The Ethics of Transitioning to Comfort Care in a Potentially Survivable Injury After Attempted Suicide

Outcomes 1. Upon completion of this session, participants will be able to describe the ethical challenges in decision-making for patients with life-threatening though potentially survivable injury after attempted suicide.2. Upon completion of this session, participants will be able to analyze methods for resolving clinical and ethical conflicts related to end-of-life decision making for patients with serious mental illness. Key Message Medical decision-making for patients without decision-making capacity who have attempted suicide can present ethical challenges, particularly when a patient has a life-threatening though potentially survivable injury. We present a modified case that highlights the need for interdisciplinary guidelines and best-practices for the care of these patients. Abstract Mr. C is a 56-year-old man with history of schizoaffective disorder complicated by previous suicide attempts. He presented to the hospital following a self-inflicted gunshot wound to the head. He was intubated in the field and was found to have significant intracranial bleeding and facial disfigurement. By legal default, his younger brother was his surrogate decision-maker. After emergency stabilization, providers shared that Mr. C had an estimated 50% chance of survival if he were to proceed with a high-risk series of intracranial evacuation and reconstructive plastics procedures, followed by months of high-intensity rehabilitation. Comfort-focused care and compassionate extubation were proposed as the alternative treatment plan. The palliative care, ethics, legal, and psychiatry teams were consulted, with trauma surgery and neurosurgery co-managing.Mr. C's brother desired to transition to comfort-focused care based on his mental health history and prior conversations about goals/values. However, the psychiatry team felt a “legal and ethical obligation” existed to proceed with full treatment given the potential for survival. They felt Mr. C's diagnosis of schizoaffective disorder was not treatment refractory and raised concerns that caregiver burnout may be affecting the brother's decision-making. The surgical teams also supported proceeding with treatment. After further discussion, the hospital legal and ethics teams deemed that Mr. C's brother was acting as an appropriate surrogate. As such, Mr. C was transferred to inpatient hospice, compassionately extubated, and died with his brother at his side. Conclusion Mr. C's case highlights the challenges of medical decision-making for patients with suicide attempts and life-threatening though potentially survivable injuries. These cases can lead to significant moral distress for medical providers and families. We propose a standard of care that balances surrogate decision-maker experience and knowledge of prior goals of care as well as quality of life considerations with available treatment and prognostic information. Keywords Ethical / Legal Aspects of Care; Interdisciplinary Teamwork / Professionalism