UNTIL PACEMAKER DO US PART

Millie was an 83-year-old with a history of dementia, arrhythmia, and a pacemaker. She was a resident in the nursing home in the wandering dementia unit. She was there because she was found in the parking lot on several occasions when she was a resident on the non-locked down unit. She was married to Darrell who still lived at home. He visited her for every meal and seemed to be a loving husband during his wife’s failing health. This history was only scratching the surface.

Millie had her pacemaker surgery almost ten years ago due to bradycardia. The decision to have the pacemaker inserted was between Millie and Darrell. This was before she had the signs and symptoms of dementia. It was determined the pacemaker would give her a better quality of life because she had increased fatigue, syncope, and falls. The average life of a pacemaker depended on how much demand was used by the battery. The average life of the pacemaker battery was almost ten years. Those with a pacemaker are checked regularly by a magnet which gives the read-out of how much the pacemaker fired, the estimated life of the battery, and voltage. The machines used to get these readings depended on the manufacturer of the pacemaker. Most patients with a pacemaker visit their cardiologists at least every 6 months, sometimes more or less depending on the age of the pacemaker. It was crucial to determine the end-of-life of the pacemaker battery and to schedule another surgery. Millie had seen her cardiologist for a pacemaker check 17 months before which determined at that time she had an estimated battery life of 19 months. This was concerning to myself although Darrell did not think it was something his wife wanted. He was the power of attorney (POA) who made her medical decisions. I found out by staff Darrell was having an affair for almost three years with the daughter of one of the residents who had recently passed away. I wondered what his motivation was to not get Millie’s pacemaker replaced. Although her dementia was progressing she still could understand what was going on and could make some of her medical decisions although could not remember them. When Millie was asked if she wanted to have her pacemaker battery replaced she replied yes. Darrell on the other hand was militant about not putting his wife through another surgery. Is this withholding wanted medical treatment? What is his motivation? Was it to make his wife more comfortable or to move on with his life? We did not know. A cardiology appointment was made for a pacemaker check and to possibly discuss battery replacement.

One week before the cardiology appointment Darrell canceled. He once again stated Millie would not want the surgery because she had told him she did not want to go through another procedure. Darrell was listed as the only POA and no family was listed in the chart. He continued to visit his wife for every meal. The pacemaker was discussed on numerous occasions and he determined his wife would not want to go through another surgery.

Millie will continue to live in the wandering dementia unit until her pacemaker stops. She probably will once again have increased fatigue and syncope due to a low heart rate.  She is a DNR. I am not sure if putting an 83-year-old dementia patient through surgery would be beneficial. It may give her another ten years but would that be quality life? As the provider I have to give the options as well as risk/benefits. I am although concerned with the husband’s motivation. Is this in favor of his wife’s well-being; or is there another motivation? I will never know.