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.