Heart Health

What to Expect When Living With a Pacemaker

January 18, 2019

What to Expect When Living With a Pacemaker

Here’s a morbid thought: Walk through the part of a cemetery housing newcomers and take a look at the grounds where the recently deceased were buried. 

There are half a dozen pacemakers quietly toiling away under your feet, 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 function like the faithful dog standing at the doorstep of a deceased owner who will never return, without the slightest indication that their efforts will never again lead to the pulsating blood of a living body. This concept seems straight out of a horror movie with lifeless zombies being driven through the night by the incessant bustle of their artificial pacemakers.

Will pacemakers be switched off when a patient dies?

The reality is not quite as morbid and much less exciting, despite the accuracy of the premise. We do not turn off pacemakers when patients die, nor do we remove them. Because people with pacemakers are repeatedly implanted with new batteries when the old one gives out, they are inevitably outlived by their pacemakers.

Just last week, I had a conversation with a relatively healthy patient who is a candidate for a pacemaker. He and his wife were full of questions after coming to the appointment prepared with extensive information from the Internet. One question concerned the man’s ability to actually die as soon as 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 who have raised this issue and probably even more who wondered about it without having 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 non-functioning human being.

What’s the point of a pacemaker? 

The purpose of a pacemaker is simple: it prevents your heartbeat from becoming too slow. Connected to the heart via wires called leads, the device spends its life searching for natural impulses emanating from the heart muscle. If your natural pulse drops below 60, or whatever our programmed number is, the pacemaker begins to stimulate the heart with an imperceptible electric shock once a second. 

The current flows through the tip of the lead into the adjacent heart muscle and then spreads throughout the ventricle, moving from cell to cell at lightning speed. The stimulus triggers a short restructuring of the proteins and leads to a contraction of the muscle fibers. Within a fraction of a second, the entire ventricle expresses about one hundred milliliters of blood into the aorta.

To summarize this series of events:

Step 1. Pacer sends electricity to the 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.

 

What happens to the heart when you die?

Now let’s talk about what happens to the heart at the moment of imminent doom. One thing a healthy body is really good at is eliminating waste products (and, no, I am not complimenting you on your bathroom talents): the lungs eliminate carbon dioxide and the kidneys and liver break down and eliminate unwanted metabolic byproducts. 

As these organs deteriorate, your blood becomes saturated with metabolic debris and becomes an inhospitable environment for normal cell functions. In particular, the pH of the blood drops and the normally neutral serum slowly turns into a weak acid. Once the pH drops by more than a fraction of a point, the heart muscle is no longer able to propagate an electrical stimulus or create an effective ventricular contraction.

In other words, no amount of external electricity will cause a contraction as soon as the heart muscle becomes electrically sluggish and mechanically dormant. Step 1 in the cascade described above does not matter if steps 2 and 3 fail. Therefore, we do not switch off pacemakers in dying patients – it simply makes no difference.

This, of course, does not stop people from asking us to decommission implanted devices. Occasionally, a doctor or family member will demand that we turn off a pacemaker in a dying patient and in the final stages of palliative care. Why not also remove pacemakers, when other life-saving services such as antibiotics, infusions and artificial ventilation are being scaled back?

Pacemakers can improve quality of life

I would like to clarify another concept: the purpose of a pacemaker for most people is to improve quality of life by increasing mobility, preventing fainting, and providing more energy. Indeed, it is somewhat unlikely 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 improvement rather than a life-and-death therapy. I do not have exact figures on how many patients would simply die if their pacemakers were switched off today, but I would put them at no more than 20% of patients.

Switching off a functioning pacemaker in a terminally ill patient would most likely not result in their rapid death. In a patient who dies but is not yet on his deathbed, such an intervention would most likely lead to a dramatic deterioration in the quality of life without speeding up the end of life, with the patient suffering even more exhaustion and periodic falls or unconsciousness.

Pacemakers in the terminally ill

Handling pacemakers in the terminally ill population is by no means straightforward and is often discussed in the medical literature. In the US, there is no law against switching off a pacemaker in dying patients (such laws exist in some countries), and the consensus among experts is that artificial pacemaking is nothing more than artificial ventilation and can be removed with the consent of the patient, family and caregivers. However, the simple fact remains that such a decision makes little difference to the final outcome of the patient for most patients and can cause undesirable results before death.

This issue is very different from that of the implantable cardioverter defibrillators in this patient group. This device differs from a pacemaker in its ability to deliver a shocking shock to the heart in the event of cardiac arrest. In a patient dying of other causes, it would be a blessing rather than a curse to die suddenly and without sudden arrhythmias. We routinely offer to deprogram the shock function of the ICD for patients like these, allowing them to die without the intrusion of a 35-joule kick into the chest.

Will a pacemaker keep someone alive after they die?

In short, 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 leave this earthly existence. There will be no cemetery escapees or zombies roaming the streets at night in search of edible brain tissue. 

Your pacemaker will be a reliable, useful companion for you until your body decides it is no longer needed. After that, your pacemaker will be no more alive than the fillings in your teeth or the artificial joint in your knee, slowly and quietly draining its battery while you move on to better things.

CHI Health Heart Institute’s Cardiologists can talk with you about heart care for you or a loved one.

Original post date: April, 2011. Revised: January, 2019.

11 Comments
  1. Dr. Eric Van De Graaff

    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.

  2. Kay blundell

    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 ?.

  3. DDD

    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.

  4. Shelley Ollivier

    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.

  5. Anthony G. Gelbert

    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.

  6. DIANNE Masella

    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 4:08 a.m. what could of caused this unanswered ????????????????????????????????????????

  7. Rene' Veazey

    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.

  8. Eric Van De Graaff MD

    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

  9. Dorothy

    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."

  10. Jena

    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.

  11. Jessica Soulliere

    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!

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