“If in doubt treat” is not as easy as it soundsBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5478 (Published 05 October 2010) Cite this as: BMJ 2010;341:c5478
All rapid responses
Professor Benger describes two problems. The first is what to do with
the intoxicated/confused self-harmer, and the second is who should do it.
The presentation is common (1)(2). In my view there should be robust
local guidelines agreed that give clear guidance for both. It seems
sensible that the correct people to draft the local guidelines are the A+E
department, the Psychiatry department, and the Trust solicitors.
In terms of what to do, it seems the sensible approach is to take
life saving action. This is supported by common law, capacity law
(capacity can be impaired if intoxicated, confused, or mentally
disordered), and by mental health law (sort of). While such a summary, in
the name of brevity, oversimplifies the law, the direction of current law,
despite some unconvincing arguments to the contrary, seems unquestionably
toward saving life in an intoxicated or confused self-harmer with little
else known. The most appropriate legal framework can be advised by the
The issues of who should do it, and how, are again ones for local
agreement. While I am aware some of my colleagues would not agree, to me
the solutions seem simple; presentation of self-harm is a psychiatric
issue, and management of its basic manifestations should fall in that
patch too. A decision by the patient to resist the lifesaving treatments
also looks to me like a psychiatric issue.
However common sense and efficiency should guide the local protocols on
'how to' act in the best interest of the patient. There may need to be
some co-working of the initial hours that are agreed locally (e.g. where,
and which staff).
Many of the issues are predictable, so should be decided and agreed
in advance, rather than at 3am on a weekend. Adequate service planning is
a specific recommendation in the NICE Guidelines on Self-Harm (3).
(1) The Psychiatrist (2007) 31: 255-258. doi:
Competing interests: No competing interests