Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester; and NIHR Greater Manchester Patient Safety Translational Research Centre, UK
Rebecca Nowland
Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
Sarah Steeg
Research Associate, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
Jayne Cooper
Senior Research Fellow, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, UK
Declan Meehan
Senior Mental Health Practitioner and Operational Manager, Greater Manchester Mental Health NHS Foundation Trust, UK
Joseph Godfrey
Emergency Medicine Consultant, Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
Duncan Robertson
Senior Paramedic, North West Ambulance Service, UK
Damien Longson
Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, UK
John Potokar
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
Rosie Davies
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
Neil Allen
Barrister and Senior Lecturer, School of Law, University of Manchester, UK
Richard Huxtable
Professor of Medical Ethics and Law, Department of Population Health Sciences, University of Bristol, UK
Kevin Mackway-Jones
Emergency Medicine Consultant, Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
Keith Hawton
Professor of Psychiatry, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, UK
David Gunnell
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
Nav Kapur
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
BackgroundComplex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour.AimsTo 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.MethodForty-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.ResultsAdvance 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.ConclusionsThe 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 interestD.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.
