REFUSALOFMEDICALTREATMENTINPATIENTSWHOATTEMPTEDSUICIDE

Case Summary 1,2,3

Kerrie Wooltorton was a 26-year-old woman with a history of mental illness and prior suicide attempts with anti-freeze ingestion who presented to the emergency department of a hospital in the United Kingdom in 2007 after intentionally ingesting a toxic amount of antifreeze. She presented with the following letter:

To whom this may concern, if I come into hospital regarding taking an overdose or any attempt of my life, I would like for NO lifesaving treatment to be given. I would appreciate if you could continue to give medicines to help relieve my discomfort, painkillers, oxygen etc. I would hope these wishes will be carried out without loads of questioning.

Please be assured that I am 100% aware of the consequences of this and the probable outcome of drinking anti-freeze, eg death in 95-99% of cases and if I survive then kidney failure, I understand and accept them and will take 100% responsibility for this decision.

I am aware that you may think that because I call the ambulance I therefore want treatment. THIS IS NOT THE CASE! I do however want to be comfortable as nobody want to die alone and scared and without going into details there are loads of reasons I do not want to die at home which I realise that you will not understand and I apologise for this.

Please understand that I definitely don’t want any form of Ventilation, resuscitation or dialysis, these are my wishes, please respect and carry them out.

When asked about her wishes and care she stated, “It’s in the letter, it says what I want.” She was deemed to have capacity regarding decisions about her care and died in the hospital two days later.

Assessment of Capacity 4,5

An assessment of capacity requires patient understanding of the nature of offered treatment as well as adequate comprehension, retention and processing of treatment information lending to articulate communication regarding the patient’s status relative to the proposed treatment plan.

There is a consideration that the gravity of the potential implications of the patient’s decision require a commensurate increase in the security of the assessment of competence.

Principles of Medical Ethics

The primary principles in medical ethics impacted in the presented case are the respect for autonomy, beneficence and non-maleficence. A respect for autonomy affords patients the right to make decisions regarding their medical care based on their personal beliefs and values. Affronts to this principle – by providing treatments without informed consent or after competent refusal – violate the patient’s autonomy.

If, however, the patient lacks capacity, the principles of beneficence and non-maleficence take precedence – as an incompetent patient is unqualified to express their wishes and unauthorized interventions may be performed to help the patient and prevent further harm.

Capacity in Patients with Self-Injurious Behavior 6,7,8,9

Does self-injurious or suicidal behavior itself demonstrate a lack of capacity – independently negating the principle of autonomy and requiring medical interventions to support patient well-being?

One study analyzing decision-making competence comparing patients with attempted suicide (of varying degrees of lethality) to non-suicidal though depressed patients and psychiatrically healthy participants using a scoring tool for the assessment of decision-making competence suggested that suicidal patients may be susceptible to biases that may affect reliable decision-making.

The justification for paternalistic intervention in suicide attempts rests on the notion that a suicide attempt implies a lack of rational decision-making capacity by showing a disrespect for human life, violating a duty for contribution to society, and emotionally harming friends and family. Each of these apparent affronts to rational decision-making has reasonable rebuttals. First, the individual should be afforded the right to assess the value of their own life and an attempt at suicide need not necessarily demonstrate a lack of respect for all life. Second, one’s obligation to society should at least be balanced with society’s obligation to respect the individual’s autonomy – further, compulsory interventions would themselves incur costs to society. Finally, the possibility of harm to friends and family requires the presence of emotionally-attached dependents and is unlikely to be universally true. Presuming all suicide attempts to be rooted in incompetent or biased decisions is likely inaccurate and more nuanced analysis of individual scenarios is warranted to protect individual autonomy.

My Experiences

Unfortunately, I have encountered several patients who have survived self-inflicted injuries – often refusing treatment on presentation. These patients are frequently in critical condition, requiring immediate diagnostic and therapeutic interventions. Luxuries like time and a detailed Advance Directive as in Kerrie Wooltorton’s case are rarely available. Interventions proceed emergently, without informed consent and occasionally against the patient’s often vehemently expressed wishes.  These cases are extremely troubling to me as I think I rank the respect for autonomy highest among the principles of medical ethics. If the decision for suicide was made autonomously and competently, the lengthy and often traumatizing course for these patients is likely to be only more detrimental to their well-being – such that the principles of respect for autonomy, beneficence and non-maleficence are all disrupted.

Do you think that an attempt at suicide necessarily demonstrates an irrational decision? Is it the obligation of the healthcare provider to disregard the patient’s wishes, intervening with life-saving measures assuming their presentation to be the result of a transient miscalculation of the value of their own life?

References

  1. Dyer C. Coroner rules that treating 26 year old woman who wanted to die would have been unlawful. BMJ. 2009;339. doi:10.1136/bmj.b4070.
  2. McLean SAM. Live and let die. BMJ. 2009;339:b4112. doi:10.1136/bmj.b4112.
  3. Callaghan S, Ryan CJ. Refusing Medical Treatment After Attempted Suicide: Rethinking Capacity and Coercive Treatment in Light of the Kerrie Wooltorton Case. Journal of law and medicine 18, 811-819 (2011).
  4. Ryan CJ, Callaghan S. Legal and ethical aspects of refusing medical treatment after a suicide attempt: the Wooltorton case in the Australian context. Med J Aust. 2010;193(4):239-242.
  5. Buchanan A. Mental capacity, legal competence and consent to treatment. J R Soc Med. 2004;97(9):415-420. doi:10.1258/jrsm.97.9.415.
  6. Jacobson JL, Jacobson AM. Involuntary treatment: Hospitalization and medications. In: Psychiatric Secrets. Harley and Belfus Inc; 2001:536.
  7. Great Britain. England. High Court of Justice, Family Division. Re C (Adult: Refusal of Treatment). The weekly law reports [1994] Feb 25, 290-296 (1993).
  8. Szanto K, Bruine de Bruin W, Parker AM, Hallquist MN, Vanyukov PM, Dombrovski AY. Decision-making competence and attempted suicide. J Clin Psychiatry. 2015;76(12):e1590-e1597. doi:10.4088/JCP.15m09778.
  9. Matthews MA. Suicidal competence and the patient’s right to refuse lifesaving treatment. Calif Law Rev. 1987;75(2):707-758. doi:10.15779/Z384J0G.
  1. I’ve wondered recently where to draw the line between the right to self determination, medical decisions, and the potential impact on others. Suicide may not fit into this trio if the individual’s social network is supportive of the right to die, and there are no dependents or other legal/social responsibilities. Although of course it is also possible to argue about the value of a human life altogether, some greater contribution to or effect on society, the individual may attain some perspective later for which they would regret this decision (i.e. only one option allows you to change your mind), and so forth.

    On a broader scale, what of mental illnesses that are highly treatable? Between adult partners one would assume (although not always correctly) that there is sufficient access to health and medical information; equal power in the relationship and each may speak for themselves about how the burdens are divided; and what each other’s limits are. Yet often in a family system, it may be the underage children who bear the brunt of the chaos, which may only manifest itself openly (that is, where other adults become regularly concerned) in school performance. Eventually someone might suggest the child(ren) be medicated, despite their age and unclear ramifications on their still maturing minds and bodies.

    c

    Jul 6, 07:03 AM #

  2. Hi c, thanks for your response to this and your flurry of comments on other content!

    c: The individual may attain some perspective later for which they would regret this decision (i.e. only one option allows you to change your mind), and so forth.

    That’s an excellent point and I think gets to the root of this issue. Do we take the rather paternalistic approach of saying that the individual who attempts to commit suicide is not (currently) of sound mind, and that upon recovery from the consequences of their attempt they will be grateful for the opportunity afforded by their treatment?

    Alternatively, can an individual through sound reasoning arrive at the conclusion that they wish their life to end. If so, does the principle of respect for autonomy require that their wishes be honored? Does it matter if they willingly or unwillingly present to a facility focused on reversing disease?

    Thame

    Jul 6, 04:39 PM #

  3. This is a great blog. Nice design, engaging topics, incisive observations.

    I see your point about the paternalism. This may also be an issue for the entire psychological community. Depression has very real effects on a person’s perspective. Some people who understand well their own mental health condition sign contracts with their psychiatrist/partner/clergy that should their bi-polar/depression/etc. flare up, to set into motion a series of events to protect them from themselves.

    Few people have this level of clarity.

    Otoh, the opposite becomes a sticky case indeed. Few therapists (I imagine) likely wish to be in the position of declaring a client of sound mind when they wish to commit suicide. It would not be a popular task in society today, and once again contains the seeds of contradiction in a field that is trying to help people improve their lives, mental health, and get a handle on their personal issues.

    A third issue, is that the medical profession is trying to move away from the belief that every last medical treatment available should be used to protect life. There are procedures that would only prolong life for certain individuals for a few weeks or months, at great financial cost (for the individual’s family, their medical insurance, and possibly the hospital) and physical pain/difficult recovery, whose remaining quality of life would be significantly compromised. The rising opinion seems to be against such herculean efforts. Nevertheless I have heard of physicians who have supported this philosophy for most of their professional careers, who on their own death beds, have ordered every treatment possible.

    I believe hospice is a well developed way to ease one’s transition into death that seems humane and comfortable, for those who have incurable conditions that will claim them quickly. This seems like the only clearcut case of the four here.

    Is there were a clear way to make useful distinctions between these four types of cases, to make a good decision as a society without overstepping bounds for the individual? When is healing, healing? When should society let go? When should the individual decide? For me the first scenario would be ideal, if mental health were more science than art. The second (certifying soundness of mind in order to support suicide) seems macabre. The third seems practical but we are oh so human in the end. What do you think?

    c

    Jul 9, 09:46 AM #

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