commentary review reports primary research Available online http://ccforum.com/content/5/3/115 The scenario 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 emer- gency 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 dis- cerned. 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, emer- gency teams were called to investigate a gunshot reported by his neighbours. As the anaesthesia wore off, recovery room staff were horri- fied 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-table’ ethical debate: is a suicide note an authoritative ‘living will’? David Crippen (moderator), Donald B Chalfin*, Cory Franklin*, David F Kelly † , Jack K Kilcullen ‡ , Stephen Streat § , Robert D Truog ¶ and Leslie M Whetstine † St Francis Medical Center, Pittsburgh, Philadelphia, USA *Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York, USA † Department of Medical Ethics, Duquesne University, Pittsburgh, Philadelphia, USA ‡ Department of Critical Care, Montifiore Medical Center, Bronx, New York, USA § Department of Critical Care Medicine, Auckland Hospital, Auckland, New Zealand ¶ MICU, Children’s Hospital, Boston, Massachusetts, USA Correspondence: David Crippen, MD, FCCM, St Francis Medical Center, Pittsburgh, PA 15201 USA. E-mail: crippen+@pitt.edu Abstract Living 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. Keywords: advance directives, autonomy, critical care, living wills, medical ethics, suicide Received: 20 April 2001 Accepted: 22 April 2001 Published: 2 May 2001 Critical Care 2001, 5:115–124 © 2001 BioMed Central Ltd (Print ISSN 1364-8535; Online ISSN 1466-609X)