Should Health Care Providers Uphold the DNR of a Terminally Ill Patient Who Attempts Suicide?

Abstract

An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which the DNR of a terminally ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations (Brown et al. in Am J Bioeth 13(3):3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail.

This is a preview of subscription content, access via your institution.

References

  1. Braun, U. K., Beyth, R. J., Ford, M. E., et al. (2007). Defining limits in care of terminally ill patients. British Medical Journal, 334, 239–241.

    Article  Google Scholar 

  2. Brown, S. M., Elliott, C. G., & Paine, R. (2013). Withdrawal of non-futile life support after attempted suicide. American Journal of Bioethics, 13(3), 3–12.

    Article  Google Scholar 

  3. Crowley, C. (2011). Life interrupts an attempt to die at home. Albany, NY: Times Union.

    Google Scholar 

  4. Geppert C. (2011). Saving life or respecting autonomy: The ethical dilemma of DNR orders in patients who attempt suicide. The Internet Journal of Law, Healthcare and Ethics, 7(1). http://ispub.com/IJLHE/7/1/11437.

  5. Gunderson, M., & Mayo, D. J. (2000). Restricting physician-assisted death to the terminally ill. Hastings Center Report, 30(6), 17–23.

    Article  Google Scholar 

  6. Kass-Bartelmes, B. L., & Hughes, R. (2003). Advance care planning: Preferences for care at the end of life. Research in Action, 12, 1–20.

    Google Scholar 

  7. Krischer, J. P., Fine, E. G., Davis, J. H., et al. (1987). Complications of cardiac resuscitation. Chest, 92, 287–291.

    Article  Google Scholar 

  8. Librach, S. L. (1995). Special issues in pain control during terminal illness. Canadian Family Physician, 41, 415–419.

    Google Scholar 

  9. Lizza, J. P. (2007). Potentiality and human embryos. Bioethics, 21(7), 379–385.

    Article  Google Scholar 

  10. Mercadante, S. (2014). Managing difficult pain conditions in the cancer patient. Current Pain and Headache Reports18 (2), 395.

    Article  Google Scholar 

  11. Pessin, H., Rosenfeld, B., & Breitbart, W. (2002). Assessing psychological distress near the end of life. American Behavioral Scientist, 46(3), 357–372.

    Article  Google Scholar 

  12. Rachels, J. (1975). Active and passive euthanasia. The New England Journal of Medicine, 1975(292), 78–80.

    Article  Google Scholar 

  13. Rosenfeld, B., Pessin, H., Marziliana, A., et al. (2014). Does desire for hastened death change in terminally ill cancer pateints? Social Science and Medicine, 111, 35–40.

    Article  Google Scholar 

  14. Sine, D. M. (2010). EMS, suicide, and the out-of-hospital DNR order. The Online Journal of Health Ethics, 6(1), 1–13.

    Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Lisa Campo-Engelstein.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Campo-Engelstein, L., Jankowski, J. & Mullen, M. Should Health Care Providers Uphold the DNR of a Terminally Ill Patient Who Attempts Suicide?. HEC Forum 28, 169–174 (2016). https://doi.org/10.1007/s10730-015-9289-1

Download citation

Keywords

  • DNR
  • Terminally ill
  • Suicide
  • Ethics