Full Code required for surgery?

[KDPatty]

This is a new one for me, so I'm wondering how prevalent this is.

I work in an LTACC, that is based within a host hospital. In order for our patients to have any surgical procedure, they have to be FC.

Lots of times we send a pt down for surgery, that requires intubation, they fail to wean, and we get them back a few days later, still intubated or trached and pegged. Often said patient was DNR or DNI prior to surgery, and they get re admitted to us as FC.

having come one from a big acute care hospital where this was not the case, it seems strange and unethical to me. Anyone else see this policy where they work? Thoughts?

[Jolie, BSN]

They lose their right to choose to leave the hospital and to refuse admission to a psychiatric facility if that is deemed necessary by the psych people who evaluate them after admission; however, as I stated (and as you stated), they don't automatically lose the right to make decisions about their treatment while in the hospital (or in a psychiatric facility -- the involuntary commitment laws only legally compel people to be detained for evaluation; they don't require that people participate in the evaluation, or permit people to be treated against their will without further legal proceedings).

Involuntary commitment is intended to prevent the individual from ending his/her life (among other goals.)

If a suicidal patient is not admitted, there is a high risk of death.

If a suicidal patient is allowed to demand discharge, there is a high risk of death.

If a suicidal patient is allowed to elect DNR status, there is a greater than "normal" risk of death, in part because even in a protective environment, some patients will find a way to inflict serious harm to themselves.

For this reason, it makes sense to me that disallowing DNR status of a person on a suicide hold is an extension of involuntary admission and not denial of treatment decision making.

I may just have to agree to disagree on this point.

[MunoRN, RN]

The ability of a suicide attempt patient to refuse further care is based on the underlying process that led to their decision, if it is due to a psychiatric condition that has significantly altered their ability to make rational decisions then varying levels of treatment can be imposed despite their refusals, however if the decision was based on rational thought process then that is their right. There are few firmly established standards on this, it's generally a case by case assessment. One of the more commonly referenced cases involves the Wooltorton case which occurred in Australia but is often included in US case law discussion given the similarity of legal standards on suicide. Doctors acted legally in 'living will' suicide case | Society | The Guardian

[MunoRN, RN]

It's hard even for "thinkers" to make sense out of these things because too often the rationales given to nurses are just someone's idea of something; rarely do we get the benefit of knowing how/why a legal or ethics committee came to the conclusion. And worse, we often get a superior's "take" on it (or their own emtional reasoning). I do not know the answer to this one but I think (right or wrong) it goes something like this:

We know that we allow LEOs to compel the person who expresses suicidal ideation/intention to present for evaluation. They legally can take people into protective custody and present them for evaluation. At the hospital, we can legally compel you to stay until we evaluate your situation. We also know that we hospitalize patients (sometimes involuntarily) because they have verbalized an intent to kill themselves. So, our legal system does support this idea that we as a society have an interest in trying to prevent people from killing themselves, and when we are aware of their intent to do so we legally take steps to prevent them from doing it - steps that can be considered fairly extreme if necessary (involuntary hospitalization).

If we have a suicidal patient in the hospital, we will enact precautions to prevent suicide attempts while hospitalized. Why do we do that - well (aside from the obvious liability issues), we do it because we have a societal value that we should do all we can to prevent people from voluntarily killing themselves, especially when we haven't had the opportunity to thoroughly assess judgment and insight or provide any assistance or rule out medical issues that may be contributing. All that to say that when no measures have been taken in attempt to determine whether the decision (to kill oneself) is being made in a sound state of mind, we (legally) make attempts to stop them from doing it.

The person who has already made the attempt and now is being presented for resuscitation is a bit of a different situation than a patient who presents for care in a suicidal state, but it seems like similar principles of care are applied (we will do what we can to not let you succeed with your intent to kill yourself) - - I am making no declaration or judgment about the correctness or incorrectness of this, I'm just saying I think these are some of the underlying ethical and legal points that an ethics committe would consider, and that probably have something to do with 'all patients who attempt suicide are full code.'

Right or wrong, I think the reason that we don't honor a DNR when one is found in extremis following suicide attempt is because we also don't/wouldn't legally "honor" your statement that you want to die when you are alive. Instead, we take direct actions against it. The laws of our society still support the idea that we can compel you for a mental health evaluation and take measures to ensure that you don't kill yourself up to that point.

There's an important clarification here, there is no legal basis for stopping someone from killing themselves, suicide has not been illegal for a couple of decades no, we stop people from committing suicide as a result of a decision that arose from an altering mental health condition, otherwise it's up to them.

[JKL33]

There's an important clarification here, there is no legal basis for stopping someone from killing themselves, suicide has not been illegal for a couple of decades no, we stop people from committing suicide as a result of a decision that arose from an altering mental health condition, otherwise it's up to them.

I agree with you and should have been more clear that indeed, suicide is not "illegal." Just the same, the clarification probably should be that we stop people when we don't believe there has been an opportunity for evaluating their mental health status, or when we directly suspect/believe that their decision arose from an altering MH condition.

Not trying to nitpick your important clarification (which I do think it is).

Again, I do not think we can totally look to our treatment of patients with suicidal ideation to explain why some places do not honor DNRs of patients who have(presently) attempted suicide. But, it's possible that the concern is that the patient has not had the benefit of a MH evaluation, and that may be a fair assumption. I'd think that planned suicide where all the appropriate planning steps have been taken is not the usual situation where someone calls 911 after the fact...kwim?

Thank you for the discussion, Muno.

[4boysmama]

I can top that -- in the large academic healthcare system in which I currently work, anyone who comes in as a suicide attempt is automatically a full code, even if that person has had a legitimate DNR order for years. It's automatically voided by any attempt to harm yourself, as far as my employer is concerned. I don't know if that's a state-wide thing or just my employer.

how is that even legal? DOes your state have a DNR registry?

[MunoRN, RN]

I agree with you and should have been more clear that indeed, suicide is not "illegal." Just the same, the clarification probably should be that we stop people when we don't believe there has been an opportunity for evaluating their mental health status, or when we directly suspect/believe that their decision arose from an altering MH condition.

Not trying to nitpick your important clarification (which I do think it is).

Again, I do not think we can totally look to our treatment of patients with suicidal ideation to explain why some places do not honor DNRs of patients who have(presently) attempted suicide. But, it's possible that the concern is that the patient has not had the benefit of a MH evaluation, and that may be a fair assumption. I'd think that planned suicide where all the appropriate planning steps have been taken is not the usual situation where someone calls 911 after the fact...kwim?

Thank you for the discussion, Muno.

Based on the full context of your post I don't think we disagree, just wanted to clarify since there are those who believe a suicide attempt by itself makes a person an involuntary hold or that they have some how automatically forfeited decision making capacity.

There those planning an 'unassisted' suicide who seek out a psychiatric evaluation first to avoid potential interference or involuntary hospitalization, denial of decision making capacity.

[JKL33]

Based on the full context of your post I don't think we disagree, just wanted to clarify since there are those who believe a suicide attempt by itself makes a person an involuntary hold or that they have some how automatically forfeited decision making capacity.

There those planning an 'unassisted' suicide who seek out a psychiatric evaluation first to avoid potential interference or involuntary hospitalization, denial of decision making capacity.

Yes. It is an injustice to not respect the planned decisions mentioned in your last paragraph. Well, I think so anyway.

Do you believe there is a distinction between a well-planned unassisted suicide (s/p psychiactric evaluation, etc) and someone who is DNR (doesn't want to be resuscitated from a death due to natural causes) who may at some point become suicidal? I guess what I am asking is - I feel there is an ethical conundrum for a provider of resuscitation when s/he doesn't have any way to know whether the patient's suicidal act was the result of stressed decision-making in the setting of mental illness or if it was well-considered and planned with professional input, as in your last paragraph. And, does that distinction even matter. I do not yet have a well-formed belief about this particular matter, but I feel that I should; it is the situation I am in (ED) when presented with a suicide-resuscitation-in-progress.

An interesting article I came across in the course of this reply. I'm sure there are more.

Again, thank you for helping me think this through.