A combined ethics & psychiatric consultation.

A case presentation is used to illustrate how psychiatrists can contribute to clinical ethics. A 75-year-old man with end-stage COPD was admitted to the ICU. His condition deteriorated and he lost decision-making capacity without expressing his wishes about end-of-life care. Although he no longer needed care in the ICU his surrogate decision-maker objected to his being transferred. Seven months after the patient's admission an ethics consultation was carried out by a psychiatrist-ethicist. The following issues are discussed, elaborating on points previously made by the authors [1,2]: the absence of an advance directive, surrogate decision-making, the allocation of ICU beds, guidelines for discharge from the hospital, the lateness of the ethics consultation, and the interweaving of ethical questions with psychiatric factors. The psychiatrist-ethicist was ideally suited to address all these issues and to make a significant contribution to the care of the patient and his family.