Do-Not-Resuscitate Orders After Suicide Attempts: To Uphold or Suspend?

When a patient with a pre-existing DNR attempts suicide, physicians must decide between two conflicting options: upholding the patient's DNR and risking a potentially avoidable death or suspending the DNR and risking violating the patient's autonomy. The bioethics literature has proposed a variety of principles to guide decision-making in such cases, but provides little clarity and fails to address all principles cited by physicians when confronted with such cases. Furthermore, little attention has been paid to the ongoing ethical dilemmas medical teams may face when treating a patient with a DNR after a suicide attempt. Using a composite case derived from four clinical cases in which patients with pre-existing DNR attempted suicide and the principles their physicians cited, we develop an ethical framework for the ongoing decision-making required of medical teams treating these patients. We analyze three primary factors, assessing their relevance and utility for decision-making: patient decision-making capacity, physician complicity in suicide, and expected quality of life. We conclude that although physician complicity in suicide and a patient's expected quality of life have intuitive appeal and may influence decision-making in practice, clinicians should set these principles aside and instead focus on assessing a patient's decision-making capacity at the time of their DNR request.