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Self-harm, capacity, and refusal of treatment: implications for emergency medical practice. A prospective observational study
  1. R Jacob1,
  2. I C H Clare2,
  3. A Holland3,
  4. P C Watson4,
  5. C Maimaris5,
  6. M Gunn6
  1. 1Division of Psychiatry, Fulbourn Hospital, Cambridge, UK
  2. 2Department of Psychiatry (Section of Developmental Psychiatry), University of Cambridge, Cambridge, UK
  3. 3Health Foundation Professor of Learning Disability, Department of Psychiatry (Section of Developmental Psychiatry), University of Cambridge, Cambridge, UK
  4. 4MRC Cognition and Brain Sciences Unit, Cambridge, UK
  5. 5Emergency Department, Addenbrooke’s Hospital NHS Trust, Cambridge, UK
  6. 6Dean of Nottingham Law School, Nottingham Trent University, Nottingham, UK
  1. 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;


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.

  • self-harm
  • capacity
  • refusal of treatment

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  • The study received no separate funding but while the work was carried out, RJ and IC were supported financially by Cambridgeshire & Peterborough Mental Health Partnership NHS Trust, AH by the Health Foundation, MG by Nottingham Trent University, CM by Addenbrooke’s NHS trust, and PW by the Medical Research Council. We are grateful for the support of these organisations; none, however, has influenced the paper’s content.

  • Competing interests: none declared

  • Ethical approval for the study was obtained from the Cambridge Local Research Ethics Committee (LREC 02/179). Following discussions with this Committee, and a medical lawyer, we decided to try to include both those with and without the capacity to consent to the research. Great care was taken throughout to ensure that the participants were assenting to their involvement.

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