A Pacemaker Dilemma

“Oh, boy,” the electrophysiologist remarks in the dictation room. Eighty-six years old. SA node dysfunction, post-AV node ablation. Dual-chamber pacemaker. RA lead placed in coronary sinus in 2016. EF 25 percent. As a fourth-year medical student reaching the end of my second-to-last semester of medical school, I know an ejection fraction of 25 percent is not good. “Well, we will just need to see how she’s doing and go from there,” the doctor remarks. I grab my stethoscope and prepare to find a patient who appears fatigued, short of breath, and overall run down. Is she on GDMT for HFrEF? We knock and enter.

Instead, I find a perky, older woman in a red sweater with a cable behind her neck; the cable is attached to an O-shaped interrogator resting over her shoulder like a scarf. She has a warm smile and says hello. Several centimeters beneath the interrogator, after bypassing wool and skin, sits a generator reaching the end of its life. After setting the agenda for the visit, the doctor proceeds to get information from the tech about the parameters of the pacemaker and then asks the standard questions to elicit any heart failure symptoms that would likely correspond to such a low ejection fraction. She says “no” to the long list of symptoms, and “life is good.”

My eyes wander from the somewhat outdated-appearing machine with its screen depicting graphs and electrical waveforms back to the patient. The O-shaped interrogator caught my eye when we first entered the room; now, it’s her eyes that catch mine. She has kind blue eyes that are surrounded by wrinkles, a sign of a life well lived. She lives independently in a single-family home with a laundry room in the basement. She reassures us that she has had two handrails installed. She runs a bed-and-breakfast inn but feels it might be time to let that go. Her joints slow her down more than her heart, she reports. She is not a candidate for any joint replacements due to her soft bones.

The doctor begins discussing options to add an additional lead during the procedure to replace the pacemaker battery in six months, as that would help her heart pump more efficiently. After describing a venogram and why it would help to plan for the revision procedure, she quietly says, “What if I decide to let the battery die?” The mood in the room plummets. “Tell me more about that,” inquires the doctor after a pregnant pause. The patient wonders whether her heart would simply stop once the battery runs out. Upon reading our faces, she quickly assures us that she enjoys living, but she has no desire to end up in a nursing home without her independence, unable to do the things she enjoys. She is doing well now, but the average pacemaker battery can last up to 10 years — where will she be in half that time? A few more pauses. She wipes her eyes and says, “I just don’t want to be a burden.”

Not changing the battery wasn’t a branch in the algorithm. In this scenario, medicine indignantly asks: Why in the world would someone not want their battery changed? The better question, however, might be: Why would someone want it replaced? A pacemaker sends electric signals to help the heart pump, but what is the pumping for, if not for relieving burdensome symptoms and enabling patients to live the lives they desire? But doing less when there is a safe, effective way to do more is a dilemma that medicine often faces. A dilemma I will face as a future family medicine doctor. We find out that she discussed this with her family prior to the appointment; they would like her to get the battery replaced, but they will support and respect her decision if that is not what she wishes. It’s a big decision, a heavy decision. And one that needn’t be made entirely today.

I see her at the check-out counter on my way to the parking garage. “Take care,” I say. She smiles back. I feel tears welling up in my eyes as I descend the stairs in the parking garage to reach my car. The heaviness of the conversation makes me sad, especially after I recall her remarking that her family is gathering at her home to celebrate Christmas next week. Possibly her last Christmas. Although I’ve only known this woman for 30 minutes, the act of her sharing her hesitation about replacing the battery was profound and reminds me of the immense vulnerability and trust that patients share with us as their doctors, and this is not something that should be taken for granted. Throughout medical school, I have met hundreds of patients, a dozen of whom — much like this patient — have stories with endings unbeknownst to me, which is difficult. Whatever her decision will be, I hope it will be hers and hers alone and that she will come to peace with it.

About the Author

Aynsley Hartney, MD ’25, wrote this essay before she earned her medical degree from the University of Wisconsin School of Medicine and Public Health (SMPH). She has begun a family medicine internship and residency in Colorado.

Originally from Memphis, Tennessee, Hartney chose SMPH due to its emphasis on community and public health. She appreciated the way the school supports and values primary care. She also enjoyed the school’s statewide campus model, through which she had rotations around Wisconsin.

Hartney completed six months of her clerkship year in Marshfield, Wausau, and Weston, Wisconsin.

“I am grateful to my mentor, Dr. Elizabeth Fleming. She was a huge support and advocate for me during my time in Madison, and she is a huge reason why I began to write during medical school and continue to do so,” says Hartney.

For example, during medical school, Hartney participated in the Medical Writing Interest Group, for which she served as editor in chief for a year. She also participated in the Healer’s Art course as a first-year medical student and again as a co-facilitator the following year. She notes, “This was a fantastic course that looks at the important humanistic components of medicine and the importance of mystery, awe, grief, and uncertainty.”

Hartney coordinated and served as emcee of the Alpha Omega Alpha’s annual Night of Storytelling for students, residents, and faculty members. She also led a workshop that discussed narrative medicine strategies at the Family Medicine Midwest Conference in 2024 and helped plan the inaugural Midwest Physician Writers Retreat.

“Narrative medicine was a huge thread during my time in medical school,” exclaims Hartney.

She says, when not in a library or a clinic, she enjoyed two summers of gardening in the Eagle Heights community garden. She also took in many Wisconsin traditions: spending evenings on the Memorial Union Terrace, bicycling around Lake Monona, and visiting Door County in the fall.

“Madison will always have a special place in my heart,” concludes Hartney.