Patients who attempt suicide and withdrawal of medical care

If a person tries to commit suicide, could that be considered as a statement that this person wishes to die and does not want aggressive treatment to save his or her life?

Not from a legal standpoint, and not if you are living in the United States.

A middle-aged man with a long standing history of depression decides to end his life. He puts a large caliber gun straight to his forehead and squeezes the trigger.

Patients who attempt suicide and withdrawal of medical care

The bullet shutters his frontal lobe leaving many bullet fragments behind. The damage is extensive with the bullet track ending in the occipital lobe. The skull x-ray above demonstrates multiple bullet fragments in the frontal lobe (small black arrows) and the main bullet fragment in the occipital lobe (large black arrow).

The patient was unresponsive at the scene and remains so in the hospital. He was put on a ventilator and remains stable otherwise.

No signs of the neurological recovery are evident. The patient is unable to follow any commands and remains completely unresponsive. The conclusion of the physicians involved in his care is that no meaningful neurological recovery is possible. Yet, his brainstem remains intact, so the basic reflexes like corneal and cough reflexes are present, precluding a progression to brain death.

The patient has no family. No appointed legal guardian or representative to assist with decision making is available. How do you decide if withdrawal of care is in the patient’s best interests? No meaningful recovery is possible, so can we consider the fact that the patient was trying to commit suicide as a statement allowing doctors to withdraw care?

The answer would be “No” if you ask your corporate attorney. A legal guardianship is necessary to be able to withdraw care.

Things get even more complicated when organ donation is considered. In a sense, the patient is a “perfect” organ donor -– previously healthy and with isolated brain damage. The family’s consent is necessary to proceed with donation. Since no family is available, it all comes down to legal guardianship. Obtaining guardianship could take time and it could be expensive as well. Waiting for the legal paperwork to go through might simply preclude the possibility of successful organ donation all together.

On the flip side of this issue is a concern that many suicide attempts are, indeed, cries for help rather than a genuine desire to end one’s life. Depression which is very prevalent among patients attempting suicide is a treatable condition and, thus, a future suicide can be prevented.

What if the person “didn’t mean” to die by committing suicide, but simply “overdid” it. In many cases the patients admit that trying to end one’s life is a bad idea and they would never do it again. Some patients simply underestimate the harmful effects of various medications used for suicide. Many people do not realize that serious liver damage and death can occur from a high dose of Tylenol, even though it is readily available over the counter.

Suicide and withdrawal of medical care could be a complicated issue. There might not be good ethical or legal support to facilitate decision making in these cases. It doesn’t help that the patient, who has no chances for recovery, is unable to die.

Ralph Gordon is a critical care physician who blogs at realICU.

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  • madoc

    I am interested in suicide.
    But I am more interested in the doctors that kill themselves.
    I have had too many of my doctor friends
    commit suicide.
    Let’s do something about that.

  • KP Internist

    Doctors don’t commit suicide any more frequently than any other profession. In fact less so than say dentists.
    I say that the soul is not inside this body any longer and the state should be able to remove life support or donate the organs depending on what will be the greater good to society.

  • BobBapaso

    The answer is NO, unquestionably. A suicide attempt, successful or not, does not mean a person wants to die. It means they want to live but just can’t figure out any way to succeed at it at the moment. Most people who awaken from suicide “attempts,” even seriously maimed, verbalize their wish to live almost immediately.

    This should be obvious. Normal human nature is to want to live, period. To live forever. Normal conscious thought is often ambivalent and sometimes loses sight of the person’s real desires. If you think about doing anything it is good to “sleep on it” and see if it feels like something that’s right for you.

    Life support should be removed from all bodies that have no potential to regain consciousness and some quality of life.

  • Dr. Bioethics

    At this point, a guardian ad litem needs to be appointed and, despite the fact that the patient may never regain any mental faculties, this patient needs to be under the care of a multi-facted group of physicians (and others who are looking out for the patient’s best interests). Despite the fact that the patient attempted suicide, does not mean that the patient is not deserving of all life-sustaning measures (unless legally stated otherwise). Look at the Dax Cowart case. This man continuously refused medical treatment, and upon his release, he then attempted suicide several times (unsuccessfully), and now he advocates for patients to refuse any kind of life-sustaining treatment under the principle of autonomy.

    Subsequently, taking into consideration the potential for organ donation, only further obscures the fact that this specific patient is not being honorably treated as an autonomous human being. Instead, he is being looked at as a person who could fulfill other ends, for other patients.

    This is a complicated situation. Obviously nobody wants this patient to end up like Nancy Cruzan, yet others don’t want to override his rights to life sustaining treatment. At the end of the day, appointing a guardian ad litem is the ethical thing to do. And based on the recommendations of the clinical team, in correspondence with the legal (guardian ad litem) and the ethics consultation team, can a true decision be made about the fate of this specific patient.

  • TellinThaTruth

    Wow! What a situation to be in. I think obtaining legal guardianship should be the goal of the doctor that way he’d be able to donate the patient’s organs to those in need.

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