Intended for healthcare professionals

Practice The Competent Novice

When and how to treat patients who refuse treatment

BMJ 2014; 348 doi: (Published 25 March 2014) Cite this as: BMJ 2014;348:g2043

This article has a correction. Please see:

  1. Rosemary A Humphreys, specialist trainee year 4, psychiatry1,
  2. Robert Lepper, mental health act adviser and policy lead2,
  3. Timothy R J Nicholson, academic clinical lecturer3
  1. 1Barnet, Enfield and Haringey NHS Trust, St Ann’s Hospital, London N15 3TH, UK
  2. 2 South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK
  3. 3 Section of Cognitive Neuropsychiatry, Institute of Psychiatry, King’s College London, London, UK
  1. Correspondence to: R A Humphreys rosemary.humphreys.13{at}
  • Accepted 9 January 2014

Navigating the legal frameworks relevant to treating patients who refuse treatment can be daunting. This article provides a guide to which framework to choose in which situation

Summary points

  • Common law can be used to treat patients in emergencies, especially when the diagnosis is unclear. It allows necessary and proportionate restraint until Mental Capacity Act (MCA) or Mental Health Act (MHA) assessments are completed

  • The MCA can be used to restrain and treat patients without capacity (for a specific decision) as long as it is in their best interests but cannot be used for the protection of others

  • The MHA can be used only to treat patients with a mental disorder, including those due to physical health conditions (such as delirium). It can also only be used in situations where there is concern about patient’s health or safety, or the safety of others

  • Patients’ and clinicians’ values may differ, and patients are entitled to make decisions that clinicians think are unwise. Patients can be treated against their wishes only if their decision making capacity is impaired and if the proposed treatment is for something serious enough to warrant over-riding their wishes

  • Seek specialist advice (for example, from a psychiatry team) if it is unclear whether the patient has capacity to refuse treatment and which legal framework should be used

Knowing when and how to treat patients who refuse treatment is challenging. About 30% of acute medical inpatients lack capacity to make key decisions about their treatment,1 and this rises to above 40% for psychiatric inpatients.2 Clinicians tend to overestimate patients’ capacity and miss cases where capacity is lacking.3 Navigating the relevant legal frameworks (common law, the Mental Capacity Act (MCA), and the Mental Health Act (MHA)) can seem daunting. This article explains the basics of this complex area and …

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