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Ethical Dilemma!

A 65-year-old man who was diagnosed with amyotrophic lateral sclerosis three years ago presented to the emergency department for dyspraxia. While in the emergency department he wrote on a whiteboard “not ready to die”. Therefore, he was promptly sedated, intubated, and mechanically ventilated. He was admitted to the intensive care unit and workup has revealed respiratory failure is due to his ALS and he will not wean from the ventilator. Off sedation, he follows commands and responds appropriately.

During his visit three months ago the patient had a significant bulbar weakness with dysarthria and dysphasia and there was a decline in the pulmonary function test to a forced vital capacity of 30%. After discussion with his primary neurologist and his wife who is the power of attorney he decided against tracheostomy and mechanical ventilation. A DNR order was signed at that time. Now tracheostomy is indicated for definitive management of his respiratory failure, what would be the appropriate action?

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