(359) Ethics in the ICU: A Case of an Intentional Opioid Overdose

Introduction: End of life is common in the intensive care unit (ICU) where the transition from living to dying is frequent. As a result, the incidence of ethical conflicts is higher in the ICU than in general wards. In our case we discuss the care of a patient with an intentional opioid overdose.

Description: Our patient was a 78 year old male retired physician with metastatic sarcoma. He presented following a complication from the repair of a pathological femoral fracture. He was admitted and awaiting evaluation by orthopedic surgery. On hospital day (HD) 2, he said he could not take the pain anymore and verbalized to his wife that he wanted to end his life on his terms. When briefly left alone, he ingested a bottle of oxycodone and was found unresponsive. Naloxone was administered and he was transferred to the ICU for hypercapnic respiratory failure due to opioid overdose. He was placed on noninvasive ventilation but remained poorly responsive.

The patient’s surrogate requested cessation of naloxone and all other medical interventions, including mechanical ventilation. This led to an ethical dilemma as the patient engaged in self harming behavior. The hospital Ethics Committee was consulted and determined that although the patient self administered narcotics, it did not invalidate his surrogate’s report of his preferences or the surrogate’s ability to consent to or refuse treatment. The Ethics Committee determined refusal of treatment was valid and that because the patient did not want to engage in treatment that would prolong suffering, there was no ethical reason to continue naloxone. The surrogate’s request to transition to hospice was honored. The patient was transferred to hospice on HD4 and passed away the same day.

Discussion: Involving ethics committees in these situations is imperative to honor patient autonomy while also providing medically and legally appropriate care. As providers it should be our goal to make recommendations concordant with our patient’s values, which was achieved as our patient did not want treatment that prolonged suffering. This case highlights the importance of involving ethics committees so that we can treat patients compassionately while being guided by the experts in the field with understanding of the law.