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DNR in Suicide or Choking Cardiac Arrest
Question# 941
I have a question regarding honoring DNRs in the context of a patient who arrests due to unnatural causes. Two specific examples I was thinking of are: a patient who is VSA following a complete airway obstruction, or a patient with a terminal illness who is VSA following a suicide attempt. Both of these situations seem to present an ethical dilemma since the cardiac arrest is from unnatural causes not related to whatever condition prompted the patient to obtain a DNR, and in the context of a suicide attempt I could see the argument being made that the patient was not in a state of mind to be able to make a rational decision about their medical care, regardless of if they have a terminal illness. I'm hoping to get some physicians to weigh in on the ethics surrounding this and if this issue has been encountered before.
Answer:
Patients found to be in cardiac arrest with a valid DNR in unusual circumstances can pose some ethical challenges for paramedics.
With regards to a completed suicide attempt a DNR would generally not apply. Please see DNR Validity in Suicide in Suicide for further articulation of the reasoning for this.
It is worth noting that in a study of people who survived a suicide attempt significantly more reported being happy they were alive than wished they had been successful. Suicide attempters' reaction to survival as a risk factor for eventual suicide - PubMed
With regards to the specific case of choking you raised:
When encountering a person who is choking paramedics should perform lifesaving interventions such as abdominal thrusts, chest compressions, and laryngoscopy with FBOA removal up until the person is in cardiac arrest. Once the person with a valid DNR has suffered cardiac arrest the DNR should be respected.
The difference between these two cases is about the validity of the DNR rather than the nature of the cardiac arrest.
For more information on handling cases with respect to goals of care and DNRs see the following RPPEO resources and polices:
Patient Consent & Do Not Resuscitate
RPPEO Policies - CLI-230 - Management of Death in the Prehospital Setting