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C&C

by Reynolds on Mon 07 Dec 2009 12:15 PM GMT | Permanent Link | Cosmos

Once more I find myself concerned with Capacity and Consent.

Capacity and Consent are two linked words that govern how I can treat patients and it always needs to be at the forefront of my mind.

Capacity Is the ability for someone to understand what I am telling them and to be able to make a decision based on being able to understand the risks of choices that they make now.

Consent is my patient allowing me to do things to them, be that blood pressure measurements, giving them medicine or taking them to hospital.

For most of my jobs both capacity and consent are implied - someone calls an ambulance, I arrive, I do certain medical things to them and they do not complain and then I take them to hospital - the patient, for their part goes along with this and everyone is happy.

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In short,

If a patient gives both consent and has capacity - everyone is happy.

If a patient refuses consent, but still has capacity - then I am less happy, but I will leave them alone (and write reams of documentation in order to 'cover my arse')

If a patient consents, but doesn't have capacity, I find myself acting in a parental role - in which I trust that I will do what is best for my patient.

However, If a patient refuses consent but doesn't have that capacity to understand what refusing treatment may do in the future I'm on a bit of a sticky wicket.

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Take the drunk alcoholic who has sunk a couple of bottles of Jack Daniels, swallowed some pills and scrawled what he considers to be a suicide note (but is actually just some wavy lines as he is too drunk to write). He has then thrown himself down in the living room in front of his wife.

We arrive and, after he's already told us to 'fuck off' and taken a swing at us, he refuses to go to hospital.

I'm now dealing with someone who does not consent to treatment, but who - because of the effects of alcohol - can't be considered to have the capacity to refuse treatment.

He may get violent if I try to forcibly remove him to hospital - so I ask for police assistance.

The police may be able to forcibly remove someone to a 'place of safety' (normally an A&E dept.) under Section 136 of the mental health act, but the person needs to be in a public place.

My options come down to (a) Leaving him at home where he could die, and he probably doesn't really want to die, he was just temporarily suicidal because he's drunk, or (b) I drag him off to hospital against his will where he can then try suing me for kidnapping him against his will.

I'd like to think that the law was certain in this point, and while I have no doubt that I'm right and that the law would protect me, I may still lose my job.

(I direct you to the case of a nurse who lost their job after swearing at a patient after the patient had punched him in the face as evidence of how easy it is to lose your job, I also invite you to read my account of 'my first complaint')

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So what did I do in this circumstance? Luckily for me the patient pretended to become unconscious after performing one of the least effective 'fits' I've ever seen, so we managed to cart him off to hospital.

If he hadn't decided to make it easy for me, well I'd have used the help of the police to forcibly remove him and worry about my job later - after all I'm more scared of the Coroner than my bosses.

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The very next day I had a similar situation - someone so drunk that they could barely stand, teetering on the top of a long flight of stairs complaining of chest pain, but refusing to come to hospital because they wanted to have transport home.

He also said that he'd rather die than have to make his own way home from the hospital.

Again, his reasoning impaired by virtue of alcohol, I was left in a dilemma - do I leave him at home when he then dies and I'm up before the coroner, or do I 'trick' him into coming to hospital by saying that they will get him home, thereby risking a complaint and my job.

Once more the imaginary coroner sitting on my shoulder asking me why I left someone vulnerable at home to die won out, and I took him to hospital on the promise that tey would give him transport back home.

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So yes, when a patient doesn't have capacity, but may well complain later - I'll take the route that has them less likely to die. Even if it does risk my job.

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Comments

Re: C&C

by Burnside at 02:30PM (GMT) on Dec 7, 2009 | Permanent Link

My understanding is the Mental Capacity Act 2005 would have given you the power to act in the best interests of the man, as the alcohol would mean he was temporarily lacking the capacity to make such decisions. This would obviously mean taking him to hospital. As he would no doubt resist this, the police should help. This is a different power to s136, and does not need to be in a public place.

Re: Re: C&C

by Reynolds at 03:09PM (GMT) on Dec 7, 2009 | Permanent Link

I agree, but if he were to complain later there is the possibility of me getting into trouble - after all, I nearly got into trouble after I was assaulted.

That is the gist of this post.

Re: C&C

by dungbeetle at 09:04PM (GMT) on Dec 7, 2009 | Permanent Link

There are many people that make a good living by complaining, as it is easier to pay off than to investigate the complainers complaint when the known Quantity has given their explanation and validated. There should be a hot sheet with finger prints of repeat complainers.

Re: C&C

by Buckman at 02:40AM (GMT) on Dec 8, 2009 | Permanent Link

There is an answer to this Tom, but for some reason no one wants to go there. We have to come up with a standard set of simple assessments that can be used as a field assessment for capacity. We also need to do what many cops in the U.S are doing which is wirelessly recording our interactions with a patient refusing care. So then what you do is you go back and say, "Lookie here, I have this assessment which said they had capacity, they signed my run form refusal box, and I have the whole thing on tape so you can see that it is on the up and up. By the way, I notified the police as to my suspicions, and I drove away." After that we are going to have to do something that legislators are loathe to do, actually hold people accountable for their actions. So the courts and your superiors can look at this and say, "They offered help, he refused, he had capacity, he signed the form, the police were notified...what the hell else could they do. And yet, this guy is dead after all that. I guess natural selection is correct after all."

But for some reason they don't want to do that. And don't tell me that it is not in the budget. They will pay to put a camera on every street corner, but they want to remain in the dark in someone's home who has called 911? I hate gray areas that don't need to be gray.

Re: C&C

by Paramedic Blogger at 10:55AM (GMT) on Dec 8, 2009 | Permanent Link

I think that its a simple case of your damned if you do and your damned if you dont.

The training within service on this subject is pretty poor and ambiguous or incorrect at times. I have also covered this subject at length at University but am still not really any the wiser of my available options, if anything I am just more worried about loosing my job by leaving them at home and they die or coercing my patient (which is against all of our HPC codes of conduct etc) and still loosing my job.....

Re: C&C

by Redcat2 at 02:08AM (GMT) on Dec 9, 2009 | Permanent Link

An annoying drunk teetering at the top of a long flight of stairs would have more to worry about than 'chest pains' if I was behind them -but then that's why I couldn't do the job you do.

Do you never wish you had tasers?

Re: Re: C&C

by Tec at 08:04PM (GMT) on Dec 9, 2009 | Permanent Link

Had a hell of a job deciding what sort of sandwiches to have for lunch today. In the end settled for chicken and bacon.

Welcome to Random Acts Of Reality, a Blog based in London, England, written by an E.M.T working for the London Ambulance Service. Also, number one search result for "Womble porn". All names have be changed to protect the guilty. This Blog was previously known as "Why I Hate Humanity" but the antipsychotic medication seems to have kicked in.
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