Do-Not-Resuscitate Orders in Suicide Attempts
The National Institute of Mental Health (NIMH) has published a fact sheet of statistics on suicide in the United States. In 2007, it is reported that suicide was the tenth leading cause of death. Furthermore, for every suicide committed, eleven were attempted. A total of 34,598 deaths occurred from suicide with an overall rate of 11.3 suicide deaths per 100,000 people. (NIMH, 2010). Risk factors were also noted on this report and listed “depression and other mental disorders, or a substance abuse disorder (often in combination with other mental disorders). More than ninety percent of people who die by suicide have these risk factors (NIMH, 2010).” Since the mid-1970’s, mentally competent individuals have had the option to forego life saving or life sustaining treatment through the implementation of Do-Not-Resuscitate (DNR) orders (Cook, Pan, Silverman, & Soltys, 2010). Medical codes of ethics, public policies, and judicial decisions advanced in the 1990’s with the development and implementation of the Patient Self-Determination Act (PSDA) which facilitates a patient’s autonomy through knowledge and use of advance directives that consists of one or all of the following: living will, medical care directive, and durable power of attorney (Butts & Rich, 2008). An advance directive is an important tool in assisting the medical profession in knowing how aggressive they need to be in treating patients that are unable to make their wishes known. Many individuals with terminal illnesses have an advance directive and DNR in place that was developed while the individual was considered to be mentally competent. The problem, however, comes when an individual obtains a DNR and develops an advance directive as part of their suicide plan. These individuals generally are not considered to be mentally stable. This leads to the dilemma of do we, as healthcare professionals, ignore the patient’s right to autonomy and resuscitate in a suicide attempt? Are we doing harm when we do resuscitate or don’t resuscitate? Impact on Nursing
Nurses are bound to practice in accordance with the Code of Ethics for Nurses established by the American Nurses Association. The ethical principles of autonomy (self-determination), beneficence (to do good), and nonmaleficence (to do no harm) are three of the main principles that guide nursing practice. At the same time, these very same principles collide when an individual with a DNR in place attempts suicide. Additionally, the dilemma is made obvious when one reads the contemporary definition of nursing as set forth by the American Nurses Association: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations (ANA, 2010). Nurses practice in all types of settings; therefore, the possibility of a nurse finding an individual who is attempting to commit suicide is very real. “Most state protocols instruct emergency medical service personnel to provide CPR to individuals in the field who attempt suicide, to allow time for them to be transported to hospitals where more highly trained physicians can sort out the ethical and clinical issues (Geppert, 2011).” As patient advocates, are nurses that are faced with a suicidal situation supposed to advocate for life saving measures or honor the patient’s wishes to be a DNR? How would we best protect the patient? Would we be alleviating or promoting suffering? The nurse-patient relationship often times differs greatly from that of the physician-patient relationship. Nurses spend more time with their patients which afford them the opportunity to build a strong bond with the patient resulting in the patient being more likely to confide in them. As a result, a...
References: American Nurses Association (2010). Nursing Scope and Standards of Practice. (2nd ed.) Silver Spring, MD: Author.
Butts, J. B. & Rich, K. L. (2008). Nursing Ethics Across the Curriculum and Into Practice. (2nd ed.) Sudbury Ma: Jones and Barlett Publishers, LLC.
Cook, R., Pan, P., Silverman, R., Soltys, S.M., (2010). Do-not-resuscitate orders in suicidal patients: clinical, ethical, and legal dilemmas. Psychosomatics, 51(4), 277-282. Retrieved from www.ncbi.nlm.nih.gov/pubmed/20587754.
Geppert, C.M.A., (2011). Saving life or respecting autonomy: The ethical dilemma of DNR orders in patients who attempt suicide. The Internet Journal of Law, Healthcare and Ethics, 7(1). Retrieved from http://www.ispub.com:80/journal/the-internet-journal-of-law-healthcare-and-ethics/volume-7-number-1/saving-life-or-respecting-autonomy-the-ethical-dilemma-of-dnr-orders-in-patients-who-attempt-suicide.html.
Patel, A.Y., (2012). Suicide by Do-Not-Resuscitate Order. American Journal of Hospice and Palliative Medicine, 00(0), 1-3. Doi: 10.1177/1049909112438461.
U.S. Department of Health and Human Services, National Institute of Health, National Institute of Mental Health. (2010). Suicide in the U.S.: Statistics and prevention. (NIH Publication No. 06-4594). Retrieved from http://www.nimh.nih.gov/health/publications/suicide.
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