Respecting Spinal Cord Injury Patient Autonomy in the Context of Terminal Extubation

Terminal extubation, or palliative or compassionate extubation, is a legally and ethically accepted practice in the United States where mechanical ventilation is withdrawn when ongoing life-sustaining treatment no longer aligns with a patient's stated goals of care. Nearly 42% of intensive care unit deaths involve withdrawal of such measures. Despite its legal acceptance, terminal extubation remains a nuanced decision, particularly in patients with spinal cord injury (SCI). Approximately 18,000 new traumatic SCIs occur annually in the US, with respiratory failure as the leading cause of death. While extubation protocols exist, none are specific to the SCI population. Discussions regarding goals of care may be complicated by quality-of-life concerns and potential ableist bias when physical dependence is misinterpreted as incompatible with meaningful life. We present a case-based ethical analysis of an 88-year-old male with traumatic high-level cervical SCI who requested terminal extubation following prolonged hospitalization. His course was complicated by respiratory failure requiring tracheostomy, ventilator-associated pneumonia, and persistent ventilator dependence. Psychiatric evaluation initially raised concern for depression and adjustment disorder. However, he consistently expressed a wish not to live ventilator-dependent. Over weeks and months across multiple care settings, he reaffirmed this request. After interdisciplinary evaluation confirmed decision-making capacity and with strong family support, he elected hospice care. He was extubated with palliative support and passed 48 h later. This case highlights the intersection of autonomy, capacity, and ethics in end-of-life decisions for patients with SCI and underscores the importance of ethical, patient-centered approaches when considering withdrawal of life-sustaining treatment.