The National Institute of Mental Health (NIMH) has published a fact sheet of statistics on suicide in the United States. In 2007, it is reported that suicide was the tenth leading cause of death. Furthermore, for every suicide committed, eleven were attempted. A total of 34,598 deaths occurred from suicide with an overall rate of 11. 3 suicide deaths per 100,000 people. (NIMH, 2010).
Risk factors were also noted on this report and listed “depression and other mental disorders, or a substance abuse disorder (often in combination with other mental disorders). More than ninety percent of people who die by suicide have these risk factors (NIMH, 2010). ” Since the mid-1970’s, mentally competent individuals have had the option to forego life saving or life sustaining treatment through the implementation of Do-Not-Resuscitate (DNR) orders (Cook, Pan, Silverman, & Soltys, 2010).
Medical codes of ethics, public policies, and judicial decisions advanced in the 1990’s with the development and implementation of the Patient Self-Determination Act (PSDA) which facilitates a patient’s autonomy through knowledge and use of advance directives that consists of one or all of the following: living will, medical care directive, and durable power of attorney (Butts & Rich, 2008). An advance directive is an important tool in assisting the medical profession in knowing how aggressive they need to be in treating patients that are unable to make their wishes known.
Many individuals with terminal illnesses have an advance directive and DNR in place that was developed while the individual was considered to be mentally competent. The problem, however, comes when an individual obtains a DNR and develops an advance directive as part of their suicide plan. These individuals generally are not considered to be mentally stable. This leads to the dilemma of do we, as healthcare professionals, ignore the patient’s right to autonomy and resuscitate in a suicide attempt?
Are we doing harm when we do resuscitate or don’t resuscitate? Impact on Nursing Nurses are bound to practice in accordance with the Code of Ethics for Nurses established by the American Nurses Association. The ethical principles of autonomy (self-determination), beneficence (to do good), and nonmaleficence (to do no harm) are three of the main principles that guide nursing practice. At the same time, these very same principles collide when an individual with a DNR in place attempts suicide.
Additionally, the dilemma is made obvious when one reads the contemporary definition of nursing as set forth by the American Nurses Association: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations (ANA, 2010).
Nurses practice in all types of settings; therefore, the possibility of a nurse finding an individual who is attempting to commit suicide is very real. Most state protocols instruct emergency medical service personnel to provide CPR to individuals 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 (Geppert, 2011). ” As patient advocates, are nurses that are faced with a suicidal situation supposed to advocate for life saving measures or honor the patient’s wishes to be a DNR? How would we best protect the patient? Would we be alleviating or promoting suffering?
The nurse-patient relationship often times differs greatly from that of the physician-patient relationship. Nurses spend more time with their patients which afford them the opportunity to build a strong bond with the patient resulting in the patient being more likely to confide in them. As a result, a nurse may have more of an insight into a patient’s real motives for obtaining a DNR from their physician. A patient may give clues with or without realizing they have done so; therefore, the nurse needs to be cognizant of such and relay the information to the physician.
Even if the patient has a terminal illness and has decided to end his life, the nurse who has picked up on this decision still needs to relay this information to the physician for it to be explored further. Ethical Implications An ethical dilemma arises when a patient who has an advance directive and/or a DNR in place attempts suicide. “The idea of saving people vs. allowing people to die or commit suicide is at the very essence of one of the most debated and controversial dilemmas today. As long as there is difficulty in determining rationality in suicide, this controversy will remain (Butts & Rich, 2008). Not only do the principles of autonomy, nonmaleficence, and beneficence collide with one another, but legal, religious, and/or economic values are also impacted (Cook, Pan, Silverman, & Soltys, 2010).
According to Butts and Rich, “rational suicide is a self-slaying based on reasoned choice and categorized as voluntary active euthanasia and that individuals who contemplate rational suicide have a realistic assessment of life circumstances, are free from severe emotional distress, and have a motivation that would seem understandable to most uninvolved people in their community. Contrary to that statement is the finding in the various articles read indicating that individuals who attempt suicide and either fail or succeed suffer from mental illness. Therefore, one would have to question the mental capacity of those individuals attempting suicide, the mental capacity when obtaining a DNR and planning their advance directive prior to attempting suicide, and what, if any, other medical conditions may be in place that lead to the decision to commit suicide (i. e. terminal illness).
The problem, whether to initiate life saving treatment or not, only becomes an issue when an individual is found prior to succeeding in their attempt at suicide. Of course, if it is not known that an individual has a DNR in place, then life-saving measures are automatically initiated. However, the ethical dilemma arises when there is a known DNR in place. What steps should be initiated under those circumstances? Do medical professionals honor the DNR or attempt to save the individuals life?
What if the patient is not in cardiac or respiratory arrest, does the DNR even have an impact on the situation? “The National Center for Ethics argues that questioning valid DNR orders fails to honor patient preferences and may lead to patients receiving CPR against their wishes, with the attendant physical and psychological suffering (Geppert, 2011). ” Even with that being said, “it is important to understand that respect for a patient’s autonomy goes beyond a simple consent form and entails a true understanding of a patient’s self-identity and evaluation (Patel, 2012).
I do not have a single position on this topic as my position stems from the surrounding circumstances. From the standpoint of an individual who is terminally ill and wants to take their life, I can understand their reasoning of wanting to end the suffering for themselves and their families. I had a great uncle who many years ago was diagnosed with cancer. After having his final affairs in order and things had become unbearable, he went out to his barn, shot and killed himself one day while everyone was gone.
My grandfather and I had talked about this several years after it had happened because I was curious as to how this had affected him. He told me that while it was a difficult situation he understood his reasoning, and that he was happy his brother was no longer suffering because that would have been much harder to watch. In a situation of this type, I would advocate for the patient and his wish to not be resuscitated. Additionally, it would be important to take into consideration the quality of life the individual will have if resuscitated.
I am a firm believer in “quality” not “quantity” of life. I believe it would be just as difficult, if not even more so, on family and friends for a patient to be revived and simply exist in a persistent vegetative state than it would be to allow them to expire. On the other hand, a DNR and advance directive that is obtained as part of an individual’s suicidal plan should not be honored. This, in my opinion, would be an action taken by an individual who is not completely mentally stable.
Since, as previously stated, ninety percent of individuals who attempt suicide are suffering from a mental disorder; resuscitative efforts need to be exhausted under these circumstances with follow-up psychiatric treatment to reverse the mental disorder. Most disorders are treatable with medication and counseling. It is the duty of physicians and nurses to look for signs of non-compliance with medication regimens and intervene when necessary. I don’t believe that we, as a society, have socially accepted the act of suicide as a “rational act”.
Society, I believe, looks to the medical profession to resuscitate and help individuals attempting suicide. In my opinion, we depend on the medical professionals to keep our family and friends safe and well. With the advancement of medical technology over the years, society, again in my opinion, expects greater and improved treatment options that extends and increases the quality of life. Sometimes, however, this is not possible and can result in a patient’s self inflicted demise. Possible Resolution
When physicians are issuing a DNR order, it would be imperative for them to know if the individual were suicidal or not. Therefore, completing a suicide assessment would be paramount in the physician being able to determine if this is an appropriate action or not. In documented cases of terminal illness, this should not be a factor if the individual has a short life expectancy of six months or less. An additional suggestion would be for individuals seeking a DNR order to go through a counseling session in order to determine mental competence and confirm whether or not an ulterior motive is guiding their decision.
In cases where it is known that the individual is a terminally ill patient with a DNR order in place and they have attempted suicide, then their wishes should be honored without reservation or legal consequences. Another suggestion is to have a national DNR registry, just as there is a national advance directive registry, and mandate that physicians file DNR orders with the registry and that all hospital and rescue facilities have access to the registry.
In cases of suspected suicide and the rescue squad has been called, the dispatchers should look on the registry to determine whether or not the patient has a DNR order in place while rescue is in route to the call. There also needs to be an understanding that administering a reversal agent, such as Narcan in an overdose, is not a resuscitative act and that the term DNR means do-not-resuscitate not do-not- treat.
All medical facilities should have ethics committees in place. Additionally, there should be an emergency meeting called when presented with a patient falling under this category in order to determine the best course of action. The viewpoints of all should be addressed and measured against appropriate ethical standards of care in determining and upholding the decided upon course of action.
Suicide is a difficult subject to address from many perspectives; however, when coupled with an advance directive and do-not-resuscitate order a suicide attempt becomes even more complicated. Patient autonomy is highly stressed in the medical community and throughout bioethics in general. Nurses are also bound by their professional code to “do no harm” and to “do good”. While suicide is not an illegal act it is considered an “irrational ct” resulting in physicians initiating treatment.
Because suicide is considered an irrational act attempted by an individual who does not have decision making capabilities at the time, the principle of autonomy is invalidated and beneficence and nonmaleficence are at the forefront. (Patel, 2012). If, as stated previously, there are eleven suicide attempts for every suicide completed, and in 2007 there were over 34,000 suicides, then the possibility of facing this dilemma is very real. It is imperative for health care professionals to withhold personal judgment and make decisions based on ethical principles. (Patel, 2012).
Nurses are expected to practice ethics per standard seven of the Standards of Professional Performance. This standard has multiple competencies that nurses must embrace. Nurses are responsible for “delivering care in a manner that preserves and protects healthcare consumer autonomy, dignity, rights, values, and beliefs; contributing to the resolution of ethical issues involving healthcare consumers; assisting healthcare consumers in self-determination and informed decision-making (ANA, 2010). ” When considering the definition of nursing as previously stated, it is noted that “alleviation of suffering” is included.
A fine line exists between the duty to not cause pain and suffering and duty to end pain and suffering. In the case of a terminally ill individual, honoring a DNR order in a suicide attempt addresses those duties and assists the medical professional to justify withholding treatment and alleviating the patient’s suffering. However, in cases of mental illness and attempted suicide, it may very well be that helping the suicidal individual obtain optimal mental health instead of honoring the DNR more appropriately alleviates suffering. There will probably always be a great deal of controversy over this topic and situation in general.
Emergency ethics committees may be required to meet in order to determine the appropriate course of action to take in this type of situation. It will be important for all involved to maintain an ethical viewpoint and not allow personal judgment or feelings rule the decision. Under circumstances of this nature it may be easy to become paternalistic and not uphold the rights of the individual and or family involved.
- 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.