title: 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.
authors.affiliation: Alden March Bioethics Institute, Albany Medical Center, 47 New Scotland Avenue, Mail Code 153, Albany, NY, 12208, USA. campoel@mail.amc.edu.|Department of OBGYN, Albany Medical College, 47 New Scotland Avenue, Mail Code 153, Albany, NY, 12208, USA. campoel@mail.amc.edu.
authors.forename: Lisa
authors.initials: L
authors.lastname: Campo-Engelstein
authors.affiliation: Alden March Bioethics Institute, Albany Medical Center, 47 New Scotland Avenue, Mail Code 153, Albany, NY, 12208, USA.
authors.forename: Jane
authors.initials: J
authors.lastname: Jankowski
authors.affiliation: Health Sciences, Sage Colleges, 65 First Street, Rickets 320, Troy, NY, 12180, USA.
authors.forename: Marcy
authors.initials: M
authors.lastname: Mullen
mesh_terms: D000368:Aged; D005260:Female; D005909:Glioblastoma / Q000150:complications / Q000523:psychology; D006282:Health Personnel / Q000941:ethics*; D006801:Humans; D016414:Resuscitation Orders / Q000941:ethics* / Q000523:psychology; D013406:Suicide, Attempted / Q000941:ethics* / Q000523:psychology*; D019452:Terminally Ill / Q000523:psychology*
keywords: DNR; Ethics; Suicide; Terminally ill