Intended for healthcare professionals

Clinical Review Lesson of the week

Managing patients with deliberate self harm who refuse treatment in the accident and emergency department

BMJ 1999; 319 doi: (Published 10 July 1999) Cite this as: BMJ 1999;319:107
  1. T B Hassan, research fellow (,
  2. A F MacNamara, senior registrar,
  3. A Davy, senior house officer,
  4. A Bing, senior house officer,
  5. G G Bodiwala, head of service
  1. Department of Accident and Emergency Medicine, Leicester Royal Infirmary NHS Trust, Leicester LE1 5WW
  1. Correspondence to: Dr Hassan
  • Accepted 24 November 1998

Failure to assess adequately a patient's capacity to refuse treatment may have serious medicolegal consequences

Increasing numbers of patients attend the accident and emergency department after an episode of deliberate self harm,1 and an appreciable proportion of them refuse urgent medical treatment. Conflict may then arise between a doctor who considers a particular treatment vital and the patient who refuses to consent to it. The doctor has complex clinical, ethical, and medicolegal issues to consider. There are no published data on how doctors in accident and emergency departments in the United Kingdom currently manage these difficult cases. We used a case scenario and developed a questionnaire to investigate how doctors in accident and emergency departments in the Trent region would manage such a situation.


A scenario was constructed in which a woman who had taken a potentially life threatening drug overdose was brought to an accident and emergency department (box). A series of statements based on essential, decision making steps in her management was developed, and closed questions were used to determine what course of action doctors would take. The scenario and closed question interview style were designed to minimise any misinterpretation. Each of the four interviewers was given specific instructions on the use of the questionnaire and interview technique.


All 14 accident and emergency departments in the Trent region with at least one consultant in accident and emergency medicine were identified from the 1996 directory of the British Association for Accident and Emergency Medicine.2 All doctors working in these departments were identified and contacted by telephone. The study was explained to them, and they were asked if they wished to take part. Arrangements were made to telephone at another more convenient time if necessary. Altogether 104 doctors were invited to participate, and all agreed to do so. …

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