Print Eric Van De Graaff, M.D.

Here’s a morbid thought.  Take a walk through that part of a cemetery where new arrivals are housed and cast a glance around the grounds where the recently deceased have been laid to rest.  Beneath your feet are a half-dozen or so cardiac pacemakers quietly toiling away, providing unneeded electrical impulses to their owners sixty times per minute while their batteries slowly deplete and wind their way down to lifelessness.  The devices, like the faithful dog that stands watch on the doorstep of a deceased owner who will never return, continue to function flawlessly without the slightest clue that their effort will never again result in the pulsating blood of a living body.  This concept seems to come right out of a horror movie with lifeless zombies propelled through the night by the unceasing prodding of their artificial pacemakers.

The reality of the situation is not quite so morbid and much less exciting, despite the fact that there is truth in the premise: we don’t turn off pacemakers when patients die (and we don’t remove them, either).  Since people with pacemakers continue to have new batteries implanted whenever the old one gives out they will invariably be outlived by their pacemaker.  What happens when the rest of the body dies but the pacemaker keeps pacing?

Just last week I had a discussion with a relatively healthy patient who is a candidate for a pacemaker.  He and his wife were full of questions, having come to the appointment prepared with extensive information from the internet.  One question related to the man’s ability to actually die once he gets the device.  “If I’m on my deathbed with cancer will the pacer keep me alive even when I want to pass away?”

It was this line of questioning that prompted me to write on this topic.  I have had several other patients broach this subject and have likely had an even greater number wonder about it without working up the courage to ask me.  Surprisingly, a large number of doctors and nurses are also relatively naïve about the interaction between a functioning pacemaker and a nonfunctioning human.

The purpose of a pacemaker is simple: it prevents your heart beat from going too slow.  The device is attached to the heart via wires called leads and spends its life looking for native impulses arising from the cardiac muscle.  If your natural pulse rate drops below 60 (or whatever our programmed number is) the pacemaker will begin stimulating the heart with an imperceptible electrical shock once every second.  The current passes through the tip of the lead into the adjacent heart muscle, and then spreads to the entire ventricle by flowing from cell to cell at lightning speed.  The stimulus triggers a brief restructuring of proteins and results in contraction of the muscle fibers.  Within a fraction of a second the entire ventricle wrings out somewhere around a hundred milliliters of blood into the aorta.

To summarize this series of events:
Step 1.  Pacer sends electricity to lead tip.
Step 2.  Electrical impulse conducts to tissue at the point of contact and spreads throughout the heart.
Step 3.  The electrical impulse causes the heart to contract.

Now let’s talk about what happens to the heart at the moment of imminent demise.  One thing that a healthy body does really well is eliminate waste products (and, no, I am not complimenting you on your talents in the bathroom): the lungs eliminate carbon dioxide and the kidneys and liver break down and eliminate unwanted metabolic byproducts.  As these important organs deteriorate your blood becomes saturated with metabolic detritus and becomes an inhospitable milieu for normal cellular function.  Most notably, the pH of the blood drops and the normally neutral serum slowly turns into a weak acid.  Once the pH falls more than a fraction of a point the heart muscle becomes incapable of propagating an electrical stimulus or mounting an effective ventricular contraction.

In other words, no amount of external electricity will trigger a contraction once the heart muscle becomes electrically inert and mechanically dormant.  Step 1 (in the cascade described above) doesn’t matter once steps 2 and 3 fail.  It’s for this reason that we don’t turn off pacemakers in dying patients—it just doesn’t make any difference.

Of course that doesn’t stop people from asking us to decommission implanted devices.  Every now and then a doctor or family member will request that we shut down a pacer on a patient who is dying and in the last stages of palliative care.  Since other lifesaving services are being rolled back—such as antibiotics, IV fluids, and artificial ventilation—why not remove cardiac pacing as well?

Here’s another concept I’d like to clarify.  The purpose of a pacemaker in most people is to improve the quality of life by increasing exercise capacity, preventing fainting, and providing more energy.  It is actually somewhat uncommon that a patient’s heart would simply stop beating without the services of a pacemaker.  In other words, for most pacemaker patients, their device is a quality-of-life rather than a life-or-death therapy.  I don’t have exact numbers on how many patients would simply die if their pacemakers were to shut down today, but I’d put it at no more than 20%.

Turning off a functioning pacemaker in a terminally-ill patient would most likely not lead to his or her rapid demise.  In a patient who is dying but not yet on the deathbed, such an intervention would quite possibly lead to a dramatic worsening in quality of life without hastening end of life, with the patient suffering even more fatigue and periodic falls or loss of consciousness.

The management of pacemakers in the terminally ill population is by no means straightforward and is frequently debated in the medical literature.  In the US there is no law against turning off a pacemaker in a dying patient (such laws exist in some countries) and the consensus among professionals is that artificial cardiac pacing is no different than artificial ventilation and can be removed upon consensus among the patient, family and caregivers.  The simple fact remains, however, that in most patients such a decision makes little difference to the patient’s ultimate outcome and may produce unwanted results prior to death.

This issue is distinctly different from subject of implantable cardioverter-defibrillators (ICDs) in this patient population.  This device differs from a pacemaker in its ability to deliver a jarring shock to the heart in the event of cardiac arrest.  In a patient dying of other causes, being able to pass away suddenly and without suffering from a sudden cardiac arrhythmia would be a blessing rather than a curse.  For patients such as these we routinely offer to deprogram the shock function of the ICD and allow them to pass away without the intrusion of a 35-Joule kick to the chest.

In summary, if you are a patient with a pacemaker you can stop worrying about your device keeping your body alive long after the rest of you departs this earthly existence.  There will be no escapees from cemeteries or zombies pacing the streets at night searching for edible brain tissue.  Your pacemaker will be a reliable, useful companion to you until your body decides it’s no longer needed.  After that your pacer will be no more alive than the fillings in your teeth or the artificial joint in your knee and will slowly and quietly drain its battery as you move on to better things.



This entry was posted in Cardiology and tagged , , , . Bookmark the permalink.

11 Responses to Pacemakers and Death

  1. Jessica Soulliere says:

    Fascinating story, morbid or not!

    If patients are interested in donating their pacemakers instead of being buried with them pulsing away, it is possible. We do it at the U-M Health System: http://www.med.umich.edu/myheartyourheart/.

    Perhaps it’s something Alegent (or their patients) might be interested in pursuing as well!

  2. Eric Van De Graaff M.D. says:

    Jessica,

    Thanks so much for your comments and I personally appreciate being educated about a subject I had no previous knowledge of. The idea of recycling these expensive and incredibly useful devices had never occurred to me and I’m glad that the researchers at your facility are looking into it. I gather from a short perusal of your website that the idea of reusing implantable devices still has to navigate the hurdles of federal oversight. Please keep us posted on the progress of your research.

    Dr. VDG

  3. Jena says:

    Very interesting. I would feel more comfortable at night though if I knew Buffy the Vampire Slayer was around to stick a stake through their artificially beating hearts.

  4. Dorothy says:

    Thank you. You dealt with this potentially morbid topic in a tasteful way. Of course it could be a candidate for that wonderful man-book “why do men have nipples.”

  5. Rene' Veazey says:

    Thank you for this article. Dealing with father with lung/brain cancer has made this year rough. I had this question and you answered it in a great way. Thank you for that.

  6. DIANNE Masella says:

    My mother had a pacemaker on thurday they told us blood formed acid eatting tissue around pacemaker then mom got really sick passed away on sunday 9/2 at 4:08am what could of caused this unanswered ????????????????????????????????????????

  7. Anthony G. Gelbert says:

    Thank you for the informative article. As a pacemaker wearer, I was told electrochemical changes at death prevented the pacemaker from functioning (Medtronic Adapta DR dual chamber) but wasn’t told the specific fact about myocardial tissue’s inability to transmit an electrical signal in acidic pH.

    I would like to add just one thing. A deceased person who is going to be cremated must, by law, have the pacemaker harvested because the pacemaker explodes in the high heat. Anyone planning to be cremated should consider the added expense due to harvesting and find out the cost from a funeral home that does cremations. This will make the process easier for those you leave behind.

    Also, as to harvesting for recycling, the FDA does not have a problem with harvested pacemakers that are not going to patients in the USA. There is a worldwide demand, particularly in third world countries. The main issue is the elimination of pathogenic bacteria on the pacemaker surface. Various techniques ( I’m sure Jessica Soulliere can fill you in) exist to cleanse the devices.

  8. Shelley Ollivier says:

    In Canada, when a recipient of a pacemaker dies, the coroner, surgically removes the pacemaker at a cost to the deceased’s family of approximately $85CDN. It is then “refurbished” and reused. I think it is a delightful idea as it is a worthy instrument and should be used again. Also, it does emit a small amount of radiation. Who wants that in the ground? Of course these days more and more people desire cremation as an alternative, as the cost (if that is an issue) and quite often it is, can be far more reasonable. When it comes down to it, it is better to celebrate one’s memory of the deceased person rather than a somber good-bye.

  9. DDD says:

    Dr Degraaf,

    I am a resident physician working in a hospital and usually runs a code. If I were to encounter a patient who is coding and has a pacemaker on, will it be safe to say that the patient has a pulse if on telemetry monitoring we see a rhythm and a rate, say 120, or 60 ar any number above the set rate of the pacemaker? Does that mean it is safe to stop CPR? The reason for this question is there is usually a disagreement among staff between discontinuing CPR if a rhythm is already seen on cardiac monitoring. Some staff members think that because of the presence of a pacemaker, the monitor will always have a rhythm, but not necessarily mean a pulse.

  10. Kay blundell says:

    Reading your theory on Pacemakers on the end stages of life,very interesting ,
    I work in Age Care and over the years I have found residents that have Pacemakers seem to take longer in dying than others . these residents ,are not eating , drinking very little , there skin integrity is falling a part,skin going black ,Syringe Driver has been applied with Morphine been increased break through of Endone ,but still takes longer than most others. goes into weeks .ages are 80-90′s
    The question I would like to ask you, -How do you explain this ?.

  11. Dr. Eric Van De Graaff says:

    Kay,

    Thanks for the question. The pacemaker itself won’t prolong a person’s life longer than the other bodily systems allow. Electronically pacing a dying heart will have no effect.

    However, a person with a pacemaker often enjoys better health in the last days of life due to improved cardiac output and this effect may explain your observation that patients with pacers last longer. A better heart rate can improve a person’s level of activity as they age, thereby making them more immune to the decaying effects of advanced age.

Comment Guidelines