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?
Explore This IssueACEP Now: Vol 42 – No 12 – December 2023
The 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.