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Abstract

Harry was found near a smoking gun with his face severed from his skull. He was still breathing, so paramedics inserted an endotracheal tube and took him to the emergency room, where he displayed strong vital signs and ventilated well, with normal oxygen saturation. Surgical evaluation revealed that he had succeeded in removing everything from his chin to his ears and to his eyebrows, and had exposed and damaged numerous cranial nerves. In addition, no normal anatomical landmarks could be discerned. Debridement and a permanent tracheostomy were performed, and the remaining skin folded over.By way of past history; Harry never got much of a break in his 46 years of life. Unsuccessful marriages, failed jobs, and severe depression resulted in multiple psychiatrists and multiple suicide attempts. On this occasion, emergency teams were called to investigate a gunshot reported by his neighbours.As the anaesthesia wore off, recovery room staff were horrified to see Harry raise his left hand and examine his facial packing. An immediate neurological examination showed that he used his left arm in a semi-purposeful manner, but was otherwise unresponsive -he had deep tendon reflexes all around, and did not withdraw from painful stimuli.An electroencephalograph demonstrated 'diffuse slowing', but no other acute abnormality. Auditory evoked stimuli showed no hearing function, and coded commands on Harry's palms and chest did not result in a response in the good arm. Occasionally, Harry raised his left arm briefly into the void, but he was otherwise unresponsive. Commentary'Round- AbstractLiving wills are often considered by physicians who are faced with a dying patient. Although popular with the general public, they remain problems of authenticity and authority. It is difficult for the examining physician to know whether the patient understood the terms of the advance directive when they signed it, and whether they still consider it authoritative at the time that it is produced. Also, there is little consensus on what spectrum of instruments constitutes a binding advance directive in real life. Does a 'suicide note' constitute an authentic and authoritative 'living will'? Our panel of authorities considers this problem in a round-table discussion.

Management of patients with an advance decision and suicidal behaviour: a systematic review

“…Authors from a psychiatric perspective, in particular, viewed suicidal behaviour as a symptom of a mental health disorder that was potentially treatable with psychiatric care. 25 They also expressed concerns about the capacity of a distressed suicidal person to fully comprehend their decision and consider all treatment options available to them. 2 24 25 32 Therefore, it was suggested by some authors that a higher level of mental capacity may be required at the time of writing the advance decision for clinicians to be confident in following it.…”

“…Authors from general medical and psychiatry perspectives expressed confusion about legislation and anxiety about litigation, 2 23 30 with one stating that the advance decision document needed to be ‘ watertight’ to be considered. 25 Authors recommended that clear hospital policies be developed for advance decisions in this particular context to overcome the confusion and anxiety about ligation. 23 …”

“…Concerns were expressed that this particular presentation of an advance decision met conditions that warranted overriding patients’ autonomy because non-adherence with the advance decisions results in prevention of suicide, maintenance of the integrity of the medical professional and preservation of life. 25 …”