Pacemaker Implantation in a Severely Anoxic Brain-Damaged Patient: Medical, Ethical and Religious Considerations

Background: Advances in technology affect the practical, ethical, and religious aspects of medical care. There is scarce ethical discussion about cardiac pacemaker (PM) implantation in patients with severely-impaired consciousness, especially when the etiology is anoxic.

Case: A 70-year-old man collapsed in the street and was resuscitated with return of spontaneous circulation. Initial ECG showed complete AV block (CAVB). Urgent catheterization resulted in no intervention. CAVB resolved after temporary pacing and hypothermic therapy was applied. He never regained consciousness and was transferred to a long-term ventilation ward. Approximately 1 year later, he again developed CAVB and was transferred back to the original treating hospital. The dilemma of whether to implant a permanent PM arose; however, he regained a normal sinus rhythm. 4 months later AV block reappeared and persisted. After consideration by the Hospital Ethics Committee, a permanent PM was implanted.

Discussion: A PM can greatly sustain\extend life. However, in an unconscious patient on long-term ventilation this may prolong suffering for the patient, prolong the family’s emotional suffering, and place a substantial economic burden on the family and health system. Nevertheless, according to many religious beliefs, life has infinite value and cannot be truncated arbitrarily due to financial or emotional reasons, even if lifesaving interventions seem “futile”. According to Israeli law, once a PM is inserted, it cannot be deactivated, especially if the patient is dependent on it.

Conclusions: In patients with prolonged impairment of consciousness, the ability to sustain life with PM insertion must be weighed against the relative costs and benefits of the intervention, taking into consideration medical, ethical, and legal issues.