Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'

Leah Quinlivan; Rebecca Nowland; Sarah Steeg; Jayne Cooper; Declan Meehan; Joseph Godfrey; Duncan Robertson; Damien Longson; John Potokar; Rosie Davies; Neil Allen; Richard Huxtable; Kevin Mackway-Jones; Keith Hawton; David Gunnell; Nav Kapur

doi:10.1192/bjo.2019.42

Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'

BJPsych Open. 2019 Jun 13;5(4):e50. doi: 10.1192/bjo.2019.42.

Authors

Leah Quinlivan¹, Rebecca Nowland², Sarah Steeg², Jayne Cooper³, Declan Meehan⁴, Joseph Godfrey⁵, Duncan Robertson⁶, Damien Longson⁷, John Potokar⁸, Rosie Davies⁹, Neil Allen¹⁰, Richard Huxtable¹¹, Kevin Mackway-Jones⁵, Keith Hawton¹², David Gunnell¹³, Nav Kapur¹⁴

Affiliations

¹ Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester; and NIHR Greater Manchester Patient Safety Translational Research Centre, UK.
² Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK.
³ Senior Research Fellow, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK.
⁴ Senior Mental Health Practitioner and Operational Manager, Greater Manchester Mental Health NHS Foundation Trust, UK.
⁵ Emergency Medicine Consultant, Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK.
⁶ Senior Paramedic, North West Ambulance Service, UK.
⁷ Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, UK.
⁸ Consultant Psychiatrist, Avon and Wiltshire Mental Health Partnership NHS Trust; University Hospitals Bristol NHS Foundation Trust; and Department of Population Health Sciences, University of Bristol, UK.
⁹ Research Fellow, The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust; and Faculty of Health and Applied Sciences, University of the West of England, UK.
¹⁰ Barrister and Senior Lecturer, School of Law, University of Manchester, UK.
¹¹ Professor of Medical Ethics and Law, Department of Population Health Sciences, University of Bristol, UK.
¹² Professor of Psychiatry, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, UK.
¹³ Professor of Epidemiology, Department of Population Health Sciences, University of Bristol; and National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK.
¹⁴ Professor of Psychiatry and Population Health and Honorary Consultant Psychiatrist, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester; NIHR Greater Manchester Patient Safety Translational Research Centre; and Greater Manchester Mental Health NHS Foundation Trust, UK.

Abstract

Background: Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour.

Aims: To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services.

Method: Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis.

Results: Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient's mental capacity at the time of writing), time constraints and significant legal/ethical complexities.

Conclusions: The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area.

Declaration of interest: D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.

Keywords: Mental Capacity Act; Self-harm; emergency services; mental capacity; suicidal behaviour.

Grants and funding

RP-PG-0610-10026/DH_/Department of Health/United Kingdom