Editor’s Note: The following consultation report is based on a real clinical dilemma that led to a request for an ethics consultation. Some details have been changed to preserve patient privacy. The goal of this column is to address ethical dilemmas faced by patients, families and healthcare professionals, offering careful analysis and recommendations that are consistent with biblical standards. The format and length are intended to simulate an actual consultation report that might appear in a clinical record and are not intended to be an exhaustive discussion of the issues raised.

Column editor: Robert D. Orr, M.D., C.M., Consultant in Clinical Ethics, CBHD.

Question

Is it ethically permissible to stop this man’s ventilator at his request?

Case

This 76 year old retired minister had an acute myocardial infarction (heart attack) 18 months ago and transient vertebro-basilar insufficiency (interruption of circulation to the base of the brain causing temporary loss of function) 1 year ago. These neurological symptoms cleared quickly and he did well for 10 months.

He was admitted to this hospital 2 months ago with unstable angina, and 1 week after admission he had a 3-vessel coronary artery by-pass grafting. His post-operative course has been complicated by quadriplegia (complete paralysis of all 4 extremities), recurrent sepsis caused by different organisms, acute kidney failure (now resolved) and Adult Respiratory Distress Syndrome (ARDS). He is now medically unstable (continuing infection; requires medication to sustain low blood pressure) and is ventilator-dependent. The latter is not from the ARDS but from lack of respiratory drive, indicating that his central nervous system dysfunction has also affected his ability to breathe.

Repeated neurology consultation reports have been increasingly pessimistic about neural recovery of respiratory drive. They describe him as nearly in a “locked in” state with intact cognition, full use of cranial nerves, but minimal motor function below the C-2 level of his spinal cord. Cranial CT scanning has shown no brain infarction. It is the neurologist’s impression that this represents a high cervical spinal cord lesion, most likely from an intra-operative infarction of the spinal cord, with a dismal prognosis for recovery. This was confirmed by a CT of the spinal cord today. The ICU care-team and the neurologist believe the patient has clear understanding and decision-making capacity.

Treatment plans are being discussed. The patient has been evaluated by the Home Mechanical Ventilation team and is not a candidate because of his medical instability. He has now indicated to the ICU team that he would like to stop aggressive life-support with the expectation that he will die, and they have requested an ethics consultation.

When seen by the ethics consultant, the patient was awake, responsive and able to say a few words with his tracheostomy cuff deflated. In the presence of his wife and one son, he admitted he is discouraged, but not in pain or respiratory distress. If his cardiovascular and infection status could have been stabilized, he would have considered home mechanical ventilation, but he is now resigned to the fact that this is not possible.

Assessment

This is an allegedly competent 76 year old man whose life is being sustained in the ICU by aggressive medical measures. He has expressed a desire to have those measures discontinued so that he might be allowed to die.

Discussion

In almost all circumstances, the health care team should pursue the treatment goals of the competent patient if he is aware of his condition, prognosis and treatment options. There is no moral obligation for a patient to continue life that is dependent on technology when the burdens to the patient outweigh the benefits to the patient. There is no moral or legal difference between withholding and withdrawing any treatment. Prior to stopping any life-sustaining treatment at the patient’s request, every effort should be made to ensure that all measures have been taken to address the burdens that the patient finds unacceptable.

This patient anticipated a routine operation with relatively small risk. Seven weeks later, he is quadriplegic and ventilator dependent from a spinal cord lesion with a very poor prognosis for improvement. He has had, and likely will continue to have, additional life-threatening complications. By any definition, this gentleman is receiving extraordinary care. He would consider going home on a ventilator if his condition were stable, but now recognizes that this is extremely unlikely to be possible. I would raise 3 questions:

1. Is he suffering from treatable depression, and if so, is this sufficient reason to not follow his explicit request? He admits to being discouraged, but his caregivers do not consider him depressed. One must freely grant that he is in a depressing situation. Acknowledging discouragement should not be equated with a clinical diagnosis of depression. It does not appear that he is depressed to the extent that depression is pushing him to make an unwise decision.
2. Does his situation indicate that meaningful life is over? No, it does not. There are many patients in situations of similar physical incapacity who continue to live meaningful lives with a focus on serving others.
3. Is it morally wrong to discontinue the ventilator with the expectation that he will die? We understand that the patient is a Christian, a retired minister in fact. From a Christian worldview, death is held in tension between being seen as an enemy and in Christ a defeated enemy. This patient has undergone aggressive medical therapy to fight off the enemy of death. Now that he realistically sees the end of life approaching, he is willing to affirm his faith and accept death. It is understandable and appropriate that he desires his death to be an answer to the call of God and not as the defeat of all possible medical technologies.

Recommendations

1. If it is clinically feasible for this patient to leave the ICU, he should be offered a trial of care in a facility equipped to handle long-term ventilator patients. It would be appropriate to encourage him to embark on a new career of Christian service by praying for and encouraging others.
2. If this is not feasible or if he chooses not to do this, his request for discontinuation of the ventilator support should be honored. He should not be criticized for this. I would encourage him to summon the elders of his church to pray over him; he should be offered time with his loved ones and family; he should be given therapeutic doses of medication to relieve any distress that may be anticipated; the ventilator should be disconnected; and he should be monitored closely and given additional medication if needed.

Follow-up (editor)

Because of continued sepsis and low blood pressure, he was considered not sufficiently stable for transfer to a long-term ventilator facility. He chose not to continue aggressive treatment for these unstable conditions.

Four days after the ethics consultation, with his family and pastor present, he was given pre-medication with morphine and a sedative, and his ventilator was discontinued. He appeared to be comfortable with minimal additional medication, and he died in about 2 hours.

This case study, used by permission, originally appeared in Ethics & Medicine: An International Journal of Bioethics Volume 23 Issue 1, Spring 2007.