Events

Join us for a monthly discussion at Johns Hopkins Hospital about an important clinical ethics issue

• Open to all those who have an interest in the intersection between ethics and medicine
• CME credits available
• Lunch provided!

Lunch will be provided, RSVP to Allison Christopher if you plan to attend

Case

E.W. is a 45 year old woman who was admitted to the trauma service after a suicide attempt at home. She was found by her 21-year-old daughter in the bathtub after cutting her wrists and neck. She required massive blood transfusion and emergent tracheostomy as part of the surgical repair of her neck injuries. She has been admitted to the surgical intensive care unit. After stabilization, she is conscious and able to communicate by writing on a pad. Her oxygen requirements are minimal and she is placed on tracheostomy collar.

A psychiatry consultation is obtained. Her husband moved out of the home one month ago to live with his girlfriend, and he legally separated from the patient. He told the patient he is in the process of filing for divorce. The patient started to drink after the break-up and stopped going to work. One week prior to admission, she was fired from her job. Psychiatry consultants learn that 2 weeks prior to admission, the patient had been seen in the emergency department after a fall down the stairs. The psychiatry consultant suspects this may have been a suicide attempt, although the patient does not acknowledge this. The psychiatrist diagnoses the patient with an adjustment disorder with depressed mood. There is no evidence of psychosis, and the consultant feels it is too early in the process of evaluation to diagnose the patient with major depression. The patient continues to express suicidal ideation. She is felt to be at high risk for suicide and has a 1:1 sitter in her room.

The patient develops a fever, and CT scan of her neck reveals an abscess. She is placed on intravenous antibiotics. The surgery team determines that the wound requires incision and drainage and possible revision of her tracheostomy. This will require that the patient be placed on mechanical ventilation in the peri-operative period. The patient is approached for consent of the surgery. After the risks and benefits are explained, she declines surgery and says she never wants to be on a ventilator. She says, “Just let me die. Life is no longer worth living, so just let me go.” She has no evidence of delirium. The surgery team and psychiatry consultant question her decision-making capacity, as the reason for her refusal of surgery seems to be a manifestation of her suicidality. Her daughter, who has been visiting her, is determined to be her legally authorized surrogate decision maker. Her daughter states, “Enough is enough. My mother has been through so much. If she wants to die, let her die. If she does not want surgery, I will not consent for it.”

Questions

1. Can a patient at high risk for suicide have decision-making capacity?
2. How does mental illness affect reasoning ability in determining whether a patient has decision-making capacity?
3. Can a surrogate decision maker refuse life-sustaining treatment for a patient who does not have a terminal illness, end-stage condition, or persistent vegetative state?

Learning objectives

1. Discuss the criteria for determining decision-making capacity
2. Describe the process for assessing a hospital patient’s risk of committing suicide
3. Review hospital policy on staff responsibility in caring for a patient at risk of committing suicide
4. Describe the role of a surrogate decision maker and the criteria they use to makes decisions on behalf of a patient