Advance directives and suicidal behaviour

BMJ 2010; 341 doi: (Published 07 September 2010) Cite this as: BMJ 2010;341:c4557
  1. Navneet Kapur, professor of psychiatry and population health1,
  2. Caroline Clements, research assistant1,
  3. Nick Bateman, professor of clinical toxicology 2,
  4. Bernard Foëx, consultant in emergency medicine and critical care 3,
  5. Kevin Mackway-Jones, professor of emergency medicine3,
  6. Richard Huxtable, senior lecturer4,
  7. David Gunnell, professor of epidemiology5,
  8. Keith Hawton, professor of psychiatry6
  1. 1Centre for Suicide Prevention, University of Manchester, Manchester M13 9PL
  2. 2Clinical Toxicology Unit, Royal Infirmary of Edinburgh, Edinburgh
  3. 3Department of Emergency Medicine, Manchester Royal Infirmary
  4. 4Centre for Ethics in Medicine, University of Bristol, Bristol
  5. 5Department of Social Medicine, University of Bristol
  6. 6Centre for Suicide Research, University of Oxford, Oxford
  1. Correspondence to: N Kapur nav.kapur{at}
  • Accepted 15 July 2010

How do you manage a patient who has self harmed but states she doesn’t want life saving treatment? Anthony David and colleagues draw on the case of Kerrie Wooltorton to discuss the difficulties, and in an accompanying article Navneet Kapur and colleagues consider the validity of advance directives

David and colleagues present a comprehensive analysis of the well publicised case of Kerrie Wooltorton.1 One issue they touch on warrants further discussion—the role of advance directives in suicidal behaviour. Miss Wooltorton’s letter may not have constituted a valid advance decision.2 Even if it had been valid it would not have applied if she was legally competent when she presented to hospital.3 However, the existence of the letter was not irrelevant—it may have reassured staff that Miss Wooltorton was unwavering in her wish not to be treated.

In England and Wales the Mental Capacity Act 2005 allows people aged 18 years and over to refuse specified medical treatment in the future even if this refusal might result in death. The act refers to such refusals as “advance decisions.” Individuals need to be capable of making an informed choice when they draw up the decisions, and they apply only once they have lost the capacity to make healthcare choices. The decisions have the same force as contemporaneous refusals of treatment and are legally binding.2 Refusals of life saving treatment must be expressed in writing, witnessed, and include a statement that the decision stands even if life is at risk.

The ethical and practical problems raised by advance decisions are complex but are even more difficult in the context of suicidal behaviour. One of the most important questions is whether someone who has completed an advance directive refusing treatment should be allowed to die from the consequences of a suicidal …

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