To discuss and explore the ethical dilemmas in the unfortunate case of a 60 yo female with multiple co-morbidities on a ventilator in an ICU, I shall follow “the Four Boxes” method as described in Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, Seventh Edition (CE) by Jonsen, Siegler, and Winslade.

First, I shall communicate in private with the patient (via verbal questions by me and pen and paper answers by her) to clarify the depth of her understanding of her complex medical situation. “Has the ICU team informed you about the severity of your medical problems? Have they recommended treatments they say can help you get better? Have they discussed the risks of these possible treatments?” If she answers no, I shall promptly facilitate this process before proceeding with the remainder of the clinical ethics evaluation. If she answers yes, I shall verify that she comprehends the information by asking her to write, in her own words, what the ICU team told her about her current health problems, the recommended treatments, and the risks and benefits of the recommended treatments vs. alternative treatments vs. no treatment.

Then I shall address an important ethical dilemma in this case: Does this patient, who has apparently refused life-sustaining treatment, retain decision-making capacity? Her decisional capacity is in question due to her history of a suicide attempt (for which she has undergone psychiatric treatment for approximately 10 years), the life-threatening nature of her illnesses potentially causing metabolic disturbances incompatible with decisional capacity, and her initial atypical request to be allowed to die. These worrisome issues certainly exceed the threshold needed to invoke the sliding scale criterion (SSC), which, according to CE, asserts that the “stringency of criteria for capacity should vary with the seriousness of the disease and urgency for treatment”. The SSC justifies an evaluation of this patient’s decisional capacity — and frankly the capacity of any patient in any other “life and death” case. If time permits I shall analyze the patient’s decisional capacity via the MacArthur Competence Assessment Tool (MacCAT-T). If time does not permit, I shall analyze the patient’s decisional capacity via the legally relevant process described in Table 1 of the Appelbaum 2007 New England Journal of Medicine article entitled “Assessment of Patients’ Competence to Consent to Treatment”. Appelbaum advises asking the patient to indicate a treatment choice, paraphrase disclosed information regarding medical condition and treatment, describe proposed treatment and likely outcomes, compare treatment options and consequences, and offer reasons for the treatment choice.

If the patient does not have decision-making capacity, multiple ethical dilemmas may surface (such as the best interpretation of a vague advance directive, dealing with an unethical proxy or surrogate, or the role of substituted judgment vs. best interests when making decisions for an incapacitated patient), for I shall follow the flowchart depicted in Figure 8-1 of Resolving Ethical Dilemmas: A Guide for Clinicians, Fifth Edition (RED) by Lo.

However, if the patient has decision-making capacity, I shall advise the ICU team to inform the patient’s psychiatrist of her admission to the ICU and request he proceed with an inpatient consultation to assess the current status of her mental illnesses, provide a second opinion about her decisional capacity, and relay, in detail, the risks and benefits of possible treatments. After the psychiatric consultation, I shall visit in private again with the patient to clarify, via the process I noted in the second paragraph, the depth of her understanding of her complex mental situation and seek consent to discuss her health scenario with her family.

Second, I shall talk in private to the ICU team and the psychiatrist (in separate sessions) about the nature of the patient’s physical and mental illnesses. “What are her medical or psychiatric problems? Are they acute or chronic? Are they curable or incurable?” I shall ask the medical team and psychiatrist to explain the goals of the possible treatments for her medical and psychiatric problems. “Are the treatment options curative or palliative? Are they typically or rarely accompanied by severe side effects?” I shall also inquire about the probabilities of success of the various treatment options proposed. “Are they likely or unlikely to achieve the relevant treatment goals?” Ultimately, by reflecting on the objective facts of the case, I shall learn which medical interventions, if any, can maximize medical and psychological benefits (beneficence) and minimize medical and psychological harms (nonmaleficence) for this patient.

Third, after obtaining consent from the patient I shall meet in private with her family to explore the depth of their understanding (again via the process I detailed in the second paragraph) of her complex medical and mental situation.

Fourth, to rule out any ethical dilemmas regarding the principle of justice, I shall confirm that there are no physician or hospital financial conflicts of interest, no scarce health resources allocation issues, no religious misunderstandings, no clinical research options, and no public health/safety concerns inappropriately affecting the clinical decision-making process in this case.

Fifth, I shall then advise the ICU team to schedule a clinical ethics meeting of all the case stakeholders (the patient, the patient’s family, the ICU team, and the psychiatrist) at the patient’s bedside. Assuming the ICU team agrees, I, acting as host of the encounter, shall, as per Table 16-1 in RED, seek to illuminate the facts of the case, identify and analyze conflict over ethical issues, and build consensus among the stakeholders (by helping those present express their views and concerns, improving communication between the caregivers and the patient and the family, and providing emotional support). I shall ask the physicians to summarize the patient’s diagnoses and their treatment recommendations. I shall ask the patient’s family to confirm their understanding of the physicians’ opinions. Then I shall ask the patient to publicly confirm her understanding of the physicians’ opinions. Finally, I shall ask the patient to report her preferences for treatment. If the patient’s preferences for treatment match the recommendations of the ICU team and the psychiatrist, there is no ethical dilemma. However, if the patient’s preferences for treatment conflict with the recommendations of the ICU team and the psychiatrist, then a key ethical dilemma exists.

If the patient continues to prefer to be allowed to die, but the physicians and the patient’s family continue to prefer that the patient proceed with certain medical and psychiatric treatments, then the following serious ethical dilemma must be resolved: The prima facie duty of the physicians and the moral duty of the patient’s family to maximize medical and psychological benefits (beneficence) and minimize medical and psychological harms (nonmaleficence) for the patient are in direct conflict with the prima facie duty of the physicians and the moral duty of the family to respect the patient‘s autonomy.

In an attempt to solve this ethical quandary (by negotiating an acceptable resolution), I shall ask the patient to detail the minimum quality of life she must achieve with medical and psychiatric treatment to NOT want to be allowed to die. I shall then ask the physicians to inform the patient and the family about the probability of achieving this level of quality of life if the recommended treatments are initiated — after minimizing, as much as humanly feasible, the role of bias (racial, elderly, disabled, lifestyle, gender, and social worth) in their evaluations of the patient’s future quality of life. I shall also request that the physicians and the family, during this discussion, not deliver their subjective opinions about the patient’s subjective quality of life preference. I shall then ask the patient again to note her preference regarding treatment. If she continues to want to be allowed to die, I shall remind all stakeholders that American legal precedent, particularly the 1986 California Court of Appeals ruling in Bouvia v Superior Court, mandates that refusal of care by a competent and informed adult be respected even if such refusal of care leads to serious harm to or the death of the competent and informed adult.

If management disagreements persist after this bedside meeting, I shall proceed based on which stakeholders continue to insist that the patient receive life-sustaining interventions against her will. If the family continues to demand life-sustaining interventions, I shall follow the recommendations in Table 14-1 of RED: I shall attempt to understand the family’s perspective, respond to the family’s needs and emotions, be sensitive to cultural and religious issues, use time constructively, and find common ground for ongoing care. If the physicians continue to demand life-sustaining interventions, I shall follow the recommendations in Table 14-2 of RED: I shall object to the undermining of the right of refusal of care by a competent, informed adult patient and educate the physicians about their conflation of negative and positive rights in an attempt to resolve the ethical dilemma of patient autonomy vs. physician autonomy.

In conclusion, the various ethical dilemmas inherent in the unfortunate case of a 60 yo female with multiple co-morbidities on a ventilator in an ICU can be thoroughly explored via the “Four Boxes” method.