Happy Thursday!
Today, we will be discussing an interesting ethical topic that is based on a patient that presented to the ED a few months ago. To set the scene, imagine you are working resus and you get a notification by EMS that there is an unresponsive patient coming in who is currently being bagged. Upon arrival, EMS informs you that they were found on the floor of their home surrounded by multiple pill bottles that contain opioids and benzos. As you get ready to intubate, you find out this patient has a DNI/DNR order. What do you do in this situation if you are concern this was a possible suicidal attempt? Do you honor the DNI/DNR that the patient made while they had capacity or do you disregard it because this patient had a possible suicide attempt? Lets dive deep into this discussion.
Lets start with DNR/DNI, when you decide to make yourself DNR/DNI, DNI or DNR, at that time you have been determined to have medical capacity and able to make an informed decision about your medical care. First point, a MOLST form is different from a DNR/DNI order. A Medical-Orders for Life Sustaining Treatment (MOLST) form can only be filled out by physician, NP or PA and is intended for patients with serious health conditions who want to avoid/ receive any or all life-sustaining treatment, reside in a long-term care facility or require long-term care services and /or might die within the next year. A DNI or DNR is a medical order written by a healthcare provider stating either do-not intubate, do-not-resuscitate, or both. Under NY state law, the MOLST form is the only authorized form in New York State for documenting both non-hospital DNR and Do Not Intubate (DNI) orders.
In New York, a DNR order only refers to withholding CPR during respiratory or cardiac arrest; it does not make any determinations on other medical treatments or the withdrawal of medical care. What do you do in the setting of suicide as the emergency medicine physician when you may have limited time and information when this type of patient comes to your ER?
When researching this, it seems to be split 50/50. Some physicians believe that regardless of how if a patient has a DNI/DNR then they will respect it even in the setting of suicide while other physicians believe that suicide may have a possible reversible cause / good outcome. When I asked some of our ED attendings, there were some split points of views, one said each scenario would be different but it would be important to involve our ethics committee because each situation may not be so clear-cut.
Something to note is that immunity for physicians who disregard a DNR is provided in situations where, in good faith, the physician had reason to believe the DNR was revoked or canceled, or they were unaware of the DNR, there is not a clear answer when it comes to a suicidal patient.
When reviewing some case reports written about DNR/DNI in a suicidal patients, both courses of actions have been taken: upholding the order and disregarding it. There is no legal precedent on what to do in this situation. One case reported involved a middle aged female with a medical history of Major depressive disorder who was found unresponsive during this inpatient psych admission after presumed opioid overdose, at that time she was found holding her DNR document, in this situation the medical team and on-call psychiatrist decided to resuscitate the patient. This case was referred to the ethical board and they agreed with the psychiatrist decision of suspending that patient’s DNR during that situation because suicide represents disordered thinking and the patient had no capacity to make medical decisions and the patient had no life-threatening or terminal illnesses. There are other cases where an ethics committee has decided that the DNR order should be upheld. Many institutions don’t have set guidelines in place regarding overriding DNR /DNI orders in the context of a suicide attempt.
One of the first things we may think about when overriding a DNR is the legality of it. If we disregard it then technically we are going against a patient’s autonomy since when they made their DNR/DNI they had medical capacity… but then does the patient have medical decision-making capacity and autonomy at the time of a suicide attempt?
Key Takeaways for Decision-Making in DNR/DNI Situations with Suspected Suicide Attempts:
Start with the Basics: Verify the validity of the DNR/DNI or MOLST form. Understand what treatments it explicitly prohibits and what it permits.
Assess Capacity: Suicide attempts often suggest temporary mental incapacity, which may invalidate prior autonomous decisions.
Err on the Side of Life: When in doubt, prioritize interventions that preserve life, especially if the situation seems reversible (possibly the most controversial point but do what you believe is right for your patient, like I said, each situation is unique)
If you are truly unsure on what to do, you may err on the side of life
Take note, that some physicians will honor the DNR/DNI or MOLST form regardless of the situation, make sure to document your actions/ reasoning well
Consult and Collaborate: If time permits, involve ethics, psychiatry, and legal teams to guide complex decisions.
Document Thoroughly: Always clearly document your reasoning and actions, particularly if you decide to override a DNR/DNI order. Good faith actions are legally protected in NY State.
No Perfect Answers: Acknowledge that every case is unique and requires individualized clinical, ethical, and legal considerations.
I hope you made it til the end of this long POTD.
Resources:
https://pmc.ncbi.nlm.nih.gov/articles/PMC7805523/
https://blog.clinicalmonster.com/2022/09/22/dnr-orders-in-the-suicidal-patient/
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.corpuspublishers.com/assets/articles/crpbs-v4-23-10102.pdf
Thanks everyone,
Caroline Paz
