones should a situation such as this happen to me. A thoughtful conversation with my primary care physician helped; however, I still worry that, despite the specificity of the language in my advanced directive, there conceivably might be a reluctance on the part of the medical professionals to actually turn it off. Interestingly, this has never been a part of my discussions with the cardiac/electrophysiology team and having read your piece, perhaps it ought to be.

karen said...

That was beautiful and very touching. I work on the outskirts of the CRDM field, and you personify the type of physician we all hope to work with. Or be treated by.

shadowfax said...

Great post -- but why didn't the ER just put a magnet over the silly thing? I seem to remember having that issue with an AICD that wouldn't stop firing, only someone had swiped our magnet.

DrWes said...


why didn't the ER just put a magnet over the silly thing? I seem to remember having that issue with an AICD that wouldn't stop firing, only someone had swiped our magnet.

The patient had a pacemaker, not an ICD. Magnet behavior for a pacemaker forces the device to pace at DOO or VOO mode (depending on whether the device is a dual or single chamber device) at a set rate so we can determine the remaining battery life left but NEVER turns off pacing. For ICD's, a magnet inhibits detection of tachyarrhythmias (hence why it won't shock a patient, even if there's an abnormal rhythm), but also does not inhibit pacing.

Named Just Bob said...

Dr. Wes I concur with your other readers that your eloquent capturing of this event is moving. I continue to thank providence for having you stumble upon me seven years ago

Healthy Bastard said...

This should go in your book someday. Really good writing. Thanks for sharing.


Donna G. said...

Dr. Fisher,

Thank you for this brillant and tender retelling of an actual situation. The Heart Rhythm Society has published recommendations and the ethical/legal rights of patients/family and the clinican team. For those not yet familiar with the HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy, please use the link at: http://www.hrsonline.org/Policy/ClinicalGuidelines/ceids_mgmt.cfm
Or go to the www.hrsonline.org website where you can find the document under Health Policy/Clinical Guidance.
Thank you again for showing all sides of a real situtation and for your decision!

gradydoctor said...

What a beautiful, humanistic way to honor this patient and his family. Thank you for taking the time to be there and to write this piece.

I loved it.

Allen said...

I don't know how I missed this the first time. Terrifically well written first person narrative of doing the right thing for the patient.