A middle-aged male with squamous cell carcinoma and extensive metastases is brought to the emergency department (ED) after being found unresponsive following a believed suicide attempt (SA) by methadone ingestion. He had a recent month-long hospital stay complicated by severe cancer-related pain. Though paramedics administered naloxone, he remained somnolent. Paramedics hand you a Physician Orders for Life-Sustaining Treatment (POLST) form. The nurse asks, “You don’t want us to put him through anymore, right? His POLST says comfort measure only (CMO) and we should respect his wishes.” You find yourself in a situation which is ethically, emotionally, and legally challenging for all physicians.1 Do you intervene, or allow him to comfortably pass? You want to respect patient autonomy, but is it legal to let him die without any emergency resuscitation?
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ACEP Now: Vol 42 – No 12 – December 2023The answer is no, you cannot allow this patient to die by withholding resuscitative efforts.
Suicide is not considered a rational choice, and therefore the POLST holds no legal authority in this situation, as his POLST was created in regards to his terminal illness, not his SA.2 An emergency physician (EP) is in no position to determine if a POLST was made in sound mind. In regard to treating SA patients, EPs should focus on building rapport, completing a comprehensive history and physical exam, performing laboratory testing if clinically indicated, and placing patients under observation if at continued risk for self-harm.3
You order toxicology labs, an EKG, and a sitter to observe. The initial QTc is normal, but on repeat becomes prolonged. CMP reveals hypokalemia. You order IV potassium and magnesium. The patient’s respiratory rate decreases and he becomes more somnolent. You ultimately begin a slow naloxone infusion and admit him to the medical ICU. You question yourself for ordering IV potassium and starting a naloxone infusion, knowing you are causing discomfort for the patient who has known significant cancer-related pain. However, EPs are legally and morally obligated to resuscitate all patients after SA.
The goal in this situation was to resuscitate the patient to a level of alert awareness where inpatient physicians can continue goal-oriented care. Patients after SA who require intubation, continuous life support, or are permanently obtunded, pose a different challenge for physicians. In these situations, the hospital ethics committee must determine if the POLST was made in a rational manner to guide next steps. Some authors suggest it is reasonable to let patients die from SA if they have clearly expressed they would not want extensive resuscitation, have terminal illness, and would have a worse quality of life after the SA (such as a new permanent disability).5 This cannot feasibly be performed in the ED as it requires a significant amount of time and a multi-disciplinary assessment.
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One Response to “Suicide Attempt in the Terminally Ill Cancer Patient with Advance Directive”
January 12, 2024
Karen Quaday, MD“An emergency physician (EP) is in no position to determine if a POLST was made in sound mind…..Suicide is not considered a rational choice, and therefore the POLST holds no legal authority in this situation, as his POLST was created in regards to his terminal illness, not his SA. EPs are legally and morally obligated to resuscitate all patients after SA”.1
These statements were in a recent article in the December ACEP Now by Drs. John Detherage III and John O’Neill. The authors acknowledge that terminal patients might have special considerations, but this “cannot feasibly be performed in the ED as it requires a significant amount of time and a multi-disciplinary assessment”. As a board-certified EM provider with decades of experience, I do not agree with these statements. As a board-certified Hospice & Palliative Medicine physician, I am stunned and frustrated to think that anyone believes that “EPs must resuscitate all patients presenting to the ED for SA, including those with terminal illness and advance directive forms for CMO.”1
Several years ago, I had a patient brought to the ED after impaling himself with a large knife in his left lower sternal area. He arrived literally and repeatedly saying “Please let me die”. He was on hospice for metastatic cancer and had been struggling with uncontrolled pain despite hospice’s best efforts. The ED team quickly talked to his wife, adult children and his hospice team. We learned he had only days to a few weeks to live. They unanimously supported his POLST for comfort care only. Based on that, the trauma surgeon removed the large knife under anesthesia. He was then taken to the ICU where his family gathered, holding his hand and talking to him for the few hours before he died. His family was incredibly grateful for the care provided.
How long did it take to have those conversations in this critical patient? Less than 15 minutes. Feasible, yes, but more importantly, necessary to provide the best care for a dying patient and allowed for a more patient-centered experience!
The article started with a “believed suicide attempt” in a patient with metastatic squamous cell carcinoma who had taken extra methadone after a month-long hospital stay and poorly controlled pain. Sounds like a poor quality of life, a terminal condition and perhaps even an unclear intent by the patient. The authors seem proud that they ignored his POLST and resuscitated him. He was hospitalized 3 days and died “within two weeks”. They argue that we cannot assess the capacity of a patient who has a POLST.1 I am not sure they understand that a POLST is signed by a licensed provider who should be trusted to assess the capacity. A POLST is not the same as an advance directive. Overall, I respectfully submit that the authors’ care is more a reflection of their discomfort in managing those with terminal conditions, a misunderstanding of a POLST versus an advance directive, and a misguided interpretation of “do no harm” in patients who are truly suffering.
Studies show that patients with terminal cancer suffer greatly. Yet, few will actively choose to end their suffering. In the systemic review by Nowland et al cited in the article, “Healthcare workers report support for assisted suicide relating to end-of-life care39 and frustrations with continuing life-sustaining treatment where withdrawing treatment might be considered in the best interest of the patient when they have a life-threatening condition.23 40”. .2
I would ask that all ED providers think about these types of situations before they happen just as we consider other critical scenarios. In 10 states and the District of Columbia, physician-assisted suicide is legal. In addition, withdrawal of life support, cessation of dialysis, refusal of life-sustaining treatment (transfusions) and voluntary stoppage of eating and drinking (VSED) are well-recognized and acceptable options for terminally ill patients in every state. There may even be legal ramifications for ignoring a properly executed Do-Not-Resuscitate, POLST or Advance Directive when the patient’s intent is not clearly self-harm. Lastly, one should further consider the concept of futile care in these patients.
In summary, ED providers have a duty to treat every patient as a unique individual taking into account all information including terminal conditions, POLSTs and goals of care.
Karen A. Quaday, MD
1. https://www.acepnow.com/article/suicide-attempt-in-the-terminally-ill-cancer-patient-with-advance-directive/
2. Nowland R, Steeg S. Quinlivan L., et al. Management of patients with an advance decision and suicidal behaviour: a systemic review. BMJ Open. 2019;9(3):e023978.