“I WILL MAINTAIN the utmost respect for human life”  – from the Declaration of Geneva ed-signRecently I had the opportunity to participate in a panel discussion related to ethics and medicine. The topic was suicide attempts in patients who have a valid DNR or advanced directive/healthcare proxy.  Needless to say it elicited an incredible amount of discussion.

The case discussed was similar to this one:

  • 60 year old male found at a assisted living facility unresponsive with many empty pill bottles around him. 
  • He has a long history of depression and previous suicide attempts.
  • He arrives in the ED completely unresponsive, minimally protecting his airway but hemodynamically stable.
  • Next a relative (also his healthcare proxy) arrives with the patient’s valid advanced directive.
  • This advanced directive specifically forbids intubation (and CPR).
  • This family member/healthcare proxy is also adamant that he not be intubated.
  • To complicate matters as the patient deteriorates his good friend and lawyer is also present at bedside.

hippocratesWe in emergency medicine know that our world is various shades of gray punctuated by moments that require black or white decision making.

This case is clearly one of those moments. Most of the time our three priorities align perfectly: Protect Life, Ease Suffering, Respect Patient Autonomy.  But when they don’t we are forced to choose one over the others.

Which is the right choice?  If you  had to choose, were forced to decide, what would you do?

I think that my decision would be clear (but maybe not easy). I would be ahead and secure the patients airway including by intubation if necessary. intubationI would base my decision on the different between allowing natural death vs. allowing an unnatural death (by suicide). In doing so I accept that the patient has a valid advanced directive and a competent healthcare proxy both of which are clear on not intubating. However, my duty to prevent his suicide would override observing his written wishes.

I am a strong believer in the autonomy of patients. I believe that patients should be able to make even the stupidest decisions as long as they have capacity to understand the risks of their actions.

But there are always limitations. 003-Three-Ramped-patientsWe frequently treat suicidal patients against their will who are awake and talking. We provide them care they often explicitly don’t want. We prevent them from leaving in order to facilitate a psychiatric evaluation. Some of these treatments prevent death.

Some of these evaluations lead to involuntary psychiatric admissions. For the actively suicidal patients both these outcomes are involuntary. In this case I see treating this patient and preserving his life as being no different.

It will be interesting to see what other people think.