If a person tries to commit suicide, could that be considered as a statement that this person wishes to die and does not want aggressive treatment to save his or her life?
Not from a legal standpoint, and not if you are living in the United States.

A middle-aged man with a long standing history of depression decides to end his life. He puts a large caliber gun straight to his forehead and squeezes the trigger…

The bullet shutters his frontal lobe leaving many bullet fragments behind. The damage is extensive with the bullet track ending in the occipital lobe. The skull XR above (click on the image to see a larger version) demonstrates multiple bullet fragments in the frontal lobe (small black arrows) and the main bullet fragment in the occipital lobe (large black arrow)

The patient was unresponsive at the scene and remains so in the hospital. He was put on a ventilator and remains stable otherwise.
No signs of the neurological recovery are evident. The patient is unable to follow any commands and remains completely unresponsive. The conclusion of the physicians involved in his care is that no meaningful neurological recovery is possible. Yet, his brainstem remains intact, so the basic reflexes like corneal and cough reflexes are present, precluding a progression to brain death.

The patient has no family. No appointed legal guardian or representative to assist with decision making is available. How do you decide if withdrawal of care is in the patient’s best interests? No meaningful recovery is possible, so can we consider the fact that the patient was trying to commit suicide as a statement allowing doctors to withdraw care?

The answer would be “No” if you ask your corporate attorney. A legal guardianship is necessary to be able to withdraw care.

Things get even more complicated when organ donation is considered. In a sense, the patient is a “perfect” organ donor – previously healthy and with isolated brain damage. The family’s consent is necessary to proceed with donation. Since no family is available, it all comes down to legal guardianship. Obtaining guardianship could take time and it could be expensive as well. Waiting for the legal paperwork to go through might simply preclude the possibility of successful organ donation all together.

On the flip side of this issue is a concern that many suicide attempts are, indeed, cries for help rather than a genuine desire to end one’s life. Depression which is very prevalent among patients attempting suicide is a treatable condition and, thus, a future suicide can be prevented.

What if the person “didn’t mean” to die by committing suicide, but simply “overdid” it. In many cases the patients admit that trying to end one’s life is a bad idea and they would never do it again. Some patients simply underestimate the harmful effects of various medications used for suicide. Many people do not realize that serious liver damage and death can occur from a high dose of Tylenol, even though it is readily available over the counter.

Suicide and withdrawal of medical care could be a complicated issue. There might not be good ethical or legal support to facilitate decision making in these cases. It doesn’t help that the patient, who has no chances for recovery, is unable to die.

Modern technology and suicide

Initially, it did not sound like anything unusual. Another patient had tried to commit suicide. The unfortunate combination of an exacerbated depression and loneliness around the holidays and the availability of prescription medications, lead this unfortunate patient to try to end his life. He took multiple tablets of Vicodin (pain killer with opioid analgesic and Tylenol) and Clonazepam (sedative, anxiety medication).

What was unusual about this case is that the patient had, actually, sent his girlfriend a text message with his intentions to commit suicide. His girlfriend acted very promptly and contacted the police.

He was found at home laying in bed. The patient was unresponsive and had shallow breathing. A breathing tube was placed by the paramedic. In the emergency Department the patient was noted to have a very high Tylenol level indicating a massive overdose. The appropriate antidote medication was started immediately. He was discharged three days later with no evidence of any significant liver toxicity.

This case demonstrates yet another example of how modern technology changes all aspects of our lives. Had this patient not texted his girlfriend about his intentions, he most likely would have been dead. Texting has become so ubiquitous that there is even a concern of driving while texting. Just talking on a cell phone in a car is distractive enough; I cannot image how people can text at the same time.

With a rapid spread of other technology including social media like Twitter and Facebook, I will not be surprised that there will be more changes on how we do things in our lives, or death if you will.

It always strikes me how many young patients I admit to the hospital with a suicide attempt or overdose. Most of my patients come with drug overdose (opioids and benzodiazepines being the most common) and occasionally I see a self inflicted gun shot wound (see image above). Most of these patients do Ok and eventually discharged. What surprises me is how different my personal experience from the official statistics. According to the National Institute of Mental Health most suicide methods in male are by firearms (56%), second being suffocation (23%) and poisoning (most commonly seen in my practice) is only in 13%. The statistics is quite different for the female population with poisoning being most common (40%). Still, this is very different from what I see in my practice. Reviewing suicide statistics by state, age etc did not explain this discrepancy. One likely explanation is that the “success” rate being different for any given suicide method and thus the difference.