Understanding Consent and Capacity

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• Understanding Consent and Capacity

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• This exercise
• Is based on the NICE guideline (2004) see
  www.nice.org.uk
• Was developed by the NICE guideline development
  group, including healthcare professionals and
  legal experts.
• Is designed to help you understand consent and
  capacity issues using real examples.

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In order to demonstrate capacity to give or
withhold consent for medical treatment, an
individual should be able to

• Understand in simple language what the medical
  treatment is, its purpose and nature and why it
  is being proposed.
• Understand its principal benefits, risks and
  alternatives
• Understand in broad terms what will be the
  consequences of not receiving the proposed
  treatment
• Retain the information for long enough to make an
  effective decision
• Weigh the information in the balance
• Make a free choice (i.e. uncoerced).
• Express that choice

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Vignette 1

• A 23-year-old man is accompanied to the emergency
  
• department by a friend who reports that he has
  taken an
• unknown number of paracetamol tablets.
• Shortly after arrival, the man states that he is
  going to
• leave. The triage nurse explains the potential
  dangers of
• paracetamol poisoning, but cannot persuade him to
  stay.
• The accompanying friend tells the triage nurse
  that the man
• has been drinking heavily, and the nurse notices
  that his
• speech is slurred and that he is unsteady on his
  feet.

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• What would
• you do next?
• Why?
• Discussion

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• The assessment of the triage nurse is that the
  man
• has reduced capacity as a consequence of alcohol.
  
• She also decides that, with the uncertainty about
  
• how much paracetamol has been taken, the
• chances of the man suffering severe consequences
• are high.
• The emergency doctor confirms this view and,
• having considered the intoxication of the patient
  
• and the consequences of non-intervention,
• concludes that the patient does not possess the
• level of capacity required for a decision of that
  
• importance.

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• It is decided that the man should remain until a
• blood sample has been taken and tested for
• paracetamol. The man is held with the authority
  
• of the Mental Capacity Act 2005 and security
• guards are asked to prevent him leaving.
• Although continuing to express his refusal, the
• presence of the security guards causes
• the man to remain in the assessment area, and
• blood is taken without him having given consent.
  This is
• on the grounds that he lacks capacity to make
  this specific
• decision at this time and the treatment is in his
  best
• interest. This assumes he has not made an
• applicable advanced statement.

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• Any Questions?

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Vignette 2

• A 19-year-old woman comes to the emergency
• department having cut her arm with a knife. The
• wound is 2 inches long and would benefit from
• closure however, no underlying structures have
• been damaged.
• The department is very busy and at
• triage the woman is assigned a low
• priority.
• After waiting for three hours, the woman
• tells the triage nurse that she is not
• prepared to wait any longer and is
• going to leave immediately.

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Angry and distressed at being kept waiting,
the woman refuses a belated offer of immediate
treatment for her wound. The triage
nurse has already ascertained that the woman cut
herself to relieve stress and that this is
something that has happened before. The
self-harm was not an attempt to kill herself,
and the woman is not expressing suicidal intent.
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• What would
• you do next?
• Why?
• Discussion

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• The woman is allowed to leave. Although she is
  distressed,
• and this might be affecting her judgement and
  therefore
• her decision not to have treatment, the staff
  decide that
• the consequences of the wound not being closed
  (the risk
• of an unsightly scar) are not sufficiently severe
  to warrant
• keeping the woman in the emergency department
  against
• her will.
• Staff tell the woman that they would be happy to
  treat her
• wound should she change her mind and return, give
  her
• written information about local mental health
  services and
• self-help groups, and send a fax to the womans
  GP
• explaining what has happened.

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Any Questions?
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Vignette 3

• A woman phones the emergency ambulance service at
  
• 9 pm. When the ambulance crew arrive at her home,
  the
• woman tells them that she thinks that her
  partner, a man
• in his 30s, has taken an overdose of tablets
  after she told
• him that she intended to end their relationship.
• The man has locked
• himself in the
• bathroom and tells
• the ambulance crew
• that he is not
• prepared to see
• them or to
• go to hospital.

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He sounds distressed and angry and he refuses to
say what tablets he has taken. The
mans partner saw him open a bottle containing
sixty 75 mg amitriptyline tablets, which had
been prescribed for her, but did not see whether
he had swallowed any before locking himself in
the bathroom. The woman reports that the man has
no recent history of mental illness.
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What would you do next? Why? Discussion
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• From the information available, the ambulance
• crew suspect that the mans capacity is
• reduced by virtue of his distress and anger.
• The womans account of events also
• lead them to believe that there is a
• substantial likelihood that he has
• taken an overdose that is
• potentially fatal.
• After failing to persuade
• the man to open the door,
• they call for assistance from the
• police who force the bathroom
• door.

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• The man is drowsy and slumped on the floor
• beside the empty pill bottle. The police
• escort the man in the ambulance to the local
• emergency department.
• In this situation, the ambulance crew might
• also have called for the advice of a
  psychiatrist. If
• the psychiatrist is unable to attend immediately,
  
• the ambulance crew could at least have discussed
• the assessment of capacity by telephone.
• Note - The final decision as to the patients
  capacity and
• whether or not the intervention is in the
  patients best interest lies with
• the person carrying out the intervention

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Any Questions?
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Vignette 4

• A 55-year-old woman is brought to the emergency
  department by
• her community psychiatric nurse (CPN). That
  morning, the womans
• husband had entered a room to discover that his
  wife had just taken
• a large quantity of her antidepressant tablets.
  He had immediately
• phoned his wifes CPN who visited straight away
  because it was
• clear that the woman would not agree to go to
• hospital.
• The CPN was able to persuade the woman to
• go with her. When assessed by the emergency
• dept doctor, the woman is fully conscious, calm
• and fully understands the doctors
• explanations about the likely fatal
• consequences of the overdose, if left
• untreated.

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• She refuses to accept treatment. She states that
  she had planned the
• overdose some weeks ago, and that she had not
  intended to
• be discovered by her husband until she was dead.
  She wishes to die
• because she believes that she has become an
  intolerable
• burden on her family.
• The emergency department doctor is uncertain
  about whether the
• woman has reduced capacity and suspects that her
  wish to die might
• be due to her mental disorder. His suspicion is
  strengthened when the
• CPN and the womans husband tell him that she has
  been under
• the care of mental health services for the
  treatment of
• severe depression. The emergency department
  doctor asks
• for an urgent assessment by the duty
  psychiatrist.

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What would you do next? Why? Discussion
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• The duty psychiatrist discusses her assessment
  with the consultant
• psychiatrist on call over the telephone. They
  confirm the doctors
• suspicion that her wish to die is due to her
  morbid belief
• that she is a burden her husband confirms that
  this belief is
• unfounded and so is a symptom of her depressive
  illness.
• The psychiatrists opinion is that the woman
  lacks capacity due to
• her inability to weigh up the consequences of her
  refusal to accept
• life-saving treatment.
• The emergency department doctor decides to treat
  the
• Woman under the Mental Capacity Act, for the
  physical
• effects of the overdose.

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• The consultant psychiatrist subsequently
• comes to the emergency department to
• assess whether the woman should be detained
• under the Mental Health Act to assess and treat
• her depressive illness.
• The womans GP and an approved social
• worker are phoned to ask them to participate in
• the Mental Health Act assessment.

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• Any questions?
• Further Reading
• www.dca.gov.uk/legal-policy/mental-capacity/guidan
  ce.htm
• www.rcpsych.ac.uk/pressparliament/aboutourparliame
  ntarywork/mentalcapacitylegislation.aspx
• www.nice.org.uk (for the full self-harm
  guideline)