AbstractWe present a case of an incarcerated patient who attempted suicide while in police custody for less than 24 hours. He sustained a C1 vertebra fracture resulting in quadriplegia, poor prognosis, and little chance of neurologic recovery. The patient's urine drug screen was positive for multiple substances, indicating likely intoxication at the time of the attempt. While in the intensive care unit he was only able to communicate through eye movements and blinking. He consistently expressed a wish to withdraw life-sustaining care. This case highlights the ethical challenges involved in assessing decision-making capacity after a suicide attempt in an incarcerated individual, the impact of substance use on capacity, the complexities and potential biases in surrogate decision-making, and the emotional and moral burden of end-of-life care decisions on healthcare providers. We used a deliberate approach involving time for information gathering and deliberation, identification of surrogate decision makers, and engagement of multidisciplinary teams to reach a consensus that upheld ethical principles and protected clinicians from moral injury.