The Case of Joe

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The Case of Joe: Ethical End of Life Decisions

“Give me something. I want to die.”

“Joe” is a 62-year-old building contractor who has been in an ICU for the past 10 weeks. He had gone to his community hospital for bypass surgery (CABG) and aortic valve repair (AVR), and things didn’t go well post-op. His sternal wound became infected with Methicillin-resistant Staphylococcus Aureus (MRSA). Sepsis led to acute hypoxic respiratory failure, a tracheotomy, profound hearing loss, and then acute renal failure ameliorated somewhat by hemodialysis.

The complexity and severity of Joe’s post-operative condition has resulted in transfer to our larger tertiary facility for the past 6 weeks. He now has been weaned off the vent to a few hours of room air, but the care team is not as optimistic as Joe’s family remains. Per chart notes, he is not improving sufficiently to warrant hope for recovery. The best that can be hoped for now, says his critical care physician, is discharge to a long-term acute care hospital (L-TACH). The prognosis does not include any likelihood of return to baseline, or to home. The situation is dire, and Joe seems to “get it.”

On the Saturday of Joe’s tenth week in ICU, he mouths a message to his nurse, and then to the physician who is summoned, and then to an ethics consultant also. “Stop everything. Give me something. I want to die.”

Joe repeats his request with family at the bedside. In later conversation with the ethics consultant, they express frustration with Joe for wanting to “quit.” “That’s not Joe. He’s stubborn. Never quits. He’s been through worse than this, and then went back to work. He must be depressed or not thinking clearly now.”

Is he depressed and not thinking clearly? Psychiatry is consulted to assess Joe’s decisional capacity. He has been informed already that, “We can’t give you something to die. That’s not legal, not in this state.” Although that answer seems to frustrate Joe, he continues to ask that “everything stop.”

No more aggressive treatment. Stop the antibiotics. No more vent. “I want to die.” Joe is deemed to have decisional capacity, per Psych. Ethics thinks so too. The wife, a sister, and two adult children–one of them a nurse in our facility–claim otherwise. “You don’t know Joe. This isn’t him. He isn’t thinking clearly. He’s actually getting better. He can breathe off the vent. His color is much better compared to a week ago. Can you at least not pull the plug for a few days, maybe a week, to give this a chance?” What now should be done for Joe – and his family?

Written by: Tarris Rosell, PhD, DMin

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