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Self-Harm, Capacity, and Refusal of Treatment: Implications for Emergency Medicial Practice. A Prospective Observational Study.
Jacob, R., Clare, I.C.H., Holland, A.J., WATSON, P.C., Maimaris, C. & Gunn, M.
Emergency Medical Journal, 22(11), 799-802
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OBJECTIVES In the context of increasing attention to the rights of adults to make treatment decisions for themselves, we investigated, among patients who have engaged in self-harm, (i) the extent of valid decision-making; (ii) the impact of mental disorders; and (iii) the effect of systematically providing relevant clinical information. DESIGN A prospective observational study. Setting The Emergency Department of a large teaching hospital in South-East England. PARTICIPANTS Seventy-one adult men and women who had presented for treatment following deliberate self-harm. Main outcome measures Using a semi-structured interview, clinical judgments were made about participantsí capacity to consent prior to, and following, the presentation of clinical information about the proposed treatment(s). Demographic data, and data about mental disorder and alcohol misuse, were also collected. RESULTS Based on accepted legal criteria, only 28/71 (39.4%) of the patients were judged to have capacity to consent to the proposed intervention(s) initially. However, capacity improved significantly (p< 0.001) after presentation of the information, to 45/71 (63.4%). Those judged incapable were significantly more likely (p=0.007) to refuse treatment. Continuing incapacity was significantly associated only with cognitive impairment (p< 0.001) and/or severe psychiatric disturbance (p= 0.006). CONCLUSIONS Consistent with current views, capacity is not static, even among patients who have engaged in self-harm, but can be improved through a simple intervention. Nonetheless, legal and clinical guidance is needed in working with this group of very vulnerable individuals, many of whom are ambivalent about treatment.