A Rational Suicide?

Editor’s Note: We invite you to read the article, take the ethics quiz, and leave comments; you can also see how your colleagues answered as well as their comments. And, stay tuned, Dr Geppert will provide an ethical analysis of the Case in response to the quiz results and your comments in an upcoming issue of Psychiatric Times. See: A Rational Suicide? Case Consultation and Quiz Commentary.

Mrs N is a 65-year-old retired intensive care nurse who underwent an esophagectomy for esophageal cancer 3 years ago. Since then she has remained cancer-free. Despite her good prognosis, Mrs N has had a poor quality of life ever since the surgery, largely due to intractable nausea and vomiting. She has seen a variety of specialists and tried multiple medications, without significant relief. Mrs N had retired about a year before her diagnosis and surgery and was looking forward to playing golf and visiting her friends around the country . . . things she never had time to do as a critical care nurse. The refractory GI symptoms have prevented her from traveling or even playing a round of golf because she never knows when the waves of nausea will come.

Were it not for these distressing symptoms, Mrs N would say she has a very good life. Although divorced for many years, she continues to have a close relationship with her ex-husband, who is her power of attorney (POA) for health care decisions. She is financially comfortable and has stayed in touch with many friends from her nursing career, but she is unable to be socially active because of her disabling and embarrassing fits of nausea and vomiting.

Over several months, Mrs N and her ex-husband discuss her desire to end her life that she had come to find unbearable. Neither is religious and both have always believed that a person has a right to determine the timing and manner of his or her own death. Mrs N has been stockpiling fentanyl from various sources and has calculated the amount she will need to kill herself. She arranges with her ex-husband that she will text him when she is ready to die and then after a specified amount of time, he will come over and find her dead and take care of her remains and affairs.

The attempt, however, does not go as planned; when her ex-husband comes to the house, she is still alive. Panicked, he calls 911, and an ambulance takes Mrs N to the emergency department (ED) of a large hospital. The ex-husband admits he knew of the suicide attempt and expresses his view that his ex-wife should be allowed to die; at one point he even asks the paramedics “why they cannot just finish this.” The patient is revived with several doses of narcan en route and is given fluids and oxygen before transfer to a medical unit.

When the paramedics provide the history to the ED charge nurse, she calls for an ethics consultation regarding whether the ex-husband should be reported to some authority. When the hospitalist admitting the patient asks about code status, the patient requests to be DNR. The hospitalist feels uncomfortable letting a patient who just attempted suicide and who endorses an intention to try again to be DNR. The hospitalist requests an ethics consultation.

The psychiatric consultant on duty is called into the ED and interviews the patient. The patient reports no psychiatric history or previous suicide attempts. She denies feeling depressed and says there are many things in life she enjoys. The consultant can identify no signs and symptoms consistent with a diagnosis of any primary psychiatric disorder, including major depression. Mrs N calmly and respectfully explains her views regarding suicide and her disagreement with the social prohibition against the practice. While the psychiatrist has never believed in the concept of a “rational suicide,” she is now finding that belief seriously challenged.

Concerned that she may be missing something in the presentation, the psychiatrist asks that a geropsychiatrist colleague also assess Mrs N in the hospital. The geropsychiatrist sees Mrs N the next day and finds her to be completely cognitively intact and of high intelligence, with good ego strength, coping skills, and self-esteem.

Both clinicians are impressed with Mrs N’s reasoning that she enjoys her life and would want to live if only her symptoms could be managed. She is willing to have a new group of specialists work up her case and is even willing to try new medications so long as they do not impair her psychomotor ability, on which her highly valued independence rests. However, she makes very clear to the psychiatrist that she will return home and this time succeed in killing herself if these medical interventions do not improve her symptoms to a degree she finds acceptable.

CASE REPORT: Ethics Quiz

Question 1: As the ethics consultant, how would you respond to the ED
nurse’s question about reporting the ex-husband?

a. He should be reported to the police because assisting a
suicide is a crime.
b. He should be reported to adult protective services for abusing
a vulnerable elder.
c. He did nothing illegal or immoral and should not be
reported to any authority.
d. He should be reported to the hospital ethics committee who
should decide whether he should be permitted to visit the
patient in the hospital.

Question 2 on the next page.

Question 2. Should the ex-husband be allowed to serve as the POA?

a. A POA only goes into effect when a patient loses decisionmaking
capacity.
b. He should be removed as the POA immediately because
he obviously cannot act in his ex-wife’s best medical
interest.
c. The medical team and ethics consultant should review the
POA’s medical decisions to ensure they are made in the
patient’s bestinterest.
d. The ex-husband knows and honors the patient’s preferences
and values and so should remain the POA.
 

Question 3 on the next page.

Question 3. Should the physician honor the patient’s request to be DNR?

a. No, the patient is hospitalized as the result of a suicide attempt
and should be full code.
b. If the patient previously expressed a preference to be DNR,
this should be honored whether or not the patient attempted
suicide.
c. If the physician writes a DNR order at the patient’s request,
he is assisting her in committing suicide.
d. If the POA agrees that a DNR order authentically expresses
the patient’s wishes and values, the order should be written.

Question 4 on the next page.

Question 4. Once the patient is medically stabilized, which of the following
is the most ethically justifiable option if she continues to
state her intention to return home to again attempt suicide?

a. Hospitalize the patient on an inpatient psychiatric ward if she
is willing to go voluntarily.
b. Hospitalize the patient on an inpatient psychiatric ward,
involuntarily if necessary.
c. The patient has no diagnosable mental illness and does not
meet legal or clinical criteria for a psychiatric hospitalization.
d. This was a rational suicide attempt to escape intolerable
suffering; the patient should be discharged to home to make
her own choice to live or not.