Friday, July 26, 2013

Guest Blogger Simple Citizen on The Suicidal Patient's Right to Have Advance Directives Honored

Simple Citizen is a psychiatrist reader with his own blog (see our sidebar).  This started as a comment, but I asked to use it as a stand-alone post.  Dr. Citizen writes:
 

We have the right to die, but not the right to commit suicide.

This makes my life in Consult Psychiatry extremely difficult, especially when someone has an Advance Directive that states "Do-Not-Resusciate" and then they try to kill themselves.

They arrive at the hospital in critical condition, the medical team knows the need to be intubated and they are likely going to go into cardiac arrest. Should they intubate them and save them because suicide is illegal, and the person may want to live when they are not in crisis? Or do the doctor's let the patient die because of the patient's pre-written wishes?

Worse yet - what if the person didn't have an advance directive, but when they are crashing in the hospital, they tell the whole medical team that they refuse CPR and intubation. Does a person who just attempted suicide have the capacity to make that decision?

More of my thoughts here if you're interested:
http://thoughtsofasimplecitizen.blogspot.com/2012/03/right-to-die-v-right-to-prevent-suicide.html

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So here's my question: okay, it's one thing if someone checks into a hotel room, makes a serious attempt, notifies no one, has an Advance Directive in their hand and a DNR order tattoo'd on their forehead, but oops, the maid finds them.   That's it's own touchy issue -- unless you're their wife or mother or son, in which case I don't think it's a question at all.  But what do we do about the patient who overdoses, then emerges from the bathroom to tell their significant other "I just took all my pills".  Or the person who makes an attempt then dials 911 or goes to the ER.  How do you stand there and let someone die because they have a piece of paper saying they don't want CPR or intubation?  Is it really reasonable to have this type of attempt and announce it?  Isn't there an element of cruelty to it?  So many people attempt suicide and wake up glad to be alive.

I'm going to add that I don't believe Advance Directives made by people without psychiatric disorders are binding if the patient does not have a terminal illness.  A healthy  person can't go into a routine appendectomy or tonsillectomy and say "if something goes wrong, you can't even attempt to resuscitate me."  No surgeon or anesthesiologist would ever accept that malpractice risk. --"I'm so sorry Mr. Smith, buy your 20 year old son had a tension pneumothorax during the procedure, and we could have intubated him and put in a chest tube, and he'd have spent a couple of the days in the ICU then made a full recovery, but he said no tubes/no intubation."  Advance Directives are meant for situations where someone has a terminal condition -- cancer or Alzheimer's Disease, or AIDS.  And what would we do about children?  Would we allow a parent to make a healthy child DNR in the event of treatable illness?