Dorthea

Dorthea is a 69-year-old woman who was well and active until about five years ago when she developed diabetes.  She was admitted to the hospital 18 months ago with recurrent fainting and was found to have an intermittent transient heart block.  She reluctantly consented to insertion of a permanent pacemaker. 

Three months ago her kidney function was found to be diminished to about 10% of normal, probably caused by her diabetes.  It was expected that she would soon require dialysis.  However, her kidney function has since improved so that dialysis will not likely be needed for some time.  She has since said she would refuse dialysis even if it were needed, and she has refused treatment of her profound anemia.  She did consent to a colonoscopy last month to see if she had cancer (malignant change was found in one small area, presumably cured).  She is now asking that her pacemaker be turned off so that she can die.

The ethics consultant met with the patient and two of her daughters.  Dorthea says she wants to die now because (a) she misses her husband who died three years ago after 45 years of marriage; they were very close, did everything together, and she says she can’t live without him; (b) she can’t stand to live in their home (memories), but refuses to move; and (c) she wants to “set her children free.”  She has resisted attempts by her three daughters who have encouraged treatment, including grief counseling, and have even offered for her to live with them.  She has guns in her home and knows how to use them, but she says she is unwilling to take her own life.  She is an inactive Methodist.  She says her only pleasure is having her children, grandchildren and great-grandchildren visit, but she feels her misery is also making them miserable.

The patient says she was told when the pacemaker was inserted that it could be shut off whenever she didn’t want it.  It is her impression that she will die quickly without it, however, her cardiologist expects this would not be the case.  Though she demonstrates no intrinsic rhythm when the rate of the pacer is turned down to 30 beats/minute on testing, most patients do develop some rhythm after several seconds of not beating at all.  Thus she might not die, but could suffer symptoms of congestive heart failure with an unknown outcome.  She says she is miserable, is not eating (though her weight is down only 5-10 pounds), and cannot care for herself or her home, but she doesn’t want treatment for her anemia or her grief.  When asked, she said she did not have the colonoscopy last month in order to protect her life.  The only reason she consented to the procedure was that she hoped it would show she had cancer that would end her life. 

Her daughters have run out of ideas for helping her, and are now supportive of her request.  They believe “she wants quality of life over quantity of life,” but they recognize that she is refusing treatment which could enhance her quality.  They realize she has not dealt with her grief, but are convinced that she never will.

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*http://cbhd.org/content/it-permissible-shut-pacemaker