Author: Nicole Anthony, MD
Editors: Marie Murphy, MD; Alec Feuerbach, MD
Case:
A 65-year-old female with a history of COPD, chronic back pain, and major depressive disorder is found unresponsive by her aide. At the time of discovery, she is clutching a suicide note and an up-to-date, Do-Not-Resuscitate (DNR) form.
By the time she arrives in your ED, her respiratory rate is 4/min, and she has pinpoint pupils. The aide comes almost simultaneously and tells you she thinks she may have overdosed on her pain medication. The patient loses pulses in front of you. This all happens within minutes of her arrival.
Do you resuscitate this patient? Is there a legal precedent? And what is your moral obligation in this set of circumstances?
Ethical Principles
Physicians practice under the framework of the following four ethical principles: Beneficence, Non-maleficence, Autonomy, and Justice. But which ethical principle wins out when they are at odds with each other?
In the case above, there is conflict between patient autonomy and, to varying degrees, the three remaining principles– we want to perform good acts (beneficence – save the patient); we do not want to further harm the patient (non-maleficence – we do not want to perform CPR, possibly causing bodily harm if the patient themselves does not wish for resuscitation), and we want to ensure that the patient has access to resources that could have otherwise prevented this act (justice – is the patient able to afford psychiatric evaluation and treatment?).
Patient Autonomy
In a case reported by Cook et. al, a 57-year-old female with a history of Major Depressive Disorder was found unresponsive during her psychiatric inpatient admission after a presumed opioid overdose.[1] At the time of discovery, she was clutching a DNR document, rosary, and the calling card of a funeral home. Initially, there was confusion amongst the medical team over whether to resuscitate the patient given the presence of the DNR; however, the psychiatrist-on-call adamantly pushed for resuscitation and the patient was revived.
Following this incident, the DNR was placed on hold for what was supposed to be the duration of the patient’s psychiatric admission but was then reinstated by the patient’s Primary Care Provider. The psychiatrist referred the case to the ethical board. After long deliberation, the ethics committee recommended suspension of the DNR order during psychiatric treatment for the following reasons: there was clear suicidal intent, the DNR was a component of the patient’s suicide plan, the act of attempting suicide is evidence of disordered thinking and suggests the patient does not have capacity to make medical decisions, and the patient has no life-threatening or terminal diagnosis (suggesting that the patient would otherwise have a good prognosis).
There are, however, other case reports with very similar scenarios in which the DNR order was upheld by the ethics committee. The reasoning hinged on the timing of the DNR – it was initiated when the patient was competent and was created “despite” the patient’s suicidality in order to guide decisions when she was not competent. Although this is true, the patient in question overdosed on insulin and had her DNR readily available at her bedside during the suicide, suggesting that the DNR was a part of her suicide plan.[2] Different aspects of the evaluation may be given more or less weight when considering whether to uphold a DNR, leading to the possibility of opposing recommendations. It seems there is no “right” answer and, presented with identical scenarios, there may be just as many recommendations as there are ethical reviews.
Can suicide ever be a rational decision?
Consider a patient with debilitating chronic pain that leaves him unable to walk or perform his ADLs. Suppose he has exhausted all treatments without achieving improvement in his quality of life. Might suicide not then be an understandable, even rational decision if the patient feels he is unable to further live with his pain?
In the Netherlands, this patient’s situation would likely qualify him for euthanasia – he is undergoing “unbearable suffering, without the prospect of improvement” and there is “no reasonable alternative.” End-of-life clinics in the Netherlands verify that there are no reversible causes of suffering prior to approving a patient’s request for euthanasia. In the absence of end-of-life clinics, determining that there are no reversible causes of suffering or that all treatment options have been exhausted may not be realistic. Even if it was possible, the seemingly most straightforward cases can still present ethical and moral dilemmas.
For instance, suppose the patient with debilitating chronic pain is also on home hospice for bone metastases. He is brought in by his family for suicidal ideation. After a brief discussion, you discover that the patient’s home hospice nurse was on vacation for the last two weeks and, due to a miscommunication, the hospice program has not sent anyone in her place. The patient has been unable to get his pain medication.
You then receive further information from the family that the patient is also concerned about losing his housing due to the financial burden of his cancer treatment. Finally, the patient reveals that he had an explosive argument with his wife this morning which all compounded his feelings of hopelessness.
The patient in our imagined scenario has several easily-identified reversible causes of suffering that could easily be overlooked in an emergent resuscitative scenario: unmanaged pain, financial hardship, and interpersonal conflicts. Theoretically, the needs above might be easily addressed with a quick phone call to the hospice organization, an appointment with a financial counselor, and a referral for familial mediation or counseling. Although suicidal ideation in a terminal patient may seem straightforward and directly related to the terminal diagnosis, these patients are still at risk for potentially reversible or treatable causes of depression as noted earlier.[3,4]
Application to the Emergency Department
In the Emergency Department, physicians are meeting patients for the first time and deciding within seconds how to proceed with resuscitation. Oftentimes, there is little opportunity to sit down and thoroughly review the patient’s chart, contact the patient’s family and primary care provider, clarify goals of care or possible suicidal intent, or consult with the ethics committee prior to proceeding with a resuscitation. In cases that have clear suicidal intent, many, if not most, emergency medicine physicians would elect to proceed with resuscitation regardless of DNR status.[5]
In a systematic review of the management of patients with an advance decision and suicidal behavior, several recurrent themes were identified.[6] The following is a small sample that includes themes not yet addressed in this post:
1. “Advance decisions are about more than a simple assessment of capacity.” Namely, there should be (1) a full understanding of the consequences of foregoing resuscitation, and (2) there should be consistency over time.
2. “Increased gravity of clinical decision.” There is possibly no greater decision that we face as medical providers than to decide how to proceed with a resuscitation when a case is medically futile and when to cease resuscitative efforts.
3. “Length-of-time needed to consider all evidence vs rapid decision-making for treatment.” The information that will appropriately guide us to make the ethical decision may lie buried in the patient’s chart or with the family members; however, there is rarely time to discover this information.
4. “Highly emotive decision.” The patient’s age and co-morbid conditions frequently guide us in these decisions, however, they are highly subjective and emotional.
5. “Conflict with colleagues or staff participating in the patient’s care.” Staff members may hold differing beliefs about suicide and patient autonomy regarding death, and this causes substantial conflict during resuscitative efforts.
Furthermore, most institutions do not have protocols in place to address overriding DNR orders in the context of a suicide attempt, and either course of action may result in institutional discipline. It is easy to see why an emergency physician may want to err on the side of disregarding a DNR order in the context of suicide.
Whatever decision you ultimately make, there are a few steps you can take in order to assist you with the decision-making process when the time comes:
Consider the pros and cons of having an institutional policy. You can suggest developing an institutional policy, ideally with the input of the Ethics Committee.
Plan ahead how you will handle any potential conflict with colleagues or staff.
Identify scenarios in which you would absolutely disregard a DNR in the context of suicide, then identify scenarios in which you would absolutely honor a DNR in the context of suicide. Ask yourself what characteristics are involved in each. This may make it easier to make the decision in less straightforward cases.
Legal Framework
Laws governing DNR orders vary from state to state. Some states only allow DNR orders in cases of terminal illness and have even provided a pre-specified list of conditions that qualify. It is best to check your state-specific legislation.
In New York, a DNR order only refers to withholding CPR during respiratory or cardiac arrest; it does not make any determinations on other medical treatments or the withdrawal of medical care. There is no stipulation about DNRs in the setting of suicide, arrest due to iatrogenic causes, or arrest due to a reversible condition with a high likelihood of a good outcome. For instance, DNRs should not be suspended as a matter of course during routine procedures without discussion with the patient.
Although immunity for physicians who disregard a DNR is provided in situations where, in good faith, they had reason to believe the DNR was revoked or canceled, or they were unaware of the DNR, this does not shed much clarity on the suicidal patient.
Legal Precedent
I have not been able to locate any mention of lawsuits, successful or otherwise, that arose from a physician either overriding or honoring a DNR when a patient presented in arrest due to suicide. There are tangentially related malpractice suits in which physicians were successfully sued for wrongful prolongation of life when the patient’s DNR was disregarded (see below); however, the patient’s capacity to make such a decision was never in doubt in the cases referenced.[7-9]
There are widely publicized lawsuits against physicians for disregarding DNRs; however, none occurred in the context of death due to suicidal intent.
Summary
– Emergency physicians face a unique set of challenges when faced with an actively suicidal patient who is DNR.
– Separate ethics review committees have recommended both upholding AND suspending DNR orders in patients who attempt suicide, even in similar circumstances.
– Suicidal patients with a terminal illness may still have reversible causes of depression, hopelessness, and suicidal behavior.
– In a review of the literature published on the topic, there is little consistency among emergency physicians on whether or not to honor DNR orders in suicidal patients.
– DNR legislation in New York state does not address the suicidal patient.
– There is no legal precedent.
References
1. Cook R, Pan P, Silverman R, Soltys SM. Do-Not-Resuscitate Orders in Suicidal Patients: Clinical, Ethical, and Legal Dilemmas. Psychosomatics. 2010;51(4):277-282. doi:10.1016/S0033-3182(10)70697-6
2. Sontheimer D. Suicide by advance directive? J Med Ethics. 2008;34(9):e4-e4. doi:10.1136/jme.2008.025619
3. Emanuel EJ, Fairclough DL, Slutsman J, Emanuel LL. Understanding economic and other burdens of terminal illness: the experience of patients and their caregivers. Ann Intern Med. 2000;132(6):451-459. doi:10.7326/0003-4819-132-6-200003210-00005
4. Guy M, Stern TA. The Desire for Death in the Setting of Terminal Illness: A Case Discussion. Prim Care Companion J Clin Psychiatry. 2006;8(5):299-305.
5. Quinlivan L, Nowland R, Steeg S, et al. Advance decisions to refuse treatment and suicidal behaviour in emergency care: ‘it’s very much a step into the unknown.’ BJPsych Open. 2019;5(4):e50. doi:10.1192/bjo.2019.4
6. Nowland R, Steeg S, Quinlivan LM, et al. Management of patients with an advance decision and suicidal behaviour: a systematic review. BMJ Open. 2019;9(3):e023978. doi:10.1136/bmjopen-2018-023978
7. Pope TM. Legal Briefing: New Penalties for Ignoring Advance Directives and Do-Not-Resuscitate Orders. J Clin Ethics. 2017;28(1):74-81.
8. The Wrongful Resuscitation. Accessed July 10, 2022. https://psnet.ahrq.gov/web-mm/wrongful-resuscitation
9. Span P. The Patients Were Saved. That’s Why the Families Are Suing. The New York Times. https://www.nytimes.com/2017/04/10/health/wrongful-life-lawsuit-dnr.html. Published April 10, 2017. Accessed July 10, 2022.
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