Self-harm, capacity, and refusal of treatment: Implications for emergency medical practice. A prospective observational study
Open accessAbstract
OBJECTIVES: In the context of increasing attention to the rights of adults to make treatment decisions for themselves, this study 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 southeast England. PARTICIPANTS: Seventy one adult men and women who had presented for treatment following self-harm. MAIN OUTCOME MEASURES: Semi-structured interviews were used to make clinical judgements about participants' capacity to consent before, and following, the presentation of simple written 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, the number of patients judged to have capacity improved significantly (p<0.001) after the presentation of written information, to 45/71 (63.4%). Those judged incapable were significantly more likely (p<0.01) to refuse treatment. Continuing incapacity was significantly associated only with cognitive impairment (p<0.001) and/or severe psychiatric disturbance (p<0.01). 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. The findings are consistent with recent guidance about supporting this vulnerable group of patients, many of whom are ambivalent about treatment.
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Based on Cook's distance, there was only one potentially influential case, in the MMSE analysis (Jacob et al., 2005).
“Based on Cook's distance, there was only one potentially influential case, in the MMSE analysis (Jacob et al., 2005).”
From Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis (2024) · cites this paper as Jacob et al., 2005
The Data analysis section lists McNemar’s, chi-square or Fisher’s exact, and Mann–Whitney tests, but does not report a Cook’s-distance assessment. The MMSE results in Table 1 do not identify an influential case. Searches for Cook’s distance and influential observations found no passage supporting the claimed count. (LLM, conf=0.77)
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- Authors
- Jacob, R., Clare, I. C. H., Holland, A., Watson, P. C., Maimaris, C., & Gunn, M.
- Affiliations
- Fulbourn Hospital (GB)
- University of Cambridge (GB)
- MRC Cognition and Brain Sciences Unit (GB)
- Addenbrooke's Hospital (GB)
- Nottingham Trent University (GB)
- Corresponding author
- Holland, A
- Venue
- Emergency Medicine Journal
- Publisher
- BMJ
- Published
- 2005-10-21
- Volume
- 22
- Issue
- 11
- Pages
- 799-802
- ISSN
- 1351-0622 (ISSN-L)
- 1472-0205
- 1472-0213
- PMC
- PMC1726596
- OpenAlex
- W2088644448
- Cited by
- 36
- References
- 26
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 1 · 2020: 4 · 2019: 5 · 2018: 2 · 2015: 1 · 2014: 4 · 2013: 1
- FWCI
- 3.08
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Emergency Medicine Journal (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Ethics and Legal Issues in Pediatric Healthcare
- Keywords
- self-harm, decision-making capacity, treatment refusal, informed consent, emergency department, mental illness, cognitive impairment, psychiatric disturbances, written information, patient autonomy, alcohol abuse
- MeSH terms
- Adult, Aged, Aged, 80 and over, Mental Disorders, Decision Making, Emergency Service, Hospital, Emergency Treatment, Female, Hospitals, Teaching, Humans, Male, Medical Audit, Middle Aged, Prospective Studies, Treatment Refusal, Self-Injurious Behavior, Mental Competency
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