“I WILL MAINTAIN the utmost respect for human life” – from the Declaration of Geneva 
Recently 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.
We 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. 
I 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. 
We 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.
David
I agree with you treating the patient and preserving his life. I for one personally am against DNR in all cases. Yes, in many cases, the person is basically a vegetable and probably suffering in the perspective of many. However, how do we know this person is suffering? What do you define as suffering? My friend passed away at the age of 24 from brain cancer. After her diagnoses the surgeon needed to place a shunt and stated that she may go into a coma, which she did. He informed her husband that she may not wake up and despite his recommendation of making her a DNR, her husband refused. Instead she remained in the coma for about 3 months until she was medically diagnosed as brain dead. Yes she was young, but age should never matter. Regardless of an individuals mental state, a life is precious. DNR in my opinion is suicide as mentioned above and I feel that a person should die a natural death. We have seen many instances where a person was NOT a DNR and the physicians tried everything to resuscitate them with no success. Why? Because it was just not meant to be.
No question. I would intubate this patient. The Advance Directive is not a suicide note. In fact, it would not even be triggered unless it was written in a very unusual way. This patient has not been shown to have an irreversible condition where resuscitation would be futile.
Put him on CPAP and after he recovers tell the wife to take him home and the next time he ODs keep him there until he dies. It’s not our job to kill people at the directive of others. The lawyer should know this and I would wonder what the relationship is between his “good friend” the lawyer and his wife.
It is an interesting dilemma. Rather than comment I’d like to ask questions that might have already been considered.
Is Depression considered an illness? Yes.
Is depression excessivly, debilitatingly painful at times? Yes
Is depression ever considered a terminal illness when it is debilitating & resistant to treatment?
Can a person be considered Competent to make legal decisions when depressed? Yes & No.
At what point can a suicidal patient decide they have lived in pain long enough?
Even with physical terminal illness family & care providers have difficulty letting go. We now allow people to make those Advanced Directive decisions for diagnosed terminal physical illness. Is depression a physical illness that can beconsidered
Reseacrh shows that depressed patients when depressed make decisons not to extend their life. When those same patients undergo treatment half think differently and would accept care. So I would say its is an illness but it does affect decison making capacity in a bad way.
You could say the same thing of cancer. A terminal cancer patient with no wish to extend their life, who later recovers through a new, previously unavailable treatment may now think differently. Would you say that cancer “does affect decision making capacity in a bad way”?
It is obvious that a person who enjoys their life and sees a happy future would want to extend it and one who doesn’t often wouldn’t. If a person’s life situation changes it is likely their choices about the future will change also. Maybe patients diagnosed with depression should undergo treatment as quickly and rigorously as patients diagnosed with cancer. For some living with depression may be worse than dying from cancer.
As for myself, I don’t feel it is ethical for me to place my beliefs, hopes and fears above another person’s when it comes to making decisions about their life. I wouldn’t want someone else deciding for me if my life is worth living OR NOT, why would I decide that for them?
I wish I could say I have never heard of this. That being said, more and more patients who are suicidal have figured out how to utilize a living will or a DNR order as a weapon to kill themselves. Living wills and DNR orders have no prlace in the initial care and management of the suicidal patient. We are publishing more and more on this topic annd we have a few cases pending publication at present. While on the Topic of advance directives, there previous has never been any research with respect to how these documents would be utilized in patient care. We know know thru research (TRIAD STUDIES I thru IV) that these documents have a now disclosed risk to patient safety. I your practice I would recommend utilizing a Resuscitation Pause any time you encounter a Living will, DNR order or POLST document. Your patients life amy depend on it.
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Again, making decisions for adult patients goes against every ethical thought I have ever had. I believe every person has that right to autonomous decision making.
I find it interesting that we force people to live if they have the right insurance coverage. However we allow people to die from treatable conditions who want to live because they don’t have the proper insurance.
Indeed an interesting case. A scenario of this nature would require an instantaneous decision. My immediate reaction is I would not intubate. The DNR directive is an exercise of the patient’s right to autonomy. Generally these are binary in nature, resuscitate or DNR. Rarely does the advanced directive offer qualifications (e.g., resuscitate in the event of a motor vehicle accident, do not for natural causes).
In this instance, the patient has expressed a desire well within his rights. The advanced directive addresses actions at the point of treatment, not circumstances leading up to the decision point. If a competent individual states he does not desire resuscitative interventions, it is not the place of the provider to insert a differing desire based on personally held beliefs. The patient’s right to self-determination is absolute. The path to that point is irrelevant.
“I am a strong believer in the autonomy of patients.”
So long as you agree with their decisions. As soon as a patient disagrees with you, you cease believing in their autonomy. Which means you never actually believed in their autonomy.
I appreciate your comments. However I think you over simplify very complicated things. I often disagree with what my patients’ decide but do not interfere. The exception would be suicidal patients. We have a medical and legal obligation not to let people kill themselves.
I believe this stops being an issue when our culture decides allow suicide in a clinical setting. I know that may sound clinically crazy, but remove all the cultural biases, emotions, etc, and accept the fact that no person (doctor or lawyer) has the ethical right to intervene with the explicit will of another person’s body. They shouldn’t have the legal right (or responsibility) either.
What’s the fear? That a mad rush of people will being flooding clinics, demanding to be put down? I seriously doubt it, given the fact that everyone has the choice to end their life at all times. Saying this makes it more convenient is like saying a furnace makes an arsonist’s job more convenient. Allowing this would simply create a clinical path to what already occurs, clearing up much of the legal and ethical mud which currently exists.
Treat it like any life-altering treatment, where careful planning and consultation is part of the procedure. Of course, issues such as forfeiting life insurance should be discussed to remove any earthly incentive or duress to end one’s life. It is also an opportunity to ensure the patient is aware of all available treatments, leaving them to choose the one they prefer (including death).
Of course, there will still be the ER cases involving violent acts against a person’s own body, whether for dramatic effect or out of impulse. I believe the laws should change there, too. In the case of an explicit suicide (i.e. with a note saying as such), I believe intervening should be treated as assault the moment anyone becomes physically involved, and anything less than a full recovery should be reasonably compensated. I’m not litigious by any means, but a person’s autonomy needs to be protected by law (obviously). The law should be indifferent to such things, not used as a “compassionate override” to righteously justify the suppression of a person’s will.
I’m not trying to oversimplify this, I just view it as an issue that shouldn’t be so legally complex. Doctors have legal protection. People have dignity. Both could be preserved if our obsession with merely keeping a heart pumping would cease.
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