Saturday, 19 February 2011

Do what you wish



Capacity


I remember a call to an elderly lady who was sitting in her front room on a chair, staring into space as if dead. My colleague and I peered in through the patio doors in the back garden and called to her, banging on the window to attract her attention, hoping that she’d move or say something and prove herself to be not-dead.

She wasn’t dead – eventually, after we’d roped in the police and a neighbour – she moved enough to let us know (the four faces staring in at her), that she couldn’t get up to let us in. With no option, we broke the door down. I say we broke it down but, in all honesty, all I had to do was push it hard and the thing peeled itself away from the frame, leaving the Yale lock engaged and hanging in the air. Her house was a mess and there was rot in the woodwork; it was amazing that she’d been left alone by the local drug addicts and burglars.

We asked her if she was alright and she said she was. A relative had called because he was concerned that she hadn’t phoned for a while. The same relative refused to come and persuade this lady to go to hospital. We spent almost three hours in that house, joined eventually by her GP and a local Priest. She was dishevelled, hypothermic, had a low blood pressure and her breathing was off. She was sitting in her own faeces and had been in that chair for days by the look of it.

‘I’m not going to hospital! I’m staying here!’ she said repeatedly as the little gang of professionals tried to convince her that she needed urgent medical attention.

She wouldn’t let anyone touch her, except to allow myself and my colleague to stand her up so that she could convince us she was fit enough to walk a few feet. She wasn’t and she promptly crashed down onto the chair again.

The doctor told us, as we huddled in conspiracy in the small, smelly hallway, that she would certainly die, probably during the night, if we couldn’t get her to go. But the law was against us and I struggled with this call at that time for a long time afterwards, before I ended up here, working on the CSD, helping others make the same decision that I and my co-conspirators in that hallway had to make.

You see, you cannot force anyone to do anything – you cannot deprive them of their liberty or go against their expressed wishes unless they lack capacity to make decisions affecting them. The Mental Capacity Act makes it very clear that any professional person who forcibly removes someone from their own home without a damned good excuse, is liable to prosecution – tantamount to kidnapping and false imprisonment I’ll bet.

Now you may think that the physical state and clinical observations gained from the patient would be justification for removing her against her will but, unless we could actually prove (that is, we were convinced beyond doubt) that this lady would die unless we did so and that she lost consciousness there and then, we could not touch her. Even the doctor’s remark wouldn’t be enough and when we pressed him, he was very reluctant to base our planned kidnapping on his comment.

So, we had to leave her there, as she’d wished. She told us to leave and we had to go – she knew what was happening, she understood what we’d said and she acknowledged the risk she was taking and the consequences of her actions. She had capacity and therefore the right to say ‘no’ to treatment and care.

We are allowed to remove someone from their own home if they lack capacity and their removal is in their best interests because they cannot make the decision for themselves… but even then we have to be very, very sure that it is necessary (they will definitely die if we don’t). But people with capacity have the right to lie on the floor of their own home and bleed to death as we watch, as long as they retain capacity until they become unconscious, in which case they lose it by default.

Tricky and complicated it may seem but I see it as very simple. The Act protects us and gives every human being the right to make their own decisions, whether others see it as wrong or not. It is not illegal to commit suicide, so if someone wants to kill themselves in their own home, nobody can stop them and remove them, unless they can be sectioned under the Mental Health Act (and that’s not a rapid process), so long as they are not assisted in killing themselves, in which case the person helping them will be prosecuted.

Advising crews about this is hard because clinicians don’t want to hear it; they want to help, even if that means imposing that help for the sake of the patient. Unfortunately it is not legal to force care on people. They just don’t teach us about that in any depth during training, although that may well have changed.

Be safe.

13 comments:

SPara said...

Sadly training remains the same (a very serious lack of explanation). I understand that to look at every situation is impossible in the training environment but as clinicians we are built to help people. When they refuse this help, especially when it will lead to their deterioration (not when its to protect our backs from litigation) its hard to turn away and think you did right by that patient.

Mjolinir said...

Perhaps this lady had made a positive decision - the last one left to her - to spend her final days with her memories?

When I was a copper, I seemed to get quite a few 'sudden deaths' - partly because of scientific training that helped me translate the pathology reports for the CID, and partly because a didn't throw up at the sight of a corpse.

1000 am, and a 'carer' calls Police - she arrived to wash 2 x 80+ spinster sisters living in the same neat little house they had been born in. The elder, but more mobile, had helped the other out of bed and into an armchair - made breakfast - then sat down opposite to eat it and ...just died.

Survivor couldn't get out of the chair - or reach her sister - or the phone, so spent 2 hours helplessly watching.

Together with the carer & their GP (Miraculously he turned up in a few minutes, and "Certified")I persuaded her to let an Ambulance take her into hospital "While the undertakers get things sorted out"

She knew that - with no family capable of looking after her full time - she wouldn't be coming back.

As SHE put it to me; at 82 she had come to terms with the FACT of death. What frightened her was "I'll never sleep in my own bed again."

Xf said...

Mjolinir

Truly poignant. And yes, my patient had certainly made that decision and one that everyone has the right to make... just very hard on those who wish to help.

Anonymous said...

Do you mind if I copy this and use it as training material?? We are currently covering and debating gaining consent from Patients and I found this very interesting.

Xf said...

Anon

You may copy it if you wish. :-)

Colin said...

As a paramedic in Canada, we would hav.e removed her under our mental health act. Especially if she stated the desire to die or hurt herself, where we become obligated by law to have her 'arrested' by a police and transported for 72 hours.

Are there no legal obligations in Britain regarding acting on behalf of someone who is incapable of making proper decisions about her safety and wellbeing?

I only ask because our dilemma would be the opposite of yours, where we would be risking legal action by NOT acting, either from their family later on, or by the coroner.

Xf said...

Colin

The Mental Health Act and the Mental Capacity Act are two different things; we cannot remove someone from their own home (or any private place) on the basis of the MHA if they have no metal illness or a doctor does not agree that they are not mentally fit.

Anyone can threaten to harm themselves; it does not necessarily make them mentally ill, so we have no option but to leave patients where they wish to be.

Dying patients request to die at home - they have that right. So do healthy ones.

Anonymous said...

Just wanted to add a few things:

1. You mentioned that you can't act against her wishes as she has capacity until she loses consciousness. You must remember she had capacity to make the decision and after she falls unconscious she ha already made a decision and you STILL can't move her. If you found her unconscious you could act in her best interests but once she has decided then her decision( if she had capacity) is binding.

2. In terms of the comment about the mental health act as you say you could only take someone if they had a mental illness, but it must be for their own safety, and only so you can treat their mental condition. You CANNOT use the mental health act to forcibly treat someone for a physical health condition as they can retain capacity.

Cosmo

Xf said...

Cosmo

Thank you. I don't agree with you on the unconscious casualty issue. it would be ludicrous and negligent to leave someone lying on the floor unconscious just because when she was conscious she had capacity and made a decision. Clinically, when she becomes unconscious, she lacks the ability to make any kind of decision AT THAT TIME. She can wake up and change her mind if she wants but no crew is going to just walk away with the excuse you described.

As for the MHA; I don't I ever suggested it be used to remove anyone for a physical illness.

Sean said...

Did you ever find out if the patient died?

Xf said...

Sean

No, I didn't but I have to assume that she did.

Anonymous said...

It is a strange law. But that is how it works in the UK. That is why people can make a decision not to have treatment for a disease (or a blood transfusion if jehovas witness) and it is binding. You cannot then start treating them (or transfusing them) once they black out. It counts as assault in UK law. I am just saying that is how uk law works. I don't agree with all of it.

Cosmo

dr din said...

I think I agree that one should not force treatment on a capacitious individual specially for physical disorder everyone should have freedom to choose whether to live or die that's what mental capacity act teaches us