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Interview l Providing for the future in good time – being able to die despite a pacemaker
"Honestly and empathetically you can talk about death surprisingly well", says internist and head of palliative medicine at Vivantes Klinikum Friedrichshain, Dr. Matthias Gockel. He deals with people every day who have to decide at the end of life which medical treatment they still want and which they don’t want. A pacemaker with defibrillator function (ICD) could trigger a shock in the dying process and thus prevent a peaceful death. If you don’t want that, you should take precautions in good time.
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Is the topic "pacemakers at the end of life"? a topic you often encounter?
Most of the patients we care for are oncological patients. The topic of pacemakers, or implantable defibrillators, plays only a marginal role in this context. But this is different in facilities where more patients with cardiac problems are cared for. I personally have seen relatively few people bring this up on their own, maybe a handful. It’s more like we actively address this with patients in the last phase of life when we know the person has such an ICD pacemaker. Or we look in the records to see if this is someone for whom this is relevant.
The interviewer
vivantes.de – Dr. Matthias Gockel
Internist and Head of Palliative Medicine at Vivantes Klinikum im Friedrichshain
Landsberger Allee 49
10249 Berlin Friedrichshain
Where do you see your task as a palliative care physician in this process??
The main experience is that you have such a break to the previous experience. These are devices, which were mostly worn for years by the people concerned, which gave life because they prevented a fatal cardiac arrhythmia.
When people are seriously ill or dying, it’s a matter of reversing the perspective. And that is in the direction that when it comes to dying, this device can also be a potential source of additional stress. In some cases, you have to help people cognitively and, above all, emotionally to make this change.
How do patients react to this information??
What makes it easy for me as a palliative care physician is that, yes, a defibrillator pacemaker is supposed to prevent a fatal cardiac arrhythmia. That is, if a fatal cardiac arrhythmia occurs without such a pacemaker, those affected usually lose consciousness within a few seconds and die without ever regaining consciousness.
That is actually what the vast majority of people want for their death: no suffering, no shortness of breath, I am suddenly simply gone. From there I try this association: if we turn off the device, you have with your severe cardiopulmonary disease a much higher chance to experience this actually desired death. With it one can make clear to humans then also: Man is right, this is exactly what I want. And if I can’t prevent death, then I can at least make sure that it is gentle.
But you also have to remain open to results, or?
That is anyway with each palliativmedizinischen consultation the point: It must be result-openly. I can explain to the patient what to expect with this disease and what our options are. But the decision of how much chance of more life in relation to what risks of treatment I am personally willing to take, that decision can only be made by each person for themselves. And then it is also my task to accept this decision. And if someone says I’ll risk the extra burden, I’ll risk suffering for the chance to maybe have a few more months, then of course I accept that.
Info on the net
guidelines.dgk.org – Statement of the German Society of Cardiology and its sister societies
heart foundation.en – German Heart Foundation
bmjv.de – Information from the Federal Ministry of Justice and Consumer Protection on the subject of living wills
hospiz-aktuell.de – Information from the Central Hospice Contact Point in the Unionhilfswerk
What advice do you give to people who want to decide and specify in good time which medical measures they want at the end of life and which they do not want??
I can only advise everyone to seek advice on this point in good time, either through their own GP or. Cardiologists or through an independent patient counseling service, whose staff are trained in these issues. This should then be put into a form, i.e. a living will.
It is also important to have a power of attorney that specifies who should make decisions for me if I am no longer able to do so. If I do this at such an early stage, I can see how close the subject is to me, how well I can talk about it with family or friends, and who is also prepared to take on the responsibility of a health care proxy.
What often happens in the hospital: it’s Saturday morning, four o’clock, a patient is brought to the emergency room by the ambulance service – which is the worst possible time to talk calmly about what is actually important to me in life and how I think about dying.
If the patient is no longer able to make decisions for himself and there is no living will or health care proxy, there is often no choice but to go to the guardianship court and initiate urgent care, which is a major administrative burden. Apart from the fact that the personal will of the seriously ill person is much more difficult to take into account in the process.
More on the topic
Emergency disposition – Provisions for the case of emergency: How the COVID-19 treatment can be regulated
Pictures of COVID-19 patients in intensive care units raise questions: How do I want to be treated acutely in such a case? Do I want artificial respiration? With a living will can be regulated. Recently supplemented in an abbreviated form, the "emergency directive. What can be arranged with it and where one finds consultation, has the rbb practice with Dirk Mueller, director of the special consulting center "central approach place hospice", discussed.
Service to the radio report – Precaution and emergency planning
Did you listen to the radio report "Emergency order regulates treatment for Covid 19 disease"? heard and search further links? Information on the net, service numbers and a sample download of the "Medical Emergency Plan" can be found here.
rbb Praxis Scanner l Being able to die where you are at home – palliative care in Brandenburg
Many people wish to spend the last part of their lives at home, even if they have a serious, incurable illness. This is possible with the help of Specialized Ambulatory Palliative Care (SAPV). There are now ten bases in the state of Brandenburg that organize and coordinate medical treatment and care. We have put you together in a map.
Accommodation and financing – Series: The case of care – Palliative care
When life is coming to an end, it is even more important to spend the remaining days and weeks in good care and pleasant surroundings. But where to get the best palliative care? What options are there? And who pays for it? The rbb practice gives an overview.
As a wearer of an ICD, can I be sure that I will not be constantly resuscitated against my will?? Say that I have the right to have it switched off if I want to?
In principle, every treatment – both the initiation of treatment and the continuation of treatment – requires the patient’s consent. That is, it is not only that I have a right to have my ICD pacemaker issued, but that actually no one has the right to continue to operate it against my will; unless they set out to commit bodily harm.
Of course, it is always necessary to discuss in concrete terms what this means, where do you stand in your life story, in your curriculum vitae?? What are the positive and negative side effects when we leave it on or when we turn it off?? Therefore, the consultation with the medical knowledge is a very important part.
Is the will of the patients also implemented by the doctors??
Experience shows that it is always easier at the moment when a clear decision has been made. It is difficult if I have no information, do not know whether the affected person now life time over quality of life or vice versa puts. Therefore, I also think that with living wills, this consultation is important to say again and again, what are your values, what is more important to you, time or quality of life? And, is it okay for you to die tomorrow??
And then it is also important to find a specialist, i.e. a cardiologist, who will implement this will. Of course, in medicine, as in the rest of life, there are people who find it easy to talk about death, to think about their own death as well. And there are people who find this difficult – doctors are no different than other people. There are and the art is to look for the right contact person in time.
How does the switching off of the ICD pacemaker happen concretely?
In an acute emergency, the ICD pacemaker can easily be switched off from the outside with a magnet. This magnet is placed on the chest where the ICD was implanted. This does not necessarily have to be done by a cardiologist. With this measure, the defibrillator function is deactivated as long as the magnet is there, but the pure pacemaker function is retained.
Or, the device is reprogrammed and the defibrillator function is turned off when the patient is at the cardiologist’s office for a routine check-up. Since the devices can be read externally, they can also be reprogrammed in this way.
What would you like to see in the handling of the issue?
We should live in a society in which it is completely natural that everyone takes note of the fact that they only live for a certain amount of time. And that he can talk to everyone else about the fact that he is finite and what his wishes, fears and worries are for his death. I assume that in 50 or 100 years we will have the same thing. Until then, we just have to live with the world as it is.
Mr. Dr. Gockel, thank you very much for the interview!
The interview was conducted by Ursula Stamm