You 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 Dilemmas
With 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 Principles
Ethical 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.
Chitty and Black (2011) have defined fidelity as “an ethical principle that values faithfulness to one’s responsibilities” (p.110). Autonomy is defined by Chitty and Black (2011) as “self-determination, control over one’s own professional practice or life choices” (p. 108). “The need to respect the patient’s autonomy applies whether a life-sustaining device is internal or external to the body” (Bharadwaj & Ward, 2008, p. 398). In this particular case, family members need to understand the diagnosis and treatment options involved with pacemaker deactivation.
Veracity and fidelity are additional ethical principles to consider in attempting to resolve the dilemma. Chitty and Black (2011) have defined veracity as “truthfulness” (p. 110). This supports the ANA Code of Ethics for Nurses Provision 5.1 moral self-respect. Truthfulness and personal integrity are important while educating family members regarding possible outcomes related to deactivation of the pacemaker. Chitty and Black (2011) have defined fidelity as “an ethical principle that values faithfulness to one’s responsibilities” (p. 110). One will always question if they are doing right by the patient, but by remaining truthful and faithful to one’s commitment to resolve ethical dilemmas using the Code of Ethics, an appropriate patient response will be achieved.
Interpretation of ethical principles for decision-making can be emotionally draining for the patient, family, and nurse providers. Whenever in doubt, the nurse should collaborate with the patient, family, doctor, and even bring in members of an ethics committee. For their own future mental health, nurses need to know that the final decision is, and should be, a collaboration of everyone involved.
Personal Values Used to Resolve the Dilemma
The following personal values are important to recognize in resolving the dilemma: accountability, awareness, commitment, discipline, expertise, honesty, leadership, preparedness, professionalism, respect, trust, and wisdom. A nurse is accountable to the patient, family, and staff responsible for the care provided. Being aware of pacemaker deactivation policies and procedures is paramount. As a professional, the nurse has the expertise and knowledge necessary to treat this patient. Preparedness is necessary for answering family questions or concerns in an honest and respectful manner. The nurse must have an understanding of this dilemma, both the pros and cons of the action, in order to understand ethical considerations in carrying out the family's wishes.
ANA Code of Ethics Provisions That Supports the Decision
The following provisions support the resolution of this dilemma:
- 1.1 Respect for human dignity
- 1.3 The nature of health problems
- 1.4 The right to self-determination
- 2.1 Primacy of the patient’s interest
- 2.2 Conflict of interest for nurses
- 2.3 Collaboration
- 3.5 Acting on a questionable practice
- 4.2 Accountability for nursing judgment and action
- 4.3 Responsibility for nursing judgment and action
- 5.1 Moral self-respect
- 5.4 Preservation of integrity
In whatever role or setting the nurse is working, the ANA Code of Ethics can be applied. This particular dilemma poses several different problems that beg for additional answers. For instance, does the patient have advanced directives that specify what support should be provided? To watch someone who is suffering linger near death is never easy or something the nurse would want to happen. The nurse is always the patient advocate and must try to support and respect the family in whatever decision is made. Unless a person is put into this dilemma, it is difficult to say without a doubt what one would do.
In conclusion, it is imperative that nurses discuss advanced directives and informed consent with patients prior to a time when it is not possible to ask these types of questions. Patients and family members need to have thought about and communicated their wishes regarding end of life interventions before those decisions need to be made. As nurses, we are faced with many dilemmas. When time is limited, decisions must be made in haste. Whatever decision is reached in an ethical dilemma similar to the one described here, the decision and the process of making it can elicit significant psychological and moral distress (Whitlock, Goldberg, & Singh, 2011). It is important for nurses to think through ethical dilemmas in advance, using ethical principles and the ANA Code of Ethics to guide decisions.
Column Note Added April 15, 2014:
Several readers have questioned deactivation of pacemakers with a magnet. The author of this column, Heather M. Hosmer-Cernava, replies to this concern below:
My thanks to readers who contacted me to identify the need for clarification of this column. Although some of the earlier articles discussing deactivation of pacemakers (Bharadwaj & Ward, 2008) suggest that all pacemakers can be deactivated with a magnet, more recent articles, for example, Jacob et.al (2011), distinguish between deactivating pacemakers and deactivating implantable defibrillators. It is true that basic pacemakers cannot be deactivated with a magnet. However, an automatic implantable cardiac defibrillator (AICD) can be deactivated via a magnet for ventricular fibrillation and ventricular tachycardia. The intent of this ethics column was to address the difficult ethical decision regarding the deactivation of a device for someone who is in end-stage heart disease, as was the patient described in this column.
Heather M. Hosmer-Cernava, RN
Jacob S., Panaich, S. S., Makeshwari, R., Haddad, J. W., Padanilam, B. J., & John, S. K. (2011). Clinical applications of magnets on cardiac rhythm management devices. Europace, 13 (9), 1222-1230
© 2013 OJIN: The Online Journal of Issues in Nursing
Article published September 4, 2013