ORIGINAL ARTICLE

Self-harm, capacity, and refusal of treatment: implications for emergency medical practice. A prospective observational study

R Jacob¹, I C H Clare², A Holland³, P C Watson⁴, C Maimaris⁵, M Gunn⁶

¹ Division of Psychiatry, Fulbourn Hospital, Cambridge, UK
² Department of Psychiatry (Section of Developmental Psychiatry), University of Cambridge, Cambridge, UK
³ Health Foundation Professor of Learning Disability, Department of Psychiatry (Section of Developmental Psychiatry), University of Cambridge, Cambridge, UK
⁴ MRC Cognition and Brain Sciences Unit, Cambridge, UK
⁵ Emergency Department, Addenbrooke’s Hospital NHS Trust, Cambridge, UK
⁶ Dean of Nottingham Law School, Nottingham Trent University, Nottingham, UK

Correspondence to:
Correspondence to:
Professor A Holland
Health Foundation Professor of Learing Disability, Department of Psychiatry (Section of Developmental Psychiatry), Douglas House, 18b Trumpington Road, Cambridge CB2 2AH, UK;
ajh1008{at}cam.ac.uk

Objectives: In the context of increasing attention to the rights of adults to make treatment decisions for themselves, this study investigated, among patients who have engaged in self-harm (i) the extent of valid decision making; (ii) the impact of mental disorders; and (iii) the effect of systematically providing relevant clinical information.

Design: A prospective observational study.

Setting: The emergency department of a large teaching hospital in southeast England.

Participants: Seventy one adult men and women who had presented for treatment following self-harm.

Main outcome measures: Semi-structured interviews were used to make clinical judgements about participants’ capacity to consent before, and following, the presentation of simple written information about the proposed treatment(s). Demographic data, and data about mental disorder and alcohol misuse, were also collected.

Results: Based on accepted legal criteria, only 28/71 (39.4%) of the patients were judged to have capacity to consent to the proposed intervention(s) initially. However, the number of patients judged to have capacity improved significantly (p<0.001) after the presentation of written information, to 45/71 (63.4%). Those judged incapable were significantly more likely (p<0.01) to refuse treatment. Continuing incapacity was significantly associated only with cognitive impairment (p<0.001) and/or severe psychiatric disturbance (p<0.01).

Conclusions: Consistent with current views, capacity is not static, even among patients who have engaged in self-harm, but can be improved through a simple intervention. The findings are consistent with recent guidance about supporting this vulnerable group of patients, many of whom are ambivalent about treatment.

Keywords: self-harm; capacity; refusal of treatment

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Article

Primary Survey

Colville Laird
Emerg. Med. J. 2005 22: 759. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Vardy, J, Mansbridge, C, Ireland, A (2009). Are emergency department staffs' perceptions about the inappropriate use of ambulances, alcohol intoxication, verbal abuse and violence accurate?. Emerg. Med. J. 26: 164-168 [Abstract] [Full Text]  
• Luke, L., Redley, M., Clare, I., Holland, A. (2008). Hospital clinicians' attitudes towards a statutory advocacy service for patients lacking mental capacity: implications for implementation. J Health Serv Res Policy 13: 73-78 [Abstract] [Full Text]  
• OKAI, D., OWEN, G., McGUIRE, H., SINGH, S., CHURCHILL, R., HOTOPF, M. (2007). Mental capacity in psychiatric patients: Systematic review. Br. J. Psychiatry 191: 291-297 [Abstract] [Full Text]  
• (2005). Minerva. BMJ 331: 1152-1152 [Full Text]