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Management of Patients with an advance decision and suicidal behaviour – a systematic reivew

Article in Review: Nowland, R., Steeg, S., Quinlivan, L., Cooper, J., Huxtable, R., … & Kapur, N. (2019). Management of patients with an advance decision and suicidal behaviour: A systematic review. British Medical Journal Open, doi:10.1136/bmjopen-2018-023978

Summary:  Advance care directives are legally binding directions for medical treatment when a person does not have the capacity to make decisions about their treatment or care. This includes decisions around treatment for life-threatening injuries following a suicide attempt. This research explores some of the challenges described by clinicians in facing complex ethical and legal work.



There are complex legal and ethical factors that can arise in the work of suicide prevention. Some of the more confronting questions can pertain to legal rights, including advanced care decisions, otherwise known as the right to refuse treatment – even if that treatment is lifesaving. In this article, we acknowledge the range and depth of beliefs and opinions influencing clinician practice and professional decision making.

What are advance care directives?

When examining advanced care directive or plans, it is assumed that a person has the capacity to make a decision. That is, the person can weigh, reason and understand information relevant to their care, including all options and consequences concurrently (that is, retaining all information for long enough to make an informed decision). Further, their decision is voluntary (rather than coerced). A guide for understanding how mental capacity is legally understood in Australia can be found here or here for New Zealand. It should be noted that Australia’s approach to understanding advanced care is similar to those of New Zealand, UK and the USA. There is no statutory advance care directive, however, they are legally binding via common law (see Advance Care Planning Australia).

Why have advance care directives?

Advance care directives arguably offer significant benefit for people with health and psychological conditions, including enhanced autonomy, engagement and motivation to participate in treatment, including medication, according to Nowland et al. (2019).

Concerns have been raised, however, that the use of advance care directives or plans may facilitate the death of those with suicidal behaviours. The primary question is whether someone has the capacity to make decisions about whether or not to accept life-saving treatments when they are suicidal. A further question is whether there should be exemptions to advance care directives when the life has been threatened by suicidal behaviours. Nowland and colleagues report that treatment refusal in the context of suicidal behaviour is common.

What is the current approach to advanced care directives for suicidal people?

This research sought to identify and describe research exploring clinician management of people presenting to hospital with suicidality (in the absence of terminal illness or chronic pain) when also maintaining an advance care decision or directive.

Results and Discussion

It should be noted, these matters are certainly challenging when a clinician (and indeed the treating team) are under pressure to make a rapid decision, in the context of a person’s lethal behaviours and the consequences.

There were multiple ethical challenges described, including that the

“gravity of the clinical decision was increased… because the patient could die if the advance decision was adhered to when recovery from the mental ill-health may be possible”

(Nowland et al., 2019, p. 11)

Ensuring the decision was valid and made at a time when the person had capacity was concerning. Additionally, if the directive was ‘old’ and advances in treatments and options were deemed to have improved since the time of writing the advance care decision. As such, it was argued that advance care decisions should be co-drafted with a clinician to evidence that the person had the capacity and where possible, leveraging a broader network of psychiatric, legal and ethical expertise.

Evidence reported by Nowland and colleagues (2019) of current practice, largely demonstrated that clinicians followed advance care directives, with the exception of one case, where the directive was deemed made proximally to, and in the context of suicidality.  Cases, where the advance care directive was upheld, were validated by the clinicians due to the poor prognosis of the person due to their suicide attempt (which did result in their death).

Understandably, the research described disagreement or arguments between clinicians, including psychiatrists emphasising that mental health conditions are entirely treatable and should not be a cause of death. This was contrasted by emergency physicians emphasising the legally binding nature of advance care directives.

Some further ethical challenges…

The difficulties in this research were highlighted by the fact that suicidality and the intent to die can fluctuate, whereby a person may change their mind about their desire to die if they have an opportunity to be well. In addition, it was reported that many people that make suicide attempts, later regret the action.

The emergence of advance care decisions appeared in the context of terminal illness and poor prognosis for quality of life, whereby the ethical and medical reflections for this population are clearly different to those of suicidal people, where there may be potential for a full recovery. Nowland and colleagues (2019) described, rather ironically, the compassion towards people with terminal illness maintaining an advance care directive versus those with unbearable psychological pain, as with a person that wants to end their life.

In the UK at least, it was reported that although some people attempting suicide may have the capacity to make an advance care decision, the “overwhelming likelihood is that capacity is impaired at least to some degree” allowing clinicians to “protect the vulnerable person” by disregarding any directive made by a suicidal person.


  • Any advance care decision made proximally to and in the context of suicidal behaviour should be made in consultation with a team of psychiatrists, legal and ethical consultants.
  • Decisions should include relevant contextual information, with time to examine additional evidence.
  • Clinicians require additional support and supervision around these issues, due to individuals’ values, beliefs and the emotional impacts of how such decisions are made.
  • When a person has a mental health condition and makes an advance care directive, this should be done with family and a healthcare provider. Further that it should be updated as capacity, treatment options and decisions may change.

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