Monday, September 29, 2008

'Suicide by advance directive'

The Journal of Medical Ethics has a case discussion provocatively titled 'suicide by advance directive.' The case involves a woman who tried to commit suicide by an insulin overdose who was ventilator dependent and in a coma (who had a poor, but uncertain, prognosis of neurologic recovery) who had an advance directive saying that she would not want to be on a vent if her prognosis was poor etc. In fact, she lay her advance directive next to her when she tried to kill herself, and it was obviously ignored by EMS/the emergency department as would be the standard of care with any suicide attempt.

The report analyzes the decision making that occurred, eventually leading to withdrawal of life-prolonging treatments including the ventilator and the patient's death. It's clear to me from the discussion however that it's not fair to label this a 'suicide by AD.' A long, careful decision-making process occurred with the patient's loving family, her doctors, and an ethics team which clarified that the patient would not want to be maintained in such a state under any circumstances. The AD was one piece of 'supporting evidence' for the patient's wishes/values, but it was not applied blindly and without great reservation and careful deliberation. Not intubating the patient in the first place because she had an AD next to her or a DNR bracelet on her may reasonably constitute a 'suicide assisted by an AD' but not this case.

None of this is to criticize the paper itself as it contains a really good discussion about decision-making in patients who have 'nearly' committed suicide and families and doctors are faced with the agonizing decision of what to do - maintain a patient in a permanently disabled state (which may be an affront to a patient's dignity) or let them 'complete' their suicide. Cases like these come up for my time at least once or twice a year. My own feeling is that, assuming the prognosis is relatively firm, if a patient's loved ones/decision makers support the idea that the patient would never want to be maintained in such a state (no matter how they got there - car crash, cardiac arrest, suicide attempt) it is certainly appropriate to stop life-prolonging treatments.

J Med Ethics also has a discussion about DNR orders, warning about them being over-interpreted and misapplied (e.g. interpreting them to mean no intubation under any circumstances when the order really is supposed to mean no intubation - and other advanced life support measures - in the case of a cardiopulmonary arrest).

These are well-established concerns of course and what's new here (at least to me) is their proposal of having "No chest compression" orders instead of 'DNR' orders for those patients who could benefit from/would want many 'aggressive' treatments in non-arrest situations. It's not a bad idea by itself (although inevitably then you'd get people worrying it means they should intubate a patient who has arrested but not give them chest compressions), but it seems that what institutions really need are policies and forms which parse out the different scenarios reasonably (e.g. elective intubation for pneumonia OK, but no resuscitative efforts for an arrest, etc.) without creating a menu-check-box system which will encourage residents to ask patients 30 questions along the lines of "If your heart stops do you want chest compressions? If your heart stops do you want electric shocks? If your blood pressure is low do you want medications to raise it?" - without them actually having a conversation about prognosis and goals.
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