BB

BB was a thirty-seven-year-old woman, in good health, employed and pursuing martial separation. Without warning, she suffered a brain stem stroke in November, resulting in the diagnosis of locked-in syndrome. She was left fully alert mentally, although quadriplegic and unable to speak; she preserved limited voluntary head movement, vertical gaze, blinking, and minimal voluntary movement of her left arm. Before her stroke, BB had a history of major depression with psychotic features, with on previous psychiatric hospitalization ten years earlier. Over the past decade, her symptoms were well controlled with weekly psychotherapy and medications. She was an effective and skilled professional in a competitive technical field. Ten weeks after her injury, BB was transferred to a rehabilitation facility for possible weaning from a ventilator and assistance with communication and mobility. Here she learned to communication with a computer system and received a modified power wheelchair. After some difficulty, she succeeded in breathing without the ventilator. However, her success disappointed her, to the surprise of the staff. It was then that the medical team learned of BB’s wish to die.  BB told a psychotherapist that she was suffering, which was primarily psychological rather than physical. She did not believe that this could ever accept life with her extreme physical limitations. BB’s medical team encouraged her to reconsider, saying many who suffer catastrophic injury have suicidal ideas year only, but after a year or two often regain their desire to live.  BB initially promised to postpone the discussion for 6 months, but after three weeks she changed her mind and said she wanted to die by stopping all nutrition, hydration, and medications, except for morphine to control her pain. BB manifested significant fluctuations of mood since admission, but a psychologist noted that she did not appear to have depression or a formal thought disorder.

            BB’s attending physician felt he could not continue to act as her doctor if she wanted to terminate food and fluid. The physician described to BB his idea of the suffering she would endure as she died of starvation and dehydration. He would not offer her pain medication, for to do so, in his opinion, would hasten her death, in violation of his ethical and personal beliefs. The physician believed BB’s request was more akin to assisted suicide. BB is not a candidate for local hospices as her imminent death is her own choice. BB’s disability makes the option of dying at home and impossibility, as she would need significant assistance to manage pain, possible seizures and routine care.