Themes from the selected articles
| Theme | Subthemes | Theme descriptor | Perspectives | References | Count (%) |
| Tension between patient autonomy and protecting a vulnerable person. |
Professional dilemma: promoting patient autonomy versus providing appropriate care.
Societal expectation to protect vulnerable person and prevent suicide. | Tension between acting in accordance with patients’ wishes for their medical treatment while promoting their best interests presented clinicians with a professional ethical dilemma. Clinicians also had a personal ethical dilemma, as there is societal pressure to protect vulnerable people and prevent suicide. | Psychiatry, bioethics, legal. | 7 22 24 27 29 | 5 (33) |
| Appropriateness of advance decisions for suicidal behaviour. |
Mental health symptoms and suicidal ideation fluctuate.
Advance decisions for mental and physical health conditions—are they the same? | There were questions about whether an advance decision ‘fits’ in relation to suicide without an existing physical illness because mental state, mental health and suicide ideation fluctuate. Such scenarios are different from decisions made about treatment for a chronic or terminal physical condition. | Medical, psychiatry, bioethics, legal. | 2 6–8 23–25 27 29–32 | 12 (80) |
| Uncertainty about the application of legislation. |
Confusion and anxiety about litigation.
Advance decisions are about more than a simple assessment of capacity. | Legislation around advance decisions was seen as confusing and there was anxiety about ligation. It was noted that mental capacity legislation overlapped with mental health legislation and policy. There were concerns that relying on a capacity decision was not sufficient and the authenticity of the advance decision needed to be considered. | Medical, psychiatry, bioethics, legal. | 2 8 22–29 31 | 11 (73) |
| The length of time needed to consider all the evidence versus rapid decision-making for treatment. |
Need to fully consider the totality of evidence.
Increased gravity of the clinical decision. | Clinical decisions were considered to be complex, involving an assessment of mental capacity, verification of the advance decision and consideration of contextual factors. Therefore sufficient time was needed in which to consider all of the evidence. | Medical, psychiatry, bioethics, legal. | 2 8 25–27 | 5 (33) |
| Importance of seeking support and sharing the decision. |
Drawing up an advance decision as a collaborative process.
Shared decision-making. | Sharing the decision-making and seeking support, both at the time of writing the advance decision and when treating the patient, was viewed as important. | Medical, psychiatry, bioethics, legal. | 2 7 24–28 30 31 | 9 (60) |