Virtual Ethics Committee Case Study: A Rational Suicide adapted from The Suicide Note by Joseph C. D Oronzio Cambrid

1. Virtual Ethics Committee Case Study: A Rational Suicide?(adapted from �The Suicide Note� by Joseph C. D�Oronzio Cambridge Quarterly of Healthcare Ethics, 2002)  Ronn Huff Ethics Consultant Group October 9, 2009

2. The Patient 2:30 PM �68-year-old man brought into a New York City ER by paramedics in response to a 911 call from his neighbor, who found him unconscious in his bed. The cause of his condition is not known, but the man is unresponsive and requires immediate life support, including intubation, IV fluids, and pressors.

3. An Advance Directive Son arrives, denies permission for LSMTx, States his father is in end-stage ALS and has a Living Will The copy of the directive he produces is ambiguous in this situation because it qualifies refusal of LSMTx for � irreversible conditions� and no one is sure if this situation is reversible.

4. Distant Proxy Daughter is Medical Power of Attorney, en route by car but 10 hours away Under these circumstances, the ED attending continues full treatment to determine the cause of the current crisis Son is extremely agitated; wants to know �if there is some kind of Dr. Kevorkian person around to help in this.� Disruptive, removed from ER

5. Consensus 12:30 AM Daughter arrives, reaffirms brother�s contention that patient would certainly have refused intubation Daughter enters into conversations with the healthcare team (includes ethics consultant and priest); mutual agreement to withdraw aggressive treatment and provide palliative care

6. A Second Directive? Minutes before extubation, brother reemerges with another document Suicide note he found in the printer tray of his father�s computer, dated the day before.

7. The Letter Letter apparently written over a period of weeks; describes decline of faculties Said goodbye to friends, ex-wife Give thanks to God for his good life and asks understanding from all concerned; reminds reader to honor directive Daughter recalls conversations in which father stated he would take his own life �if the time was right.� The daughter confirms its authenticity, including clear recollections of conversations she had with her father in which he expressed his intention to take his own life �if the time was right.� The daughter confirms its authenticity, including clear recollections of conversations she had with her father in which he expressed his intention to take his own life �if the time was right.�

8. Ethics Consult The hospital attorney is called by the risk management officer, and all further action is put on hold.

9. Terminal or Suicidal? The resolution reached destabilized by �suicide note� ED clinical team now views case as a botched suicide; treatment must be continued under these circumstances

10. More Information Patient was found in bed and unconscious by a housekeeper, who called 911 and notified the family On return to the apartment, son discovers empty pill in the bedside table drawer.

11. Resolution Hospital lawyer and risk manager feared legal ramifications of withdrawal since suicide intent was discovered Lawyer also felt that daughter (the legal proxy) and her brother were the only likely complainants, and both were supportive of patient�s wishes

12. Physician Misgivings Attending mistrusts son; questions motives Was suicide attempt due to clinical depression? Uncomfortable with attorney�s understanding; feels it might amount to assisted suicide Extensive ED-related literature about duty to treat suicide attempts

13. Resolution Risk manager advises transfer to hospice status Surprisingly, patient is successfully extubated and remains in the ER overnight Discharged to home hospice, dies the following day

14. Discussion questions Is there such a thing as a �rational� suicide, or do all suicide attempts presuppose a mental or emotional disorder? What are the clinical responsibilities in such a case?

15. Mike Meyer, Chair Santa Clara University Philosophy Department "Suicide at the end of life is so much more likely to be a reasonable choice for an individual than suicide at any other point in life�(W)e ought to think of it as voluntary euthanasia so that the fair-minded social stigma at other times of life might be diminished or in the best cases simply eliminated�Suicide at the end of life might well be connected to a person's sense of her dignity, while suicide at other times is altogether less likely to be a genuine issue of dignity."

16. Paternalism vs. Autonomy in the Emergency Department �When we confront a suicide attempt without any specific information about the circumstances that lead to it, we intervene without misgivings; only a wealth of detailed information about the case can persuade us not to act. And sketchy accounts of those circumstances cannot suffice, we know how fallible we are about understanding sources of motivation for drastic action. That realization, combined with our respect for the value of life, produces a strong disposition to intervene.�

17. On the Other Hand� �A�reflective (clinician) might say, �This man�s life cannot be saved by us or anyone else. He will soon die as a result of his underlying disease. All we can do is prevent his dying from the wound he inflicted on himself today�But he does not want us to do that, and I can well understand why he does not. Whatever we do, his life is essentially ending, and it is not up to us to impose on that ending a shape that we might prefer to the one he has chosen.� -Samuel Gorovitz, Ethics in Emergency Medicine

18. Reflections Were the ethical issues in this case deliberated in an appropriate and effective manner? Did the hospital make the right decisions in this case? Why or why not?

19. Bibliography �The Suicide Note� Joseph C. D�Oronzio. Cambridge Quarterly of Healthcare Ethics (2002), 11, 422�431 Attitudes of patients with amyotrophic lateral sclerosis and their care givers toward assisted suicide. N Engl J Med. 1998 Oct 1;339(14):987-9. Amyotrophic lateral sclerosis and physician assisted suicide. 1: Am J Hosp Palliat Care. 2006 Aug-Sep;23(4):332-7. Ethics in Emergency Medicine, Second Edition. Kenneth V. Iserson et al. Galen Press, Ltd. Tucson, AZ. 1986, 1995: 65-72. The contribution of demoralization to end-of-life decision-making. David W. Kissane. The Hastings Center Report; 7/1/2004. �Does Old Age Make Suicide Ethical?� Rob Elder. http://www.scu.edu/ethics/publications/ethicalperspectives/elder0302.html

20. Where do we go from here?