A patient in the preoperative area suddenly refuses to go forward with the removal of infected wires unless he is given assurances that the rest of his brain implant will remain in place. He indicates that he will go home and die rather than have the implant removed. The patient, surgeon, ethicist, and wife all convene to resolve the time sensitive issues. The short-term outcome is very positive, but there is an unexpected longer-term outcome that was unsettling.

A sixty-nine-year-old man with severe necrotizing fasciitis in the setting of a newly diagnosed, metastatic cancer is transferred from an outside hospital for further evaluation of treatment options, including surgical debridement. His family indicates he is a member of a small, adherent religious community that holds the belief that all life-sustaining measures should be pursued and that any breath he takes constitutes meaningful life, even if it causes severe suffering. The patient’s altered mental status due to brain metastases prevents him from verbally communicating with the team, but he intermittently tracks movement of the healthcare team and grimaces in response to painful stimuli. This case narrative explores surgical ethics and moral distress evoked by this haunting case, with analysis from a consulting clinical ethicist who supported communication with family about treatment options and a clinical ethicist who provided guidance on code status and led nursing ethics rounds with the care team.