Ethics: Deactivating a Cardiac Pacemaker: Is It Ethical?

Citation: Hosmer-Cernava, H., (September 4, 2013) "Ethics: Deactivating a Cardiac Pacemaker: Is it Ethical?" OJIN: The Online Journal of Issues in Nursing Vol. 18 No. 3.DOI: 10.3912/OJIN.Voll8No03EthCol01You are the charge nurse at a local nursing home. You have an 86-year old resident whose spouse died several years ago; the patient is now lingering near death. The patient had a pacemaker inserted in the distant past and lives with multiple comorbidities, including diabetes with painful neuropathy and blindness, as well as congestive heart failure. The family has stayed faithfully by the patient's side, watching her suffer for weeks. The oldest adult child approaches you and confides that the siblings have talked and are in agreement regarding their mother's care. They request that the doctor be called and a magnet be placed over the pacemaker to disable it. You listen and assure the adult children that you will address this as soon as possible. You walk away unsure what to do. In the meantime, the staff nurse calls the physician, and the physician gives the order to deactivate the pacemaker.New Technologies Bring New Ethical DilemmasWith new medical technologies, older adults now survive health crises that once would have been lethal, making the "oldest old" the nation's most rapidly growing age group (Butler. 2010!. Older adults and their families often face difficult decisions at end of life. One study found that patients are far more likely than their doctors to refuse aggressive treatments when they are fully informed of advantages, disadvantages, and alternatives; yet approximately half of patients say they do not get this information (Butler. 2010!. Lampert et al. (2010) posed the question: "If your loved one could wake up for 15 minutes to understand his/her condition fully, but then had to return to it, what would he/she tell you to do?" (p. 1017).In an era of advance directives and surrogate decision makers, nurses must be prepared to discuss ethical dilemmas with patients and family members. The process of deactivating a pacemaker by applying a magnet is fairly straightforward; but the ethical decision-making related to the process is complex. Patients and family members need to understand how insertion of a pacemaker may affect end-of life care.The Heart Rhythm Society has recently released consensus guidelines that outline the ethical and legal principles for withdrawal of devices such as a pacemaker (Whitlock. Goldberg. & Singh, 2011). Bharadwaj and Ward (2008) have emphasized that discussions about what to do with pacemakers and other technological interventions when a patient becomes terminally ill should be part of the Informed consent process before the insertion of the device, rather than waiting until the dying process is underway.Framing the Decision with Ethical PrinciplesEthical principles that provide the context for the dilemma described above include: beneficence, nonmalificence, fidelity, and autonomy. Chitty and Black (2011) defined beneficence as "the ethical principle of doing good" (p. 108). By deactivating the pacemaker, are you doing good for the patient? The ANA Code of Ethics for Nurses Provision 1.1 calls for respect for human dignity. You have a duty to do right by this patient; but often this 'right' may be difficult to determine.Chitty and Black (2011) defined nonmalificence as "the duty to do no harm or evil" (p. 109). By deactivating a pacemaker it is uncertain what might occur. Bevins (2011) has noted "essentially one of three possible scenarios may result: a) deactivation has no discernible clinical consequences, either in causing symptoms or death, b) deactivation causes death immediately, or c) deactivation causes new symptoms that may accelerate death" (p. 108). The ANA Code of Ethics for Nurses Provision 1.3 advises the nurse to provide care regardless of the nature of the health problem. It is important to recognize that results of deactivating the pacemaker could have unanticipated results that prolong suffering for the patient. …