Three days after hospitalization for diabetic ketoacidosis, an 87-year-old woman refuses insulin injections. She says that her medical condition has declined so much that she no longer wishes to go on living; she is nearly blind and will likely require bilateral leg amputations. She reports that she has always been an active person and does not see how her life will be of value anymore. She has no family and most of her friends are sick or deceased. On mental status examination, she is alert and cooperative. She accurately describes her medical history and understands the consequences of refusing insulin. There is no evidence of depression. She dismisses any attempts by the physician to change her mind, saying that the physician is too young to understand her situation. She says, “I know I will die, and this is what I want.” Which of the following is the most appropriate next step in management?

(A) Discharge the patient after she has signed an “against medical advice” form

(B) Seek a court order to appoint a legal guardian

(C) Offer insulin but allow the patient to refuse it

(D) Admit to the psychiatric unit

(E) Administer insulin against the patient’s wishes

(Answer: C)