A Conundrum

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  • Specializes in Psych (25 years), Medical (15 years). Has 44 years experience.

Is it self-harm when a patient refuses care to extend life?

Patients are involuntarily admitted to a psych unit for one of two reasons:  Either they have an altered mental status to the point that they could no longer function adequately, or they are a threat of harm to themselves and/or others.

On the geriatric psych unit, if a patient was diagnosed with a terminal illness and had suicidal ideation, they could, and often would, be admitted involuntarily.

Theoretically speaking, if a patient is diagnosed with a terminal illness and refuses medical treatment that would extend or prolong their life, isn't that a form of self-harm? However, it is known that a patient has the right to refuse treatment.

Really: What do you think?

Emergent, RN

2 Articles; 4,065 Posts

Specializes in ER. Has 30 years experience.

I'm a libertarian, if someone wants their life to end, who am I to tell them they can't? In my state terminally ill people can request euthanasia.

Nurse Beth, MSN

159 Articles; 2,857 Posts

Specializes in Tele, ICU, Staff Development, Freelance Writer. Has 30 years experience.

I think refusing medical treatment is a constitutional right.

JBMmom, MSN, NP

4 Articles; 2,353 Posts

Specializes in New Critical care NP, Critical care, Med-surg, LTC. Has 11 years experience.

Maybe this is splitting hairs, but my thought process is that suicide is a desire to unnaturally end one's life while refusing treatment for a terminal illness is not being willing to unnaturally extend one's life through measures that also have potentially negative outcomes or side effects. I do not think that are the same thought process and I would support anyone's decision to not seek treatments for a terminal illness, while I also support involuntary commitment for those that are suicidal. (although I'm sure that many people that are suicidal may view experiences in their lives as being not worth living through.)

Davey Do

1 Article; 10,194 Posts

Specializes in Psych (25 years), Medical (15 years). Has 44 years experience.
1 hour ago, Emergent said:

I'm a libertarian, if someone wants their life to end, who am I to tell them they can't? In my state terminally ill people can request euthanasia.

I'm a Frisbeeterian who believes that when we die, our souls fly up to the roof and get stuck.

Seriously, it's great that terminally ill people can choose to meet their ends in their own way. What is the time frame laws on such matters?

We're all terminal, so to speak, and there must be certain legal grounds and boundaries. Like a professional medical giving a diagnosis and expected time of departure.

I'd like to learn more, from your perspective, Emergent, on the what to and wherefores.

Davey Do

1 Article; 10,194 Posts

Specializes in Psych (25 years), Medical (15 years). Has 44 years experience.
53 minutes ago, Nurse Beth said:

I think refusing medical treatment is a constitutional right.

A constitutional right, is that right?!

As they sang in Grease, "Tell me more, tell me more".

Davey Do

1 Article; 10,194 Posts

Specializes in Psych (25 years), Medical (15 years). Has 44 years experience.
52 minutes ago, JBMmom said:

Maybe this is splitting hairs, but my thought process is that suicide is a desire to unnaturally end one's life while refusing treatment for a terminal illness is not being willing to unnaturally extend one's life through measures that also have potentially negative outcomes or side effects. I do not think that are the same thought process and I would support anyone's decision to not seek treatments for a terminal illness, while I also support involuntary commitment for those that are suicidal. (although I'm sure that many people that are suicidal may view experiences in their lives as being not worth living through.)

By all means, JBMmom, split some hairs!

It's almost as if, take for example Emergent's home state, people with, a terminal illness can choose euthanasia, but have to do so by the book.

In essence, if we do as they say, we can have our way.

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Hoosier_RN, MSN

3,663 Posts

Specializes in dialysis. Has 30 years experience.
6 hours ago, Nurse Beth said:

I think refusing medical treatment is a constitutional right.

There's nothing in the constitution that gives rights, one way or another, in direct relation to medical care. CMS put out a "patients rights and responsibilities" years ago, and it was listed on that. I'm sure it still is, I just haven't seen an updated copy. I'll see what I can find

ETA: I googled CMS Patient rights and responsibilities, and it's still there

Specializes in Oncology, ID, Hepatology, Occy Health. Has 37 years experience.

Fully agree with the poster who said refusing treatment for a terminal illness is not the same as suicide. It is a passive process whereas suicide is an active priocess, and again I agree that the thought processes behind those actions are very likely to be different.

Having worked in oncology for the last 13 years I've seen patients refuse more chemo, refuse bone marrow transplant, refuse participation in the only clinical trial that may offer them hope etc. Some people have just had enough and want to go quietly with dignity. I have no problem with that. Patients in such cases will be offered two choices: 1) do they want to stay awake and enjoy their family and friends in which case we'll apply the maximum treatments available for symptom control; or 2) do they want to be placed under profound sedation to just sleep away their remaining days. 

We don't have actuve euthanasia in France but I would have no problem were it to be legalised. We do have the right to refuse care and anticipated directives can now be electronically attached to your social security card  so that no doctor will be in any doubt that you don't want to be "saved" at all costs. 

However Davey, are you asking what to do if somebody has an active psychiatric illness and is making a decision they may regret during a "well" phase? That I agree, really is a conundrum! I certainly don't have the answer and I think this is when we need recourse to ethics and standards committees which need to be made up of clinicians, human rights experts and legal experts.

Daisy4RN

1 Article; 2,188 Posts

Specializes in Travel, Home Health, Med-Surg. Has 20 years experience.
On 12/6/2022 at 3:49 PM, Davey Do said:

It's almost as if, take for example Emergent's home state, people with, a terminal illness can choose euthanasia, but have to do so by the book.

I think this is the correct answer. If one wants to be euthanized there are proper channels to go through (ie needs to jump through the hoops). We all have the right to refuse medical treatment unless deemed (by the appropriate authority) that we are not capable of making decisions for ourselves. So in this case one who is diagnosed with a mental incapacity would not be able to refuse treatment or willingly self euthanize until an MD states they are mentally capable. 
This is from Oregon but I would assume all states are similar:

Q: Who can participate in the DWDA?

A: To participate, a patient must be: (1) 18 years of age or older, (2) capable of making and communicating health care decisions for him/herself, and (3) diagnosed with a terminal illness that will lead to death within six months. It is up to the attending physician to determine whether these criteria have been met.

https://www.oregon.gov/oha/ph/providerpartnerresources/evaluationresearch/deathwithdignityact/pages/faqs.aspx#whocan

I don’t think that a person who is diagnosed with a terminal illness and who is refusing treatment is guilty of “self harm”. I have seen many terminal (and not terminal for that matter) patients refuse treatment. And I would personally refuse treatment if I was terminal and maybe even if I wasn’t in some cases. I would hope that a mental diagnosis in and of itself would not trump this decision. Refusing treatment is not IMO the same situation as requesting euthanasia. If one is admitted to a psychiatric facility I guess they would still have the right to either refuse treatment or self euthanasia but would need a MD to sign off on their mental capacity for decision making. 

Also, having worked in Onc I would also add that I have seen many MD,s attempting to push chemo/radiation and surgery (not palliative) off on pts who don’t want them and probably will do more harm than good. Another thread perhaps but this is definitely not the answer either. 

Specializes in Behavioral Health.

If there is capacity then there are several avenues to satisfy individual autonomy. Palliative and hospice modalities offer increasing latitude to insert alternative treatments.

Unfortunately once capacity is well established as diminished ethics committee actions and state licensing standards drive many of the ways care is implemented across the care team. The care providers as well as family members risk significant consequences if normal standards of care are withdrawn.

Personally, I recall distracting a client on the phone with shoe color options while a phone trace was established for law enforcement to physically intervene on an elderly patient who wanted to wonder out of their home into a heavy snow storm. It seemed to be the case during the call that the caller was looking to bring about a bit of control and certainty to their timeline and suffering. There isn't a week that goes by that I don't reflect on the sound of their voice. Confused, disorganized, disoriented, despiration when they realized the uniformed officers in their living room where there to stop them from leaving the house.

heron, ASN, RN

3,511 Posts

Specializes in Hospice. Has 51 years experience.

There was a time when I was looking for a new job because of chaos at the current one. I was offered a job at a small community hospital ICU. While thinking it over, I realized that the prospect of forcing someone to stay alive against their will was revolting. So … I have no objection to refusing food and medical intervention at the end of life. Not sure I would even consider that to be suicide in the first place. Hence, my love for hospice.

Yet …

Obviously on the fence about this.