Complete Heart Block in a Patient Declining Pacemaker Implantation: A Discussion on Patient-Centered Care and Shared Decision-Making

Abstract

Permanent pacemaker (PPM) implantation is the standard of care in patients with complete heart block (CHB) and second-degree type II atrioventricular (AV) block irrespective of patient symptoms when the conduction abnormality is irreversible. CHB generally constitutes a medical emergency that can be fatal if not urgently treated. This is in contrast to first-degree AV block and second-degree type I AV block, which require PPM implantation only in very special circumstances. While second-degree type II AV block is considered to be at high risk for progression to CHB, this does not occur with first-degree and second-degree type I AV blocks. Here, we present a patient who demonstrated over a number of years a progression from first-degree to second-degree type I AV block and then, quite unexpectedly, to CHB. Despite multiple discussions of the benefits of PPM implantation with cardiology staff, the patient elected to forgo the procedure. This case discusses patient-centered care and the therapeutic dilemma that can develop when there is an incongruence between the principles of beneficence and patient autonomy.

Keywords: av node; complete heart block; decision-making autonomy; first-degree heart block; goals of care; pacemaker; patient-centered care; second-degree heart block.