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The Case of Marion and the Pacemaker

Marion is a 92-year-old patient who weighs 78 pounds. She has had poor eating habits for at least 20 years and refused all attempts by her two daughters to improve her nutrition. In addition, Marion had been a heavy smoker all her life and suffered frequent respiratory problems. During the past two years she has become quite forgetful, has suffered a broken hip as a result of a fall out of bed, and has been treated for pneumonia. Her daughters, who have their own family responsibilities and cannot bring their mother to live with them, have found an excellent nursing home near them. In spite of Marion’s protests, she enters the nursing home. However, she quickly adjusts to her new home and likes the care and the attention that she receives.

During her third week in the nursing home, Marion develops a cough, high temperature, and respiratory problems. She is hospitalized with a diagnosis of pneumonia. Marion immediately becomes disoriented and attempts to remove her intravenous and oxygen tubing. Since she tried to climb out of bed, her daughters must remain at her side. The attending physician tells the daughters that in addition to treatment for pneumonia, Marion will also need to have a pacemaker inserted to regulate her heartbeat. Marion would then be unable to return to the nursing home since the facility is not equipped to care for someone recovering from surgery.

One of Marion’s daughters has been granted a medical power of attorney for her mother. Before Marion became confused, she clearly explained to her daughters her wishes not to receive extraordinary measures to prolong her life. She also signed a living will indicating her wishes. After thoughtful discussion with other family members, Marion’s daughters tell the physician that they do not want to put their confused mother through the surgical procedure. They state that they want to spare her the pain of recovery from a surgical procedure since she is quite confused and elderly. Further, they are concerned that their mother will not survive an anesthetic and a surgical procedure in her frail condition.

The physician seems to be understanding of this decision. He says that he will place their request in Marion’s chart not to have the pacemaker inserted. However, the floor nurses take the daughters aside on several occasions to tell them that this is not a dangerous procedure and that they need to sign a permit for surgery. In fact, the nurses make the daughters feel that they are not acting in their mother’s best interests by not signing the surgical permit. Marion returns to the nursing home without a pacemaker. She lives another four years without any cardiac problems.

Case Questions

- Were the nurses carrying out their responsibility as licensed healthcare professionals or were they overstepping their role?

- Were Marion’s daughters acting in the best interests of their mother since they knew that if she had the surgery she could not return to the nursing home where she was receiving good care?

- What should happen when a physician agrees with the family members and the nursing staff does not?

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