Table 4.

Description of clinical cases discussed in selected studies

Case	Reference	Age	Mental health conditions	Nature of SA	Resulting injuries/illness	Hospital admittance	Nature of the AD	When written?	Patient conscious?	Decision-making process	Rationale for decision	Outcome
A	6 26–31	26	Depression generalised anxiety disorder, PTSD, BPD	Self-poisoning (antifreeze)	Not stated	Presented herself at hospital	Letter	3 days prior	Yes	Medical staff discussed the patient’s mental capacity and sought legal advice.	The patient’s wishes were clear in the letter but the patient was conscious, judged to have capacity and refusing treatment.	Death
B	25	46	Severe depression	Gunshot to face	Pain and severe facial injury	Gunshot reported by neighbours	Suicide note	Not stated	Yes (not coherent)	The attending physicians thought life-support should be removed as the patient’s ‘will’ was clear and authoritative. The psychiatrist thought suicide was pathological and the condition was treatable so the patient should be treated. Clinicians consulted widely and sought legal advice.	The suicide note was accepted as a living will. The patient had a desire to die due to psychological pain. The suicide attempt left the patient in a severely disabled state.	Death
C	23	57	Depression generalised anxiety disorder, PTSD, BPD	Self-poisoning (opiates)	Respiratory distress	Psychiatric inpatient	DNR	Prior to inpatient admittance	Not stated	There was conflict between clinicians; the psychiatrist argued that the DNR should not be followed because it was a suicide attempt. The legal/ethics committee was consulted who supported continued treatment.	DNR considered an effort to prepare for a suicide attempt and should not be honoured.	Survived and regretted the suicide attempt.
D	7	35	Depression and drug abuse	Hanging	Brain injury	Found by family	AD	Not stated	No	There were concerns that adherence to the AD would result in the patient’s death. Clinicians sought legal advice.	The patient had poor prognosis and the family gave consent for clinicians to stop treatment.	Death
E	8 24	52	Depression generalised anxiety disorder, PTSD, BPD	Self-poisoning (insulin)	Coma	Found at home	AD	2 years prior	No	The AD mentioned no treatment for a terminal condition. The patient was not in a terminal condition and there were concerns that injury was the result of a suicide attempt and whether the AD should be adhered to in a suicidal context. Approached family and held an ethics committee consultation.	The patient’s wishes were judged to be clear, the patient was considered to be informed about treatment options and had mental capacity at the time of writing the AD and the family were in agreement.	Death
F	32	86	Not stated	Gunshot to chest	Damage to pancreas and colon	Not stated	AD	Not stated	Yes (not always coherent)	Medical team argue that the nature in which the physical condition was caused (ie, suicidal behaviour) should impact on treatment.	Not stated	Not stated

For details about articles, see table 3.

AD, advance directive; BPD, borderline personality disorder; DNR, do not resuscitate; PTSD, post-traumatic stress disorder; SA, suicide attempt.