The National Institute of Mental Health (NIMH) has published a fact sheet with suicide statistics in the United States. In 2007, suicide was the tenth leading cause of death, resulting in 34,598 deaths and an overall rate of 11.3 suicide deaths per 100,000 individuals. The fact sheet highlights that for every suicide completed, there were eleven attempted suicides (NIMH, 2010).
The report emphasized that risk factors such as “depression and other mental disorders, or a substance abuse disorder (often in combination with other mental disorders)” were significant. The study discovered that more than 90% of individuals who commit suicide have these risk factors (NIMH, 2010). Since the mid-1970’s, mentally competent people have been able to refuse life-saving or life-sustaining treatment through the use of Do-Not-Resuscitate (DNR) orders (Cook, Pan, Silverman, & Soltys, 2010).
The Patient Self-Determination Act (PSDA) introduced in the 1990’s brought significant advancements in medical codes of ethics, public policies, and judicial decisions. This act enabled patients to exercise their autonomy by providing them with knowledge and the ability to use advance directives such as living wills, medical care directives, and durable powers of attorney (Butts & Rich, 2008). These advance directives allow patients to communicate their wishes regarding medical treatments to the medical profession, particularly when they are unable to express their preferences.
When dealing with terminally ill individuals, it is typical for them to possess an advance directive and a Do Not Resuscitate (DNR) order that they created while mentally competent. Yet, difficulties arise when these documents are utilized in a suicide plan, especially if the person’s mental condition is unstable. This presents healthcare professionals with a challenging dilemma as they must determine whether to respect the patient’s autonomy and abstain from resuscitating them during a suicide attempt.
When we decide to resuscitate or not, are we inflicting harm? This question significantly affects nursing. Nurses have a duty to adhere to the Code of Ethics for Nurses established by the American Nurses Association. Autonomy, beneficence, and nonmaleficence are three primary ethical principles that direct nursing practice. However, these principles clash when an individual with a do-not-resuscitate (DNR) order attempts suicide.
Furthermore, the predicament becomes clear when reading the modern definition of nursing provided by the American Nurses Association: Nursing involves safeguarding, promoting, and enhancing health and abilities, preventing illness and injury, relieving suffering through diagnosis and treatment of human response, and advocating for the care of individuals, families, communities, and populations (ANA, 2010).
In any setting, nurses may encounter individuals attempting suicide, highlighting the potential reality of such situations. State protocols often advise emergency medical service personnel to administer CPR to these individuals so that they can be transported to hospitals where specialized doctors can address the ethical and clinical complexities involved (Geppert, 2011). This poses a dilemma for nurses: should they support life-saving interventions as patient advocates or honor the patient’s desire to be a DNR (do not resuscitate)? It becomes crucial for nurses to assess the best course of action in order to safeguard the patient and determine whether it mitigates or exacerbates their suffering.
The nurse-patient relationship is distinct from the physician-patient relationship as nurses have ample time to develop a strong bond and earn the patient’s trust. This enables patients to comfortably discuss their reasons for desiring a Do Not Resuscitate (DNR) order with their doctor. It is essential for nurses to carefully observe any indications or hints regarding the patient’s intentions and effectively convey this information to the physician.
Despite a terminally ill patient choosing to end their own life, it is crucial for the nurse to inform the physician of this decision. This allows for further evaluation of the situation. The ethical consequences arise when a patient with an advance directive and/or a DNR tries to commit suicide, resulting in heated discussions within society. Conflicting principles such as autonomy, nonmaleficence, and beneficence come into play, along with considerations of legal, religious, and economic values (Cook et al., 2010; Butts & Rich, 2008).
According to Butts and Rich, rational suicide refers to the deliberate choice of individuals to end their lives based on reasoning. It falls under the category of voluntary active euthanasia. These individuals possess a realistic understanding of their life circumstances, are not experiencing severe emotional distress, and their motivation is comprehensible to most people in their community. However, several articles indicate that those who attempt or succeed in suicide typically suffer from mental illness. This raises inquiries about the mental capacity of these individuals when making decisions like obtaining a DNR (Do Not Resuscitate) order and planning advance directives before attempting suicide. Additionally, it is crucial to consider any other medical conditions, such as terminal illness, that may contribute to their decision for self-inflicted death.
The ethical dilemma occurs when an individual is found before successfully completing their suicide attempt, regarding whether to begin life-saving treatment. If the person does not have a Do Not Resuscitate (DNR) order on record, life-saving measures are implemented automatically. However, the moral conflict arises when there is a known DNR order in effect. In such cases, medical professionals must decide whether to respect the DNR or attempt to save the individual’s life.
According to the National Center for Ethics (Geppert, 2011), disregarding valid Do Not Resuscitate (DNR) orders can result in negative consequences such as patients undergoing undesired CPR and going through physical and emotional distress. However, it is important to recognize that honoring a patient’s autonomy goes beyond consent and requires a true understanding of their self-identity and evaluation (Patel, 2012).
While my viewpoint on this matter is not fixed, it is shaped by the particular circumstances. When an individual is gravely ill and wishes to end their own life, I can understand their desire to ease suffering for themselves and their loved ones. In my personal experience, my great uncle was diagnosed with cancer a few years ago. After making necessary arrangements and enduring excruciating pain, he chose to end his life by shooting himself in his barn when no one else was around.
Years later, my grandfather and I had a conversation about the aforementioned situation. I was interested in knowing how it had affected him personally. He explained that although it was a challenging scenario, he understood the reasons behind it. He felt relieved knowing that his brother was no longer suffering, as witnessing such pain would have been even harder. In these situations, I strongly believe in respecting the patient’s decision on resuscitation and also considering their quality of life if they were revived.
I strongly advocate for prioritizing the “quality” of life rather than the “quantity” of life. It would pose similar or perhaps even greater difficulties for both loved ones and friends if a patient were revived but left in a persistent vegetative state, as opposed to allowing them to pass away. Nonetheless, I hold the belief that a Do-Not-Resuscitate (DNR) order and advance directive should not be honored if they are part of an individual’s plan to end their own life. This decision appears to originate from someone who is mentally unstable.
Given that the majority of people who attempt suicide have a mental disorder, it is crucial to make every effort to revive them during such incidents and then provide psychiatric therapy to treat the underlying condition. Many disorders can be effectively managed through medication and counseling. It is the responsibility of medical professionals to stay alert for any signs of non-compliance with medication schedules and intervene as needed. In my opinion, society has not fully embraced suicide as a “reasonable act”.
Society depends on healthcare professionals to intervene and aid individuals contemplating suicide, as we rely on experts in the medical field to safeguard the well-being of our loved ones. Advancements in medical technology offer hope for improved treatment options that can enhance and extend the quality of life. However, there are cases where this objective cannot be achieved, resulting in patients taking their own lives. Therefore, it is crucial to find a potential solution.
When issuing a DNR order, it is important to evaluate the person’s suicidal tendencies in order to assess the appropriateness of this action. However, if the individual has a terminal illness with a life expectancy of six months or less, this factor should not be taken into account. Additionally, individuals who are seeking a DNR order should receive counseling to assess their mental competence and discover any hidden motives that may impact their decision.
A national registry for do-not-resuscitate (DNR) orders should be created to fulfill the desires of terminally ill individuals. This registry would function similarly to the current national advance directive registry, requiring doctors to register DNR orders and ensuring that this information is accessible to all hospitals and rescue facilities.
When there is a suspected suicide and the rescue squad has been contacted, dispatchers should examine the registry to verify if the patient possesses a DNR order. This examination should occur while the rescue team is en route. It is crucial to comprehend that administering Narcan or any other reversal agent for an overdose does not count as resuscitative measures. Additionally, it is important to clarify that DNR stands for do-not-resuscitate, rather than do-not-treat.
All medical facilities should have ethics committees in place. In addition, there should be an emergency meeting organized when dealing with a patient falling into this category to decide the most suitable action. The opinions of everyone should be considered and evaluated according to the ethical standards of care when determining and maintaining the chosen course of action.
Conclusion
Discussing suicide, particularly in conjunction with an advance directive and do-not-resuscitate order, introduces complexity. The medical community and bioethics stress the significance of patient autonomy. Nurses are bound by their professional code to prioritize “do no harm” and “do good.” While suicide is not considered a criminal act, it is seen as an “irrational act” that prompts physicians to initiate treatment.
Due to the perception of suicide as an irrational act committed by individuals incapable of decision-making, the principle of autonomy is disregarded. Instead, emphasis is placed on beneficence and nonmaleficence (Patel, 2012). The gravity of this issue becomes evident when considering that there are approximately eleven suicide attempts for each completed suicide and a staggering number of over 34,000 suicides occurred in 2007 alone (Patel, 2012). Consequently, healthcare practitioners ought to abstain from making personal judgments and instead adhere to ethical principles.
According to Standard seven of the Standards of Professional Performance, nurses are required to follow ethical practices. This standard includes various competencies that nurses need to adopt. Nurses have the responsibility to provide care while respecting and safeguarding the autonomy, dignity, rights, values, and beliefs of healthcare consumers. Furthermore, nurses must address ethical concerns related to healthcare consumers and assist them in making informed decisions and exercising self-determination (ANA, 2010). It is crucial to acknowledge that nursing also aims to alleviate suffering.
There is a delicate balance in the responsibility of preventing and alleviating pain and suffering. This is evident when someone who is terminally ill has a DNR order. Respecting this order during a suicide attempt allows healthcare providers to fulfill their obligations by not treating the patient and easing their suffering. However, in cases of mental illness and attempted suicide, it may be better to prioritize helping the individual achieve optimal mental health instead of strictly following the DNR order. By taking this approach, suffering can be effectively reduced. The complexity of this issue leads to ongoing controversy.
Emergency ethics committees may need to convene in order to determine the most appropriate course of action in these situations. It is imperative for all parties involved to uphold ethical principles and refrain from allowing personal biases or emotions to impact their decision-making. Care must be taken in these circumstances to avoid excessive paternalism and ensure that the rights of individuals and their families are respected.
References
- American Nurses Association (2010). Nursing Scope and Standards of Practice. (2nd ed. ) Silver Spring, MD: Author. Butts, J. B. &
- Rich, K. L. 2008. Nursing Ethics Across the Curriculum and Into Practice. (2nd ed. ) Sudbury Ma: Jones and Barlett Publishers, LLC.
- Cook, R. , Pan, P. , Silverman, R. , Soltys, S. M. , (2010). Do-not-resuscitate orders in suicidal patients: clinical, ethical, and legal dilemmas. Psychosomatics, 51(4), 277-282.
- Geppert, C. M. A. , (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). Retrieved from http://www. ispub. om:80/journal/the-internet-journal-of-law-healthcare-and-ethics/volume-7-number-1/saving-life-or-respecting-autonomy-the-ethical-dilemma-of-dnr-orders-in-patients-who-attempt-suicide. html.
- Patel, A. Y. , (2012). Suicide by Do-Not-Resuscitate Order. American Journal of Hospice and Palliative Medicine, 00(0), 1-3.
