Refusal of treatment: suicide or competent choice

Increasingly, patients are exercising the right to refuse treatment. Patients who have been chronically ill or those who consider themselves terminally ill are most apt to do so. Accordingly, liaison psychiatrists are asked to determine whether refusal of treatment is an act of suicide or a competent choice. This is difficult to assess in the absence of delirium or overt psychosis. It is suggested that the dynamics and affective tones of the patients' reaction to the health care system as well as to family and friends are of major significance in this determination. The actual process of exploring these areas with patients making this choice is often therapeutic in restoring the patients' sense of control or authenticity. Often this process enables them to continue treatment and avoid the impulsive interpersonal anger that characterized the suicidal act.