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personality disorder

Respecting the right to die

20 Oct, 08 | by Steven Reid, Evidence-Based Mental Health

A BMJ blogger, William Lee, writes of his disquiet following a visit to a meeting held by Dr Philip Nitschke, director of EXIT International, who is in the UK promoting his new ‘guide to suicide’. He describes a strange-sounding meeting with little consideration of the relationship between suicidality and mental illness, and the issue of mental capacity warranting only a cursory mention, including the bizarre recommendation to ‘get a friend to do an MMSE test before your suicide to demonstrate possession of capacity’. Assisted suicide and the ‘right to die’ feature prominently in the news media at the moment. A 45-year-old woman, Debbie Purdey, is seeking clarification of the UK law relating to assisted suicide. She doesn’t want her husband to be prosecuted should he support her in visiting Dignitas, the Swiss organisation providing facilities for euthanasia. Police are currently investigating the case of David James, a 23-year-old left with quadriplegia after sustaining a spinal injury while playing rugby. After several previous attempts he committed suicide at a clinic in Switzerland

Another case has been less widely reported, although I consider it to be no less significant (read about it here). It’s a common scenario that will be familiar to anyone with experience of working in an emergency department – someone presenting with self-poisoning and then refusing treatment. The inquest began last week into the death of Kerrie Wooltorton, a woman with a history of borderline personality disorder, who was taken to Norfolk and Norwich University Hospital after drinking antifreeze (ethylene glycol). On arrival she stated that she did not want treatment and was ‘100 per cent aware of the consequences’. She also brought in a living will (advance directive) that she had written three days previously. The physician responsible for her care thought that she had capacity to make decisions about her treatment and reported that she was ‘calm’ and ‘not agitated’. He felt that it was his ‘duty to follow her wishes’. After consultation with the hospital’s medical director and legal adviser she was not given treatment and died the following day.

The law in the UK (recently codified in the Mental Capacity Act) is clear on the question of treatment for physical illness without consent. If the subject has capacity such treatment would constitute an assault or battery. Yet there are aspects of this case which are troubling. Ms Wootorton had attempted suicide by swallowing antifreeze on nine occasions in less than a year and had previously accepted treatment (including dialysis). She also had a number of recent psychiatric admissions and had been detained under the Mental Health Act. A psychiatrist who saw her in the months before her death said he believed she had the mental capacity to make the advance directive but how can he be certain that this was the case when she wrote it? Given the context of her recent history would there not have been reasonable grounds to doubt her capacity? It’s not uncommon for people turning up in A&E after deliberate self-harm to express ambivalence about treatment and subsequently change their mind, especially in those with borderline personality disorder where impulsivity is a prominent feature. Also, suicidality fluctuates in this group, and if her intent was so clear why come to hospital at all?

These decisions are always difficult and not really made any easier by the Mental Capacity Act. My inclination would have been to treat her on this occasion with an agreement that if she maintained her wish to decline future treatment and in the cold light of day clearly had capacity, an advance directive could be drawn up with the acknowledgment that it was valid by people involved in her care. A paternalistic abuse of a person’s autonomy? Maybe, but what do you think?

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