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The article presents the case of Kerrie Wooltorton, who died on September 19, 2007 from deliberate self-poisoning with antifreeze after refusing life saving treatment, to discuss the challenges in considering the role of advance directives in suicidal behavior in Great Britain. A brief overview of the Mental Capacity Act 2005 is presented. It references the findings of a research study of individuals in England who had died following self-poisoning in 2005 but had survived long enough to reach hospital. It presents particular questions that clinicians should consider when dealing with advance directives to refuse treatment after suicidal behavior. INSETS: CASE HISTORIES;ADVICE FROM MEDICAL PROTECTION SOCIETY.

Background: Analgesics are used most frequently in fatal and non-fatal medicinal self-poisonings. Knowledge about their relative toxicity in overdose is important for clinicians and regulatory agencies.Methods: Using data for 2005-2012 we investigated case fatality (number of suicides relative to number of non-fatal self-poisonings) of paracetamol, aspirin, codeine, dihydrocodeine, tramadol, paracetamol with codeine (co-codamol), paracetamol with dihydrocodeine (co-dydramol), ibuprofen and co-proxamol (paracetamol plus dextropropoxyphene; withdrawn in the UK in 2008 due to high toxicity). Data on suicides obtained from the Office for National Statistics and on non-fatal self-poisonings from the Multicentre Study of Self-harm in England. Case fatality was estimated for each drug, using paracetamol as the reference category.Results: Compared to paracetamol and based on single drug deaths the case fatality index of dihydrocodeine was considerably elevated (odds ratio (OR) 12.81, 95% Confidence Interval (CI) 10.19-16.12). Case fatality indices for tramadol (OR 4.05, 95% CI 3.38-4.85) and codeine (OR 2.21, 95% CI 1.81-2.70) were also significantly higher than for paracetamol. The results when multiple drug deaths were included produced similar results. The relative toxicity of co-proxamol far exceeded that of the other analgesics.Limitations: Data on fatal self-poisonings were based on national data, whereas those for non-fatal poisonings were based on local data.Conclusions: Dihydrocodeine and tramadol are particularly toxic in overdose and codeine is also relatively toxic. They should be prescribed with caution, particularly to individuals at risk of self-harm. [ABSTRACT FROM AUTHOR]