DOCTOR, CAN YOU HELP ME DIE? J.M. Hauser 1 ; 1 University of Chicago, Chicago, IL LEARNING OBJECTIVES: 1. Explore reasons for a request for physician-assisted-suicide 2. Learn how to respond to a requests for physician-assisted-suicide CASE INFORMATION: Mr. Hayes [name changed] was a 57 yo man with advanced esophageal cancer who requested assistance in dying. He initially presented with dysphagia and underwent endoscopy which revealed esophageal cancer. After an abdominal CT scan showed multiple liver masses consistent with metastases, he was referred to hospice. His predominant symptoms were abdominal pain treated with morphine, anxiety treated with lorazepam and dysphagia which required he stop eating solid foods. Mr. Hayes initially resisted medications because of possible drowsiness. It soon became clear, however, that his refusal was because medication could not address his most significant suffering: as a relogious person, he told me, he was angry at God for not curing his illness and for letting him die without a wife. He did not know how to cope with this anger and did not think that either hospice or his own priest could help address it. At the end of our second visit, after discussing his symptoms and his continuing spiritual distress, I asked Mr. Hayes``Is there any other way I can help you?'' He answered:``You can get put a needle in my vein and help me end it.'' I asked what he meant. "You can help me die. It's in your oath to stop suffering." I explored with him how he was suffering, whether there were things he looked forward to in his future and whether there were ways we could help him short of ending his life. After discussions with many members of the hospice team, aggressive treatment of his symptoms, and help from two of his brothers helping care for him, his desire that we help end his life waned but never completely disappeared. DISCUSSION: Requests for physician assisted suicide (PAS) are troubling, partly because they highlight intense and unrelieved suffering. This case illustrates how such a request can be a window into inadequately addressed suffering, can reveal misunderstandings about what physicians are legally permitted to do; and how palliation of many symptoms may not be adequate for some patients' suffering. Rather than a debate about the ethics of PAS, this case discussion will consider the reasons behind such requests and our possible responses to them.`I CEBERG LETTUCE AND CARROTS'': A MEAL IN SEARCH OF A DIAGNOSIS. R.D. Hobbs 1 ; 1 Oakwood Healthcare System, Dearborn, MI LEARNING OBJECTIVE: To recognize the varied presentations of Pica as well as its clinical significance. CASE INFORMATION: A 57 year-old woman presented with memory loss, a fear of becoming obese and a recent four-month history of cravings for``iceberg lettuce and carrots.'' She was eating two heads of lettuce and a pound of carrots daily. Her past history included hypothyroidism (1970) , treated with oral replacement; a hysterectomy (1970) ; severe osteoarthritis with chronic left hip pain; fibromyalgia treated with amitriptyline; a gastric exclusion procedure for weight loss (1994) ; and severe personal stress due to the recent suicide of her 27 year old son six months prior. Her weight loss procedure was a partial gastrectomy with creation on a six-ounce pouch and anastomosis of the distal duodenum to the terminal ileum. This resulted in a``four foot common channel.'' She lost 117 pounds without incident. Physical exam was unremarkable except for mild memory loss, obvious osteoarthritis with a left sided limp and well healed surgical scars. She weighed 170 pounds. DISCUSSION: Although there was obvious depression and a profound fear of weight gain, the cravings for``iceberg lettuce and carrots'' were of recent onset. Because of the history of the gastric bypass procedure and its expected result of intestinal mal-absorption, a Pica variant was suspected. Although Pica has been associated with such bizarre food cravings as laundry starch, clay, chalk, ice, and paint chips, it has been associated with normal foodstuffs such as apricots, almonds, chocolate, carrots, etc. Because of the association between Pica and iron deficiency, laboratory tests for anemia were ordered. The results were compatible with iron deficiency anemia. Additional studies revealed zinc deficiency, early vitamin B12 deficiency, and vitamin D deficiency with hypocalcemia and secondary hyperparathyroidsim. With these findings, the patient revealed that although she had taken nutritional supplements following her operation, she stopped them following the death of her son. With reinstitution of nutritional supplementation her behavior and laboratory studies have been improving. 1. Recognize (DI) diabetes insipidus clinically. 2. Confirm DI using standard diagnostic testing. 3 . Through thorough review of its possible causes, establish the etiologic lesion for DI in a patient. CASE INFORMATION: A 23 year old male came to the emergency room with a chief complaint of a nine day history of blood in his stool, lightheadedness, nausea, diarrhea, and profound weakness. He was admitted for dehydration, anemia, and bright red blood per rectum. On review of systems, it was noted that he had been drinking several gallons of water a day since 5 months prior to admission and had been urinating hourly. Diabetes insipidus (DI) was suspected when it was observed that he had a clear dilute urine despite his tachycardia and orthostatic hypotension. His urinalysis revealed a low specific gravity of 1.002 and no glucose; serum chemistries were normal. A water deprivation test was consistent with diabetes insipidus. Subsequent workup revealed panhypopituitarism and ultimately the causative lesion, a midline germinoma. The rectal bleeding, which might have lead us toward a different evaluation, was hemorrhoidal. The diarrhea was most likely secondary to his hypoadrenal state. DISCUSSION: