Monday, September 29, 2008
The Journal of Medical Ethics has a case discussion provocatively titled 'suicide by advance directive.' The case involves a woman who tried to commit suicide by an insulin overdose who was ventilator dependent and in a coma (who had a poor, but uncertain, prognosis of neurologic recovery) who had an advance directive saying that she would not want to be on a vent if her prognosis was poor etc. In fact, she lay her advance directive next to her when she tried to kill herself, and it was obviously ignored by EMS/the emergency department as would be the standard of care with any suicide attempt.
The report analyzes the decision making that occurred, eventually leading to withdrawal of life-prolonging treatments including the ventilator and the patient's death. It's clear to me from the discussion however that it's not fair to label this a 'suicide by AD.' A long, careful decision-making process occurred with the patient's loving family, her doctors, and an ethics team which clarified that the patient would not want to be maintained in such a state under any circumstances. The AD was one piece of 'supporting evidence' for the patient's wishes/values, but it was not applied blindly and without great reservation and careful deliberation. Not intubating the patient in the first place because she had an AD next to her or a DNR bracelet on her may reasonably constitute a 'suicide assisted by an AD' but not this case.