Clinical Ethics in the ICU: A Case of Attempted Suicide

Abstract

Vignette: A 57-year-old man was brought into the emergency department by paramedics for altered mental status. He was noted to be in his usual state of health the morning of the event when he became confused, vomited, and was observed to fall on the floor without trauma to the head. His baseline health was notable for diabetes mellitus, schizoaffective disorder, history of one prior hospitalization in 2009 for lithium toxicity, hyperlipidemia, and genital herpes. The patient’s wife, at bedside, denied that he used tobacco, alcohol, or street drugs. Living with him in the community, his wife indicated that the patient had a progressive brain disease and possibly early dementia, but she denied any impairment of activities of daily living.

The spouse brought to the hospital a signed living will requesting no extraordinary measures in case of a coma with little hope of recovery. His “living will” also specified that he would refuse mechanical ventilation or tube feeding even for reversible conditions. The patient was found to have severe acidosis, multiorgan dysfunction, transaminases elevated to the 6000 U/L level, and an acetaminophen level of 465 mg/L. Shortly after routine therapy was initiated, a signed note was brought in from the patient’s home stating the following: “I am doing this before my brain disease overtakes me.”

Clinical ethics is urgently consulted about whether to proceed with emergent dialysis, mechanical ventilation, and evaluation for liver transplantation. We present 3 perspectives on whether to treat and how to proceed in the setting of a potential suicide attempt with an advance directive limiting care options.