Skip to main content
PMC home page
Emergency Medicine Journal : EMJ logoLink to Emergency Medicine Journal : EMJ
. 2005 Nov;22(11):799–802. doi: 10.1136/emj.2004.018671

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

R Jacob 1, I Clare 1, A Holland 1, P Watson 1, C Maimaris 1, M Gunn 1
PMCID: PMC1726596  PMID: 16244339

Abstract

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.

Full Text

The Full Text of this article is available as a PDF (62.5 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Appelbaum P. S., Grisso T. Assessing patients' capacities to consent to treatment. N Engl J Med. 1988 Dec 22;319(25):1635–1638. doi: 10.1056/NEJM198812223192504. [DOI] [PubMed] [Google Scholar]
  2. Beck R. W., Morris J. B., Beck A. T. Cross-validation of the Suicidal Intent Scale. Psychol Rep. 1974 Apr;34(2):445–446. doi: 10.2466/pr0.1974.34.2.445. [DOI] [PubMed] [Google Scholar]
  3. Bille-Brahe U., Andersen K., Wasserman D., Schmidtke A., Bjerke T., Crepet P., De Leo D., Haring C., Hawton K., Kerkhof A. The WHO-EURO Multicentre Study: risk of parasuicide and the comparability of the areas under study. Crisis. 1996;17(1):32–42. doi: 10.1027/0227-5910.17.1.32. [DOI] [PubMed] [Google Scholar]
  4. Folstein M. F., Folstein S. E., McHugh P. R. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975 Nov;12(3):189–198. doi: 10.1016/0022-3956(75)90026-6. [DOI] [PubMed] [Google Scholar]
  5. Grisso T., Appelbaum P. S., Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions. Psychiatr Serv. 1997 Nov;48(11):1415–1419. doi: 10.1176/ps.48.11.1415. [DOI] [PubMed] [Google Scholar]
  6. Gunn M. J., Wong J. G., Clare I. C. H., Holland A. J. Decision-making capacity. Med Law Rev. 1999 Autumn;7(3):269–306. doi: 10.1093/medlaw/7.3.269. [DOI] [PubMed] [Google Scholar]
  7. HAMILTON M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960 Feb;23:56–62. doi: 10.1136/jnnp.23.1.56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Hassan T. B., MacNamara A. F., Davy A., Bing A., Bodiwala G. G. Lesson of the week: managing patients with deliberate self harm who refuse treatment in the accident and emergency department. BMJ. 1999 Jul 10;319(7202):107–109. doi: 10.1136/bmj.319.7202.107. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Haw C., Hawton K., Houston K., Townsend E. Psychiatric and personality disorders in deliberate self-harm patients. Br J Psychiatry. 2001 Jan;178(1):48–54. doi: 10.1192/bjp.178.1.48. [DOI] [PubMed] [Google Scholar]
  10. Haw C., Houston K., Townsend E., Hawton K. Deliberate self-harm patients with alcohol disorders: characteristics, treatment, and outcome. Crisis. 2001;22(3):93–101. doi: 10.1027//0227-5910.22.3.93. [DOI] [PubMed] [Google Scholar]
  11. Larkin G. L., Marco C. A., Abbott J. T. Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department. Acad Emerg Med. 2001 Mar;8(3):282–284. doi: 10.1111/j.1553-2712.2001.tb01307.x. [DOI] [PubMed] [Google Scholar]
  12. Pajonk Frank-Gerald, Gruenberg Kai Arist Simon, Moecke Heinzpeter, Naber Dieter. Suicides and suicide attempts in emergency medicine. Crisis. 2002;23(2):68–73. doi: 10.1027//0227-5910.23.2.68. [DOI] [PubMed] [Google Scholar]
  13. Raymont Vanessa, Bingley William, Buchanan Alec, David Anthony S., Hayward Peter, Wessely Simon, Hotopf Matthew. Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study. Lancet. 2004 Oct 16;364(9443):1421–1427. doi: 10.1016/S0140-6736(04)17224-3. [DOI] [PubMed] [Google Scholar]
  14. Wong J. G., Clare C. H., Holland A. J., Watson P. C., Gunn M. The capacity of people with a 'mental disability' to make a health care decision. Psychol Med. 2000 Mar;30(2):295–306. doi: 10.1017/s0033291700001768. [DOI] [PubMed] [Google Scholar]
  15. Wong J. G., Clare I. C., Gunn M. J., Holland A. J. Capacity to make health care decisions: its importance in clinical practice. Psychol Med. 1999 Mar;29(2):437–446. doi: 10.1017/s0033291798008113. [DOI] [PubMed] [Google Scholar]

Articles from Emergency Medicine Journal : EMJ are provided here courtesy of BMJ Publishing Group

RESOURCES