Friday, December 16, 2011

Al Fine

It's busy this time of year for me, so I offer this prior piece, previously published 3 Aug 2010:
“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.



Dennis said...

Well said... Oh if it was always so simple.

Marie said...

I had a pacemaker implanted following 3rd deg complete heart block. No other cardiac or health issues but I had been deeply mourning the sudden death of my 28 yr old son for ten months. I have asked my children to have it turned off if I ever got dementia. I woul ask myself if I got a stroke or cancer or some other disease that was making my life utterly miserable. It is a internal life support and I don't see stopping it as wrong. It just letting nature take it's course as it would have before modern technology. I am 70 yrs Mum , granny, and already have had a full and happy life. The story above is beautiful. Patient was allowed a natural and peaceful exit.

Margaret A Rost said...

My wonderful husband of 67 years has a living will stating: If I have an incurable illness or injury, I do not wish my life to be artificially prolonged.
My husband had by-pass surgery in his 60's a stent years later and has only two functioning arteries to the heart.,
In 2013 he had a pacemaker implanted, and shortly thereafter had prostrate cancer diagnosed. In his late 80's he chose palliative care over surgery, chemo etc.
In 2017 the cancer had metastasized and went on Hospice. At that time we decided that if he ever became bedridden we would have the pacemaker deactivated in order to die a natural death.
With a PSA of over 240 it appears that the cancer has spread to the brain, with weakened legs that have made him entirely bedridden, and seizures and serious mental issues from two serious falls, one where is neck was broken - C1 vertebrae fracture.
When he became bedridden I tried to arrange to have the pacemaker deactivated and have been going through a nightmare ever since as all the doctors involved - cardiologist,primary doctor and hospice doctor all claim it would be assisted suicide.
This is heart breaking for me, and depressing for my husband who faces lying in bed 24 hrs. a day, embarrassing for him incontinent.
He wants to leave this life and go to his spiritual home, and is waiting for his Dad to come & get him, and asks several times a day if I have seen or heard from his Dad.
This shouldn't be happening, and I and my son are desperately trying to find a doctor who will help my husband.