A middle-aged male with squamous cell carcinoma and extensive metastases is brought to the emergency department (ED) after being found unresponsive following a believed suicide attempt (SA) by methadone ingestion. He had a recent month-long hospital stay complicated by severe cancer-related pain. Though paramedics administered naloxone, he remained somnolent. Paramedics hand you a Physician Orders for Life-Sustaining Treatment (POLST) form. The nurse asks, “You don’t want us to put him through anymore, right? His POLST says comfort measure only (CMO) and we should respect his wishes.” You find yourself in a situation which is ethically, emotionally, and legally challenging for all physicians.¹ Do you intervene, or allow him to comfortably pass? You want to respect patient autonomy, but is it legal to let him die without any emergency resuscitation?

The answer is no, you cannot allow this patient to die by withholding resuscitative efforts.

Suicide is not considered a rational choice, and therefore the POLST holds no legal authority in this situation, as his POLST was created in regards to his terminal illness, not his SA.² An emergency physician (EP) is in no position to determine if a POLST was made in sound mind. In regard to treating SA patients, EPs should focus on building rapport, completing a comprehensive history and physical exam, performing laboratory testing if clinically indicated, and placing patients under observation if at continued risk for self-harm.³

You order toxicology labs, an EKG, and a sitter to observe. The initial QTc is normal, but on repeat becomes prolonged. CMP reveals hypokalemia. You order IV potassium and magnesium. The patient’s respiratory rate decreases and he becomes more somnolent. You ultimately begin a slow naloxone infusion and admit him to the medical ICU. You question yourself for ordering IV potassium and starting a naloxone infusion, knowing you are causing discomfort for the patient who has known significant cancer-related pain. However, EPs are legally and morally obligated to resuscitate all patients after SA.

The goal in this situation was to resuscitate the patient to a level of alert awareness where inpatient physicians can continue goal-oriented care. Patients after SA who require intubation, continuous life support, or are permanently obtunded, pose a different challenge for physicians. In these situations, the hospital ethics committee must determine if the POLST was made in a rational manner to guide next steps. Some authors suggest it is reasonable to let patients die from SA if they have clearly expressed they would not want extensive resuscitation, have terminal illness, and would have a worse quality of life after the SA (such as a new permanent disability).⁵ This cannot feasibly be performed in the ED as it requires a significant amount of time and a multi-disciplinary assessment.

Fortunately, this patient became responsive enough for reevaluation by psychiatry and palliative medicine, and retained CMO status.

DNR/DNI status should not necessarily be rescinded after SA, especially in patients with comorbid terminal conditions. Although the majority of SA patients do not have decision making capacity (DMC), a minority are still capable of decision making. The physician’s determination of DMC must be made from evaluation of the patient’s persistent wishes throughout time, discussion with family and friends, and if terminal illness is present.⁶

This patient was discharged three days later and died within two weeks.

In summary, EPs must resuscitate all patients presenting to the ED for SA, including those with terminal illness and advance directive forms for CMO. After resuscitation, the patient should be evaluated by a multi-disciplinary team in the hospital to re-affirm the patient’s code status and medical treatment goals.

Dr. Detherage is a third year emergency medicine resident at Allegheny General Hospital in Pittsburgh, PA and current Chair of the EMRA Sports Medicine Committee.

Dr. O’Neill is the associate program director and research director for the emergency medicine residency program at Allegheny General Hospital in Pittsburgh, PA.

References

1. Nowland R, Steeg S, Quinlivan L, et al. Management of patients with an advance decision and suicidal behaviour: a systematic review. BMJ Open. 2019;9(3):e023978.
2. Pauls, M, Larkin GL, Schears RM. Advance directives and suicide attempts—ethical considerations in light of Carter v. Canada, SCC 5. CJEM. 2015;17(5):562–564.
3. Wilson MP, Moutier C, Wolf L, et al. ED recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med. 2020;38(3):571-581.
4. Sontheimer, D. Suicide by advance directive? J Med Ethics. 2008 Sep;34(9):e4.
5. Bode MJF, Huber J, Roberts DM. Decision‐making in suicide: When is the patient not for resuscitation? Emerg Med Australas. 2022 Jun;34(3):473-474.
6. Brody, BD, Meltzer EC, Feldman D, et al. Assessing decision making capacity for do not resuscitate requests in depressed patients: How to apply the “communication” and “appreciation” criteria. HEC Forum. 2017;29(4):303-311.

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