In my recent research I found a strong relationship between high insight and suicidal thoughts. My results confirm some studies in the literature (Ho, 2003; Nordentof, 2014)

Let's start by asking the question: Why are these persons being put in "seclusion" in the first place? Rather than "seclusion" and "surveillance" we should be offering CARE and ACCOMPANIMENT!! Our research consistently shows that listening to the patient and believing in them is what's most helpful (ie:offering space or presence when they say they need it vs 'getting them to comply' with our rules & regulations or making decisions for them such as deciding when they're 'ready'--or not--to go out, attend groups. etc). Instead, clinical interventions should focus on helping patients make decisions for themselves.

Gros, C.P., Jarvis, S., Mulvogue, T., Wright, D., (2012), Les interventions infirmières estimées bénéfiques par les adolescents à risque de suicide, Santé mentale au Québec, (37) 2, 193-207.

I understand that seclusion is sometimes necessary for patient and staff safety. Our policy for over 40 years has been that there has to be a nurse with eyes directly (not via monitors) on the patient 24/7 when they are in seclusion. This is not specific to suicide prevention but it was the perfect anti-dote 45-50 years ago when seclusion was much more common and at times may have been partially used to reduce the staff burden of being with  patients on constant observation.  This policy change back then meant that seclusion would never be used  a means to reduce staff observation time with a patient.  If the nurse is at the door watching the patient, he or she can summon staff quickly if the patient is attempting to injur him or herself.  Although not common we do have patient's attempting to injur themselves and the staff come in numbers  to the patient's side when that happens.  The corollary is that whether it is seclusion or some other form of restraint, the nurses and doctors are well trained to reduce the time that this is required in these circumstances by prepping the patient verbally and in any other way to safely come out of restraints and out of seclusion.  The restraints and or seclusion is reduced and stopped initially on a test basis wtih plenty of staff support.

This raises a fundamental ethical question to which I do not know the answer, and rarely see discussed.  If we respect patients, then we should respect their decisions even though we may disagree with them.  So what right do we have to stop a patient committing suicide, or to aggressively treat them when they arrive in the Emergency dept after nearly succeeding in killing themselves?

"Instead, clinical interventions should focus on helping patients make decisions for themselves."

Yes, but this does not address the ethical dilemma.  What do you do when patients decide for themselves that suicide is the best option? 

Anthony Gordon wrote:

"Yes, but this does not address the ethical dilemma. What do you do when patients decide for themselves that suicide is the best option?"

Unfortunately, in most parts of the world, clinicians are legally required to do anything necessary to prevent the patient from killing themself regardless of how logical the patient's suicidality may be for their particular situation (e.g. a patient slowly losing control of their body due to ALS).  In most places, the law has made the ethical decision for clinicians.  Patients with suicidality are not afforded the same level of dignity that patients with other health conditions are given.  A person with cancer can decide not to get treatment for their cancer even though it is probable that leaving the cancer untreated will lead to their death.  However, a person with suicidality is not allowed to refuse treatment for their suicidality because leaving it untreated may lead to their death.  There is a very clear double-standard.

"In most places, the law has made the ethical decision for clinicians."

Yes, and many clinicians are only too grateful to hide behind this  RG provides an opportunity for them to say what they really think about the ethical principles behind this. 

Here is a concrete example where the obvious wish of the patient was not respected (J Forensic Sci 2013;58:537):

A 54y old man with liver cancer left a suicide note then shot himself 3 times, in head, heart and lung.  When police and medical personnel arrived, he repeatedly assured them "that he did shoot himself  and did want to die.  Transportation to the nearest General Hospital was decided.  The man was declared dead in the ambulance, on the way.. capable of comprehension and satisfactory verbal communication just until 1-2 min prior his death"

So, when do we respect the wish of the patient, and when don't we?

To whoever downvoted my last posting:  Would you like to answer my last question, rather than trying to block discussion of it?

To clarify the dilemma, in the case here where there is no evidence the patient is mentally ill or irrational, we jump in and act paternalistically, not necessarily in the patient's best interests, whereas in the psychiatric unit where patients may lack insight and judgement, we step back and try not to interfere.

Although I did not down vote your comment I will entertain the discussion (which has strayed from the question that was posed), having myself considered the double standards concerning refusing treatment, DNR and suicide (illegal in my country).

I think that when it comes to mental health, the decision to take one's life is by itself an indication of mental disturbance, almost any of which can be dealt with through therapy.

Concerning the medical personnel's action that were counter the patient's wishes recall that they take a hippocratic oath which includes “first do no harm” and based on their training and the absence of the knowledge of the patients tribulations not intervening will be doing harm. 

Yanik Quesnel wrote:

I think that when it comes to mental health, the decision to take one's life is by itself an indication of mental disturbance, almost any of which can be dealt with through therapy.

I do not believe this is accurate.  My prior example of someone with ALS is not someone that has a "mental disturbance" that "can be dealt with through therapy."  I believe this is a common misconception that is tied to both Durkheim's work and Shneidman's work.  While the theories of suicidality these two men wrote about are accurate in some cases, I do not believe they are accurate in all cases.  I believe we need to stop looking at suicidality as being a symptom of depression (which was suggested by Shneidman's work) or as it being the result of some life event (which was suggested by Durkheim's work) and begin to understand that there are other ways people experience suicidality.

Yanik Quesnel also wrote:

Concerning the medical personnel's action that were counter the patient's wishes recall that they take a hippocratic oath which includes “first do no harm” and based on their training and the absence of the knowledge of the patients tribulations not intervening will be doing harm.

I guess this depends upon the definition of harm.  If a patient has a form of suicidality not tied to the currently understood theories of suicidality then there are very limited treatment options for this patient.  Some patients experience unwillful daily suicidal ideation that they are unable to control and that current treatments (anti-depressants, ECT, CBT, DBT and other treatments) were not helpful in treating.  Some of these patients will argue that they are being harmed by being forced to continue struggling through life when no appropriate treatments are available to treat their suicidality and they are tired of their suicidality controlling their life.  This is the justification I frequently hear from some patients as to why they believe they should have the right to decide to kill themself.  If nothing else, expecting people to struggle with a health condition that there does not appear to be proper treatments (specific anti-suicidality treatments) for can be argued to be causing the patient emotional harm since they are not allowed to die which may be the only way they can end their emotional suffering.1

There are countless instances over the course of history of physicians that took the Hippocratic oath conducting experiments on patients that would never be allowed today because we would currently view the experiments as barbaric.  Although I would prefer anti-suicidality treatments to become available to these patients, if that is not possible (and even if it is possible but the informed patient decides not to use the treatment), then I believe these patients should have the dignity of deciding if they want to allow their health conditon (their suicidality) to kill them (via a suicide attempt) which is the same dignity afforded other people with potentially terminal health conditions (in some areas of the world). 

1Some my prior points about a patient's condition are explained in the following publication which is available at the following link after registering for a free account on the journal's website.

Giddens JM, Sheehan DV. The Complexity of Assessing Overall Severity of Suicidality: A Case Study. Innov Clin Neurosci. 2014;11(9–10):164–171.

http://innovationscns.com/the-complexity-of-assessing-overall-severity-of-suicidality-a-case-study/