Legislation allowing individuals to decide in advance to refuse life-saving treatment presents serious risks in cases of attempted suicide, a leading psychiatrist has warned.
Under the Mental Capacity Act 2005, those aged 18 years or over in England and Wales can legally refuse specified life-saving treatment through what are known as advance directives or ‘living wills’, providing they are capable of making an informed decision when the contract is drawn up.
But writing in the British Medical Journal, Professor Nav Kapur, from The University of Manchester’s Centre for Suicide Prevention, argues that health workers should be cautious about adhering to advance directives in suicide cases.
“Firstly, it is difficult to be certain about an individual’s capacity at the time of drawing up an advance directive and, although this is an issue with advance directives generally, it may be particularly pertinent for suicidal individuals,” said Professor Kapur.
“Suicidal behaviour is clearly linked to psychiatric disorder, with most people who die by suicide having evidence of a psychiatric illness at the time of death. This can affect decision-making capacity and even the law recognises that advance directives may not apply if a person is likely to be detained under the Mental Health Act.”
Professor Kapur suggests that suicidal patients are more likely than others to change their mind about the decisions made in their advance directive by the time they reach hospital.
He said: “Suicidal ideas and behaviour are often characterised by acute distress and ambivalence, so it is likely that an individual’s views on seeking intervention will have changed in the interval between drawing up the advance directive and presenting at hospital.
“In a recent study of individuals who had self-harmed, we found that suicidal intent varied between episodes of harming and, sometimes, even within the same episode. Even those who have made serious attempts to end their life may change their minds about wanting to die. In a study of survivors who had jumped from the Golden Gate Bridge in San Francisco, all were glad that they had survived, while other research has shown positive long-term outcomes for those who make serious suicide attempts.”
Professor Kapur says the use of advance directives in suicide attempts is relatively uncommon, pointing to a study he and colleagues carried out in 2005 that found only three out of 121 fatal cases of self poisoning involved an advance directive on the part of the patient. However, Professor Kapur suggests that recent changes to legislation and publicity about living wills in the mainstream media since the 2005 study could well lead to them being more widely used in the future and warns of the dangers of them being strictly adhered to.
“The advance decision element of the Mental Capacity Act helps to empower patients but blanket application of well-meaning legislation that legitimises non-treatment may be dangerous, especially in a group of patients who some clinicians may regard as wasteful of healthcare resources and undeserving of care.”
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