Are patients with suicidal ideation considered incompetent to consent to medical procedures?

From the Guidelines

Patients with suicidal ideation are not automatically considered incompetent to consent to medical procedures, as competence is determined by the ability to understand, appreciate, reason, and communicate, not by the presence of suicidal thoughts alone. According to the Association of Anaesthetists of Great Britain and Ireland guidelines 1, a patient's capacity to make decisions should not be judged based on their appearance, behavior, or a particular condition, including suicidal ideation. The decision-making capacity of a patient is issue-specific, meaning they may have the capacity to consent to simple procedures but not complex ones 1.

Key factors in determining competence include the patient's ability to understand the information presented about a procedure, appreciate the situation and its consequences, reason about treatment options, and communicate a choice. Suicidal thoughts alone do not necessarily impair these decision-making capacities. However, if a patient's suicidal ideation is accompanied by severe depression, psychosis, or other conditions that significantly impair judgment or understanding, a formal capacity assessment may be warranted, as mental illness can impair a patient's capacity to provide valid consent for treatment 1.

In emergency situations where a patient with suicidal ideation requires immediate life-saving treatment but cannot provide consent due to their mental state, healthcare providers may proceed under implied consent or emergency exception doctrines. It's crucial to note that suicidal patients should receive appropriate psychiatric evaluation and treatment alongside any medical procedures they require, and safety measures should be implemented to protect them during their care 1. The presence of suicidal thoughts should prompt a careful assessment of the patient's decision-making capacity rather than an automatic determination of incompetence.

Some important considerations include:

• The patient's refusal of treatment is legally binding if they have capacity, even if refusal is likely to result in the patient's death 1.
• A lack of decision-making capacity may be temporary or permanent, depending on the underlying cause 1.
• Patients detained under the Mental Health Act should not be assumed to be incapable of providing valid consent for medical, surgical, or dental treatment, unless their capacity is specifically assessed and found to be lacking 1.

From the Research

Competence to Consent to Medical Procedures

• Patients with suicidal ideation may not necessarily be considered incompetent to consent to medical procedures, as competence is evaluated on a case-by-case basis 2.
• The presence of major depressive disorder may lead to an automatic finding of incompetence in some cases, as 58% of forensic psychiatrists believed this to be the case 3.
• However, patients with schizophrenia or depression may generally be competent to give informed consent to medical treatment, as found in a study where no patients with these conditions were found to be incompetent 2.

Evaluation of Competence

• Mental health professionals have not developed guidelines or standards to aid in evaluating competence to consent to assisted suicide, highlighting the need for further study 3.
• A stringent standard of competence is recommended, with 73% of forensic psychiatrists believing that at least two independent examiners are needed to determine competence 3.
• The ethical views of psychiatrists may influence their clinical opinions regarding patient competence to consent to assisted suicide, emphasizing the need for a thorough and unbiased evaluation 3.

Suicidal Patients and Medical Treatment

• Patients who are suicidal and under the influence of substances may not be able to process information provided by the doctor, making their refusal of medical services unreliable 4.
• In such cases, the doctor is still obliged to render medical services, as not providing help would mean neglecting due diligence in the treatment process 4.
• The need for clear regulations regarding patient refusal of procedures aimed at saving their life or preventing serious health impairment is highlighted, particularly in cases where the patient's ability to make a conscious decision is impaired 4.