When Silence Speaks: Capacity for Extubation Decisions in a Nonverbal ICU Patient

Introduction: Determining decision-making capacity in critically ill, mechanically ventilated patients is a challenging but crucial ethical task for ICU clinicians. While sedation, delirium, or nonverbal status can complicate assessment, patient autonomy remains central to end-of-life care. This case highlights an awake, previously intubated patient who demonstrated intact capacity through writing and gestures to direct his own extubation and transition to comfort measures — despite a conflicting code status reset during a transfer of his care.


Description: A 55-year-old man with no regular medical care presented with advanced Fournier’s gangrene and severe sepsis. He initially refused urgent surgery due to fear of postoperative pain but consented after detailed discussion. Postoperatively in the ICU, he required intubation for worsening shock and confusion. After extubating, he persistently communicated by writing and nodding that he wanted to stop all life-sustaining treatment. He was then transferred to the general medical floor. Despite prior do-not-intubate wishes, his code status had reverted to full code on a return transfer after a rapid response team alert.
Repeated capacity assessments confirmed he was awake, sober, off sedation, and able to show understanding, appreciation of risk, reasoning, and a very clear choice. He accepted that stopping support could mean death and declined reintubation, CPR, or pressors. He refused family involvement and directed his own care. Comfort measures were started in line with his wishes.


Discussion: This case emphasizes that capacity can exist in nonverbal patients if communication is clear and consistent. It highlights the duty of ICU teams to protect patient autonomy even when wishes are expressed through writing or gestures. It outlines the risk of letting system defaults, like automatic code status resets, override previously communicated goals. Respecting informed refusal is essential, even when the outcome is likely death.
ICU teams must rigorously assess capacity in nonverbal patients and ensure processes match patient-centered goals. Simple communication tools — such as written answers, nods, or head shakes — can support valid capacity assessments and guide ethical withdrawal of life support in line with the patient’s stated wishes.