Management of patients with an advance decision and suicidal behaviour: a systematic review

Rebecca Nowland, Sarah Steeg, Leah Quinlivan, Jayne Cooper, Richard Huxtable, Keith Hawton, Neil Allen, David Gunnell, Nav Kapur

Research output: Contribution to journalArticle (Academic Journal)peer-review

8 Citations (Scopus)
188 Downloads (Pure)


Background The use of advance care planning and advance decisions for psychiatric care is growing. However, there is limited guidance on clinical management when a patient presents with suicidal behaviour and an advance decision and no systematic reviews of the extant literature. Objectives To synthesise existing literature on the management of advance decisions and suicidal behaviour. Design A systematic search of seven bibliographic databases was conducted to identify studies relating to advance decisions and suicidal behaviour. Studies on terminal illness or end-of-life care were excluded to focus on the use of advance decisions in the context of suicidal behaviour. A textual synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach. Results Overall 634 articles were identified, of which 35 were retained for full text screening. Fifteen relevant articles were identified following screening. Those articles pertained to actual clinical cases or fictional scenarios. Clinical practice and rationale for management decisions varied. Five themes were identified: (1) tension between patient autonomy and protecting a vulnerable person, (2) appropriateness of advance decisions for suicidal behaviour, (3) uncertainty about the application of legislation, (4) the length of time needed to consider all the evidence versus rapid decision-making for treatment and (5) importance of seeking support and sharing decision-making. Conclusions Advance decisions present particular challenges for clinicians when associated with suicidal behaviour. Recommendations for practice and supervision for clinicians may help to reduce the variation in clinical practice.

Original languageEnglish
Article numbere023978
Number of pages14
JournalBMJ Open
Issue number3
Early online date13 Mar 2019
Publication statusPublished - Mar 2019


  • self-harm
  • suicidal behaviour
  • advance directives
  • advance decisions
  • living wills
  • Ulysses directives


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