Case history

A 62 year old woman, bed bound with severe arthritis and in constant pain despite strong opioid treatment, presented to the emergency department unconscious with an obstructed airway and absent gag reflex. A suicide note documented that she had taken an overdose up to 24 hours previously of chloral hydrate, diazepam, paracetamol-codeine combination, and alcohol. The note also clearly expressed the patient’s distress at her longstanding pain and severe restriction of function and independence. Her general practitioner had called for the ambulance with the support of her husband, who presented medical staff in the emergency department with an advance directive signed by the patient (see bmj.com) stating that she did not want life sustaining medical treatment. Her husband emphasised that although the family would ideally want her advance directive followed, they would support any actions and treatment taken by the healthcare team in …