Case Report: A 64 year old male presented 12 hours after ingesting 1.2 grams of morphone in an attempt to end his life. Past medical history included a previous cardiac arrest and depression exacerbated by the recent loss of his wife. Following his prior cardiac arrest, he had initiated a DNR/DNI order. On admission, the patient was somnolent, had a respiratory rate of 6 and was oliguric with creatinine and potassium increasing to 4.9 mg/dl (baseline 1.4 mg/dl) and 6.7mmol/L respectively, over 24 hours. He asked that he be allowed to die without further treatment. His daughter also asked that we honor his DNR/DNI request. The hospital Ethics Committee felt the patient should retain his DNR/DNI status; however, since his acute renal failure was related to the suicide attempt, dialysis, if necessary, should be performed against his wishes. Subsequently, the patient developed progressive, diffuse myoclonic activity, and asystolic arrest. No attempts at resuscitation were made.
Discussion: This case demonstrates the difficulty in caring for actively suicidal patients and is unique in that our patient had a prior, long-standing DNR/DNI order. Although the patient's daughter was able to convince him to come to the hospital for treatment, it was felt that this action did not pre-empt his advance directive. What care should be provided to a suicidal patient who has previously established advance directives is an ethical dilemma that may be encountered more as the population ages. Decision making is grounded in the principles of autonomy and justice, both of which require a rational patient. Suicide is not typically considered a rational choice, and therefore creates for physicians a possible exception to following patient wishes. In this case, the patient's long-standing DNR wishes were respected, but his desire to limit treatment for conditions related to his suicide attempt, was not considered a valid, rational decision.
(C) 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins