DNR's and Attempted suicide

went on a call 84 old YOF, arrived on scene pt out(valium ) about 80-90 pills, pt worked up by paramedic, narcain, the whole 9 yards, transported to hospital. Pt is alive throughout call, get to hospital, family states pt has a DNR, pts family says nothing on scene. important: suicide note, and important papers are found at scene, from pt

QUESTION: can the DNR be honored when the pt without a doubt, tried to commit suicide, at my company, and talking to some nurses at ER, and 1 doctor all have differing opions, we do not know how the legal interpetation would pan out, curious as to yor thoughts. case happened in New York State

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Permalink Reply by Glo on January 14, 2009 at 3:33am

Good question!
Well, like Lee, I don't know anything about NY laws, but here in MO a DNR applies to someone who is coding.
Definition of DNR: "In the United States, a Do Not Resuscitate, or DNR order is a written order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest."
1: If the patient you are referring to has not yet gone into cardiac or respiratory arrest, then you haven't reached the point where a DNR is needed. You stated, "Pt is alive throughout call", so I am assuming he did not code. If I am assuming wrong, please let me know.
2: No one told you of the DNR before you started treatment. You cannot honor something that has not been called to your attention.
3: Also, a DNR is given to a patient when they (or family member) makes a competent decision. Obviously, if he is in the state of mind to off himself, he was not in a competent state.
I think I was either told or reading somewhere (keep in mind, it was many, many moons ago) about implied consent. If memory serves me correctly (which at my age is hit and miss - lmao), rescuing a suicide attempt, even with a DNR, falls under implied consent. I could be imagining it ... or it could have just been one of the voices in my head telling me that. lol hahaha!
Besides, the way I see it, when in doubt, whip it out and go to town.
Marc, please let me know the official decision on this, okay? Thanx!

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Permalink Reply by Mike Rubin on January 14, 2009 at 8:05am

I used to work in NY. I don't remember any exceptions about not honoring a DNR if suicide is suspected. That would be asking a lot of prehospital providers in a narrow time frame.

I forget the exact wording of the protocol, but we did have the right to disregard the DNR if we thought it wasn't legitimate. However, if a family member hands you a DNR for your patient, you'd better have a very good reason for ignoring it. You could be sued.

Was your patient in cardiac or respiratory arrest? If not, the DNR doesn't apply. Most of the cases that I reviewed concerning DNR errors involved DNR vs. "DNT" (do not treat).

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Permalink Reply by Bob Walker on January 14, 2009 at 8:51am

I would think that the DNR would be invalid in this case. Suicide is against the law (I believe in every state in the US). The DNR is good for patient's with terminal disease processes that die from those diseases. I would be calling medical control and passing the buck to them,

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Permalink Reply by Lisa Ann on January 14, 2009 at 2:30pm

I do not believe that a DNR is free pass for a suicide attempt. As an RN and working at my facility I had a patient who had a valid DNR order in his chart. I stayed late one evening to spend time with my evening staff and have a staff meeting. The nursing assistant came out to the confeence room and said patient XYZ is having some increased difficulty breathing. I and my charge RN walked into the room and found him to be in aute respiratory distress. I informed him that we would make him as comfortable as possible but that he most likely need to be intubated but since that he had a signed DNR/ DNI order that i would call the house MD to come and see him and order some mediaction to help him. The patient looked right at me and said Please help me I don't want to die, do what you need to do. My charge RN paged the house MD stat to the unit and by the time he arrived the patient went into a respiratory arrest. Since I was in the room and it was witneseed by the other patient and the nursing assistant the patient clearly stated he wanted me to keep him alive I initiated a Code and began CPR.... the patient survived however I had to answer to the Chief of Staff of the Medical Department as well as my Director of Nursing, it went to the ethics committee and after much discussion and interviewing of the patient iwho was competent and it was deemed that I acted in the best interest of the patient and that the DNR was not valid when he requested that I "keep him alive".
As a Medic when I encounter a patient with a DNR order I try to make sure that they understand what I am able to do according to their written wishes, I usually try and have this discussion with family and or other EMS personnel and if it is with a nursing home unit with that nurse. Just because a patient has a DNR does not mean that I don't either work them up within the parameters.

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Permalink Reply by Marc Strauss on January 14, 2009 at 6:38pm

well I want to thank everybody for their wise answers, no answer yet from the legal end. But as in much of our work, a split second decsion is needed in saving a life, and we are a credit to society, because most people could not and would not choose to have these types of decisions thrust upon them, in seconds let alone ever. I still have not come to my own conclusion, so heres hoping to hearing from more of you. Be well and be safe

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Permalink Reply by Bob Walker on January 15, 2009 at 7:25am

Mark,
I asked my medical coordinator (central Illinois) this question his reply was if they have a pulse you work it, if they don't then you don't.

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Permalink Reply by OCIE FLOURNOY on January 15, 2009 at 10:19am

Suicide is a crime in all states, you would be facilitating this crime to allow the pt to die.

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Permalink Reply by paramedicforfun on January 15, 2009 at 11:02pm

Wow, that's tricky. With a suicide note, I would definately kick it to the medical director. I don't know of any particular protocols here, but it's easier to explain why you worked it then why you didn't. Sounds kinda like a cop-out but I would make it the ER's problem, and walk away with a clean conscience.

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Permalink Reply by Rhonda R. Inlow on January 18, 2009 at 9:56am

From Oklahoma; if pt has pulse you work them to the guidlines of the DNR IF it's not self inflicted. IF family or DNR is found or brought to you by family members you still must follow the guidlines of the DNR. (IF it's not self inflicted) When you got to the scence and pt. has JUST expired regardless if suicide or not.. and DNR is inplace then you leave it alone. Dead is dead. Unless leagal guardian or whomever has power of attorney over that person says differently.. Then it's time to "play".

I to would be curious to learn what you discover..