Bioethics Forum Essay
Should a DNR Be Honored for Patient with Suicidal Thoughts?
Case Narrative
Amy is a 52-year-old with a medical history of heart failure, hypertension, diabetes, chronic kidney disease, depression, and anxiety. She voluntarily goes to the emergency department because she is experiencing suicidal thoughts and is seeking treatment for symptoms of depression. She has not attempted suicide. Her electronic medical record shows that she has a Do Not Resuscitate (DNR) order, which she made about a year earlier. When asked about it in the ER, Amy affirms that if her heart stops, she does not want to be resuscitated. The attending physician believes she does not have the capacity to make this decision because of her suicidal thoughts. Clinical ethicists are consulted to help resolve this issue.
Ethical Analysis and Process
The attending physician asked us, the ethicists, how to determine if Amy has decision-making capacity. We explained that a psychiatric disorder such as depression, which Amy sought treatment for, might alter a patient’s decision-making capacity, but that that’s not always the case. Having a psychiatric disorder alone does not preclude decision-making capacity. Amy’s affirmation of her prior DNR wish might have been influenced by her current suicidal ideation or it might reflect her fundamental values. To help determine these two possibilities, we advised the attending to assess Amy’s decision-making capacity with special attention to her reasoning process. The physician could do this by asking her questions such as, “Tell me why you would not want to be resuscitated if your heart were to stop?” If she answers, “Because I’m not worth keeping alive,” suicidal ideation may be affecting her capacity for making a DNR decision. However, if she responds with a description of her comorbidities and concern that CPR would prolong a life full of pain, she would be giving a logical reason for the DNR request, regardless of her suicide ideation.
We also encouraged the attending to consult a psychiatrist to assess Amy’s decision-making capacity and evaluate her suicidal ideation. We explained that if she has the capacity to make this decision not to be resuscitated the team’s obligation is to honor it, given the significant weight that respect for a patient’s autonomy carries in clinical ethics. In addition, we reviewed Amy’s medical chart to gather insight into her rationale for making the DNR order a year earlier and to gather more information regarding her decision-making processes at that time. The findings from both the psychiatric evaluation and our review of Amy’s medical record would strongly influence whether Amy’s doctors should honor her DNR.
In the meantime, her attending wanted to know what to do if Amy went into cardiac arrest before these findings came in. In this case, we said that clinicians should administer CPR, regardless of the patient’s DNR unless they considered it medically inappropriate. Reasons to withhold CPR include the likelihood that, given the patient’s condition, CPR would not achieve desirable outcomes such as survival to discharge without significant debility. The harms in that case might outweigh any potential benefit. It would be unjust to force CPR on a patient for whom it would not be effective, regardless of whether the patient was having suicidal thoughts.
Amy’s attending physician felt optimistic that Amy could survive CPR, given her age, but noted that her comorbidities might adversely impact her survival to discharge and quality of life. Until more was known about Amy’s decision-making capacity and medical history, the physician decided to disregard her DNR and require “full code” if Amy were to go into cardiac arrest.
The Decision
Our review of Amy’s medical history revealed no evidence that she was having suicidal thoughts when she made her original DNR request. We learned in a chart review that she had experienced CPR and never wanted it again, though she wanted all other treatments. The psychiatric assessment found that Amy’s reasoning for her current request was the same as it was a year earlier—she had experienced CPR before and never wanted it again. The psychiatric assessment also found that Amy was at low risk of suicide at this time. The psychiatrist and the attending physician believed that Amy had decision-making capacity for her DNR decision. Furthermore, the attending physician had elicited several other physicians’ opinions, and they determined that Amy’s medical comorbidities made it unlikely that CPR would achieve an acceptable outcome. Therefore, we recommended that her DNR request be honored. The attending followed our recommendation. Amy remained in the emergency department for two days before being discharged home with outpatient therapy.
Lingering Questions
This case raised questions that were not answered during the ethics consult. How should we have responded if the patient’s request for DNR was honored and then she attempted suicide while in the hospital? Would the team be obligated to honor her DNR status again? If Amy did not have decision-making capacity and her legally designated surrogates requested that CPR not be used, should that request have been honored? These questions would likely require case-by-case consideration, but creating additional frameworks to guide clinicians is an important area for future inquiry.
Lindsay Semler, DNP, CCRN, HEC-C, is the executive director of clinical ethics and department of medicine faculty at Brigham and Women’s Hospital, a lecturer at Harvard Medical School, and president and founder of Semler Ethics Consulting, LLC. LinkedIn Lindsay Semler
Derrick Pemberton, MS, BSN, HEC-C, is the system manager of clinical ethics at INTEGRIS Health in Oklahoma. LinkedIn Derrick Pemberton
Series Editors’ Comment: Autonomy is a “Thick” Concept
A foundation of medical ethics is respect for patient autonomy in making decisions about their care. Therefore, it is standard practice for healthcare professionals to assess patients’ decision-making capacity, which should be presumed unless proven otherwise. This involves evaluating their ability to communicate a choice, understand information relevant to the medical decision, appreciate the situation and consequences of the decision, and reason about the options presented.
Suicidal thoughts can complicate a patient’s capacity to make decisions. It is particularly challenging to know what to do with patients like Amy, who have suicidal thoughts and a do-not-resuscitate code status. What if such patient attempts suicide in the hospital—should clinicians abide by the patient’s wish not to be resuscitated? When clinicians face the dual imperatives of preventing patient self-harm and honoring patient choice, emotional distress due to moral uncertainty can be significant. Decisions to forego life-saving interventions, where the risks of harm are irreversible, only intensify the gravity of this dilemma: Should Amy’s choice to forego life-sustaining interventions be respected in the context of suicidal ideation?
Assessment of decision-making capacity only scratches the surface of how to resolve this dilemma. Healthcare ethics consultants are there to dive into the “thickness” of the concept of respect for autonomy—the nuances of responding to the values and reasons that underlie stated wishes.
Healthcare ethicists do this by attending closely to patients and the context in which they make medical decisions. As the case of Amy illustrates, the way this contextual work is done—the deliberate effort to gather relevant information, talk with Amy to elicit her values and reasoning, and situate her preferences within her broader medical and psychosocial history—shapes the ethical justification for the clinical team’s actions. This process is ethically significant insofar as it helps distinguish reasons grounded in a patient’s values from those driven by suicidal ideation in moments of uncertainty.
The healthcare ethicists, the attending physician, and the psychiatrist discovered that Amy’s DNR request was the result of her desire to avoid another traumatic experience with CPR rather than thoughts of suicide. The ethical justification for honoring her request rested not only on finding that she had decision-making capacity, but also on its alignment with her longstanding values. Thus, the team’s decision to honor Amy’s DNR was ethically justified.
Not all cases will resolve as decisively as Amy’s. In cases of lingering uncertainty about whether a patient’s stated objection reflects their values or a transient drive toward self-harm, sometimes temporary action contrary to that objection may be ethically justified. But the process of contextualization only becomes more critical to the dual goals of protecting patients from harm and preserving autonomous choice.
-Adira Hulkower and Georgina Campelia
