Saving Life or Respecting Autonomy: The Ethical Dilemma of DNR Orders in Patients Who Attempt Suicide

Extensive bioethics literature discusses DNR orders, but comparatively little has been published on a topic that involves almost every aspect of end-of-life decision making: DNR orders in patients who attempt suicide. Ethics consultants are increasingly confronted with this dilemma in an area where there is little legal guidance or ethical consensus. A case-based analysis of the arguments for and against honoring DNR orders in such patients is presented. INTRODUCTION AND BACKGROUND Cardiopulmonary resuscitation was introduced in the 1960s and was intended to reverse cardiac arrests occurring during surgery. By 1974, CPR was so widely applied that the American Medical Association recommended that code status, indicating the patient’s preference regarding CPR, be documented in the medical record. 2 In 1976, hospitals began implementing DNR policies, institutionalizing CPR as the default response to an arrest, unless the patient had previously provided written consent to withhold the procedure. 3 The patient Self-Determination Act of 1990, The 1983 report of the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, and the rulings in Cruzan, Quinlan and other landmark cases 5,6,7 established the right of competent patients, through both advance directives and their surrogates, to refuse life-sustaining treatments, providing the ethical and legal basis of DNR orders. Currently, the Joint Commission standards require all health care institutions to have policies and procedures regarding advance directives and DNR orders. All 50 states have statutory requirements that uphold the autonomy of competent patients to make health care decisions, including those regarding CPR, and to exercise this self-determination through authorized surrogates should they lose decision-making capacity. Few of these statutes, including the New Mexico Uniform Health Care Decisions Act, explicitly mention the dilemma of the suicidal patient who is DNR. 8 Despite the view of courts, legislatures, and government panels, research over decades has shown that patients’ treatment preferences regarding life-sustaining treatment, especially CPR, are often disregarded. 9,10 A 1997 survey found that most emergency room physicians would resuscitate a patient even when they thought the procedure would not benefit the patient, or the case was futile, primarily out of fear of litigation or criticism. Legal advance directives were generally honored, while other expressions of patient’s wishes were not. 11 A 2009 study compared emergency room physician practices regarding initiation of CPR from 1995-2007. Advance directives were honored more than 80% of the time, but informal communications of patient wishes were not often followed. Eighty-two percent felt legal concerns should not influence resuscitation decisions, yet 92% believed that their decisions were influenced by such concerns. Because of the current legal climate, more than half of physicians surveyed had performed CPR more than 10 times in the last 3 years in cases where they believed the intervention would be futile. 12 A voluminous bioethics literature discusses these developments, but comparatively little has been published on a topic that involves almost every aspect of end-of-life decision making: DNR orders in patients who attempt suicide. Most of what has been written on the subject comes from emergency medicine or psychiatry. 13,14 Beginning in the 1980s, a growing number of states began to implement pre-hospital or out-of-hospital DNR protocols, transferring the ethical and legal dilemmas that had faced emergency room and intensive care physicians to emergency medical Saving Life or Respecting Autonomy: The Ethical Dilemma of DNR Orders in Patients Who Attempt Suicide 2 of 7 service (EMS) personnel. These policies increased the likelihood that EMS personnel would encounter individuals with DNR orders who had attempted suicide, and required that ethical and legal guidance be provided on how first responders should manage the ethical dilemma. 16 Most state protocols instruct EMS to provide CPR to patients in the field who attempt suicide, to allow time for them to be transported to hospitals where more highly trained physicians can sort out the ethical and clinical issues. For instance, the New Mexico Administrative Code states that, “if there is any question about the validity of an EMS DNR order, or there is any indication of an attempted homicide or suicide, initiate resuscitation until such time that the questions have been answered; if possible, contact medical control for consultation.” 17 Koenig and Salvucci report one of the only court decisions directly addressing the question. The San Diego County Counsel opined that a valid out-of-hospital DNR should be honored, even if the individual had attempted suicide. 18 These authors also argue for a prospective systems-based approach that removes responsibility from EMS at the scene. They also question the standard practice of default CPR for suicide attempters: Although we believe, ‘when in doubt, resuscitate, ‘ initiating truly unwanted invasive interventions can be viewed as just as egregious as withholding desired resuscitation. We have a responsibility to examine these issues proactively and attempt to preserve patient autonomy to the best of our ability. 19 Research has highlighted the inadequacies of DNR discussions that may contribute to these dilemmas, especially in teaching hospitals, and the need for improved physician education in soliciting patient preferences. 20 Sontheimer examined a case analogous to that presented in this paper in an article appositely titled, “Suicide by Advance Directive,” 21 while Karlinsky, Cook and colleagues analyzed a series of cases from a psychiatric perspective. 13,22 Physicians from all specialties were faced with a different, yet related problem, of how to handle DNR orders when the arrest was the result of an iatrogenic event.