Sign in to follow this  
Followers 0
manjupanatt

PD and capacity to consent

16 posts in this topic

PERSONALITY DISORDER AND COMPETENCE TO REFUSE TREATMENT

J. Med. Ethics 2008;34;715-716

http://jme.bmj.com/cgi/reprint/34/10/715

This is a case where a lady was deemed incompetent because she was refusing transfusion for anaemia secondary to multiple DSH attempts.

Does this mean that if a patient with personality disorder can be deemed incompetent to make decisions in situations like an od in the ward but refusing medical treatment or monitoring....

Share this post


Link to post
Share on other sites

An interesting case report.

I was wondering though:

At an HB of 2g/dl even the haem/oncs would panic - I remember them transfusing at 4g/dl. The article mentions Fe supplements - are they serious?!

Belief is not part of capacity AFAIK. If someone has persecutory delusions about their doctor and so refuse treatment surely that would fall under the MHA 2007? I thought capacity was understanding, retaining, weighing up pros and cons, and communicating the decision made. She may falter at understanding if she repeatedly continued to believe that the ankle oedema was due to anything else than CCF secondary to her anaemia - but she actually said, 'I don't know how to say yes'.

This patient was very ambivalent - which I would expect in BPD anyway. Although you could argue she was possibly hypoxic at that Hb and treat under best practice law - she seems as healthy as a horse. Time enough to involve the trust legal team for an opinion.

The fact that she has a son who she seems able to look after and the ambivalence would make me (practivally speaking) get the transfusion set and blood ready and start the transfusion without using restraints or sedation. If she pulled away then I'd ask my MPS and the trust legal team. A quick word with the medical/clinical director would always be handy too!

What do others think?

F_S

Share this post


Link to post
Share on other sites
An interesting case report.

I was wondering though:

At an HB of 2g/dl even the haem/oncs would panic - I remember them transfusing at 4g/dl. The article mentions Fe supplements - are they serious?!

Belief is not part of capacity AFAIK. If someone has persecutory delusions about their doctor and so refuse treatment surely that would fall under the [highlight]MHA 2007[/highlight]? I thought capacity was understanding, retaining, weighing up pros and cons, and communicating the decision made. She may falter at understanding if she repeatedly continued to believe that the ankle oedema was due to anything else than CCF secondary to her anaemia - but she actually said, 'I don't know how to say yes'.

This patient was very ambivalent - which I would expect in BPD anyway. Although you could argue she was possibly hypoxic at that Hb and treat under best practice law - she seems as healthy as a horse. Time enough to involve the trust legal team for an opinion.

The fact that she has a son who she seems able to look after and the ambivalence would make me (practivally speaking) get the transfusion set and blood ready and start the transfusion without using restraints or sedation. If she pulled away then I'd ask my MPS and the trust legal team. A quick word with the medical/clinical director would always be handy too!

What do others think?

F_S

It is still the MHA 1983 is it not??

Share this post


Link to post
Share on other sites
PERSONALITY DISORDER AND COMPETENCE TO REFUSE TREATMENT

J. Med. Ethics 2008;34;715-716

http://jme.bmj.com/cgi/reprint/34/10/715

This is a case where a lady was deemed incompetent because she was refusing transfusion for anaemia secondary to multiple DSH attempts.

Does this mean that if a patient with personality disorder can be deemed incompetent to make decisions in situations like an od in the ward but refusing medical treatment or monitoring....

If it was by reason of her mental disorder then this would come under the mental health act. If she was incapacitated by physical illness then capacity legislation could be used. The law is a fan of Rene Descartes, it would seem.

Share this post


Link to post
Share on other sites
An interesting case report.

I was wondering though:

At an HB of 2g/dl even the haem/oncs would panic - I remember them transfusing at 4g/dl. The article mentions Fe supplements - are they serious?!

Belief is not part of capacity AFAIK. If someone has persecutory delusions about their doctor and so refuse treatment surely that would fall under the MHA 2007? I thought capacity was understanding, retaining, weighing up pros and cons, and communicating the decision made. She may falter at understanding if she repeatedly continued to believe that the ankle oedema was due to anything else than CCF secondary to her anaemia - but she actually said, 'I don't know how to say yes'.

This patient was very ambivalent - which I would expect in BPD anyway. Although you could argue she was possibly hypoxic at that Hb and treat under best practice law - she seems as healthy as a horse. Time enough to involve the trust legal team for an opinion.

The fact that she has a son who she seems able to look after and the ambivalence would make me (practivally speaking) get the transfusion set and blood ready and start the transfusion without using restraints or sedation. If she pulled away then I'd ask my MPS and the trust legal team. A quick word with the medical/clinical director would always be handy too!

What do others think?

F_S

I used to believe the principle 'dont let anyone die' and the rest can be borne. But the capacity act makes me nervous. BUt in the end I feel what would I rather face, the relatives of a dead patient, or a live and kicking (perhaps my ass to the cleaners) person. I am in the business of saving lives. At that Hb how does she have a clear consciousness? I would use the trust legal dept and be ready with a plan on when she refuses treatment. Of course get all medics and other psych colleagues also on board. And wake up a judge in the middle of the night ( :-X) if need be.

Share this post


Link to post
Share on other sites

I couldn't help thinking that the doctors all the while knew that she was not going to refuse the transfusion.......... but deemed her incapable because of the obvious physical health risks and her responses to treatment choices.

Can i clarify one things- when you say -doesnot believe what is told does it mean that she has to be deluded or can it be just that i dont believe you situation (but not in relation to a mental illness)as in this case...

Can i possibly compare it to a case that i was involved with.  - a lady with personality disorder- staff would swear that she doesnot have depression; takes an overdose, informs me that she has taken it but doesnot want treatment >:(.  we decided she is capable and can make informed choices.  so she doesnot need active treatment now. but the decision was that if she has altered consciousness then we might intervene.  she never developed any physical symptoms so we didnot have to change our strategy. but in the worst situation does this mean that the informed choice she made when she was conscious changes when she is stuporous or does it have the same effect of an advance directive. :-/

Share this post


Link to post
Share on other sites
I couldn't help thinking that the doctors all the while knew that she was not going to refuse the transfusion.......... but deemed her incapable because of the obvious physical health risks and her responses to treatment choices.

Can i clarify one things- when you say -doesnot believe what is told does it mean that she has to be deluded or can it be just that i dont believe you situation (but not in relation to a mental illness)as in this case...

Can i possibly compare it to a case that i was involved with.  - a lady with personality disorder- staff would swear that she doesnot have depression; takes an overdose, informs me that she has taken it but doesnot want treatment >:(.  we decided she is capable and can make informed choices.  so she doesnot need active treatment now. but the decision was that if she has altered consciousness then we might intervene.  she never developed any physical symptoms so we didnot have to change our strategy. but in the worst situation does this mean that the informed choice she made when she was conscious changes when she is stuporous or does it have the same effect of an advance directive. :-/

Capacity has to be assessed when a treatment is suggested. It changes from time to time. Please read the principles in determinig capacity.

Share this post


Link to post
Share on other sites

thanks flakjack. I dont have any intentions to argue on this but want to be more clear on this next time i faced with this situation.

the bma mental capacity tool kit says

Are there any exceptions to the best

interests principle(best interest principle valid when people dont have capacity to consent; unconscious automatically means dont have capacity to consent)?

There are two circumstances when the best

interests principle will not apply. The first is

where someone has previously made an

advance decision to refuse medical treatment

while they had capacity. Where the advance

decision is valid and applicable, it should be

respected, even if others think that the

decision is not in his or her best interests.

So in my case, even if my patient becomes unconscious with the overdose do i respect her decision while she was conscious....I can obviously reassess her capacity in regular intervals say every 6 hrs or so.....but do i intervene if she has already refused consent to it............. :-/

Share this post


Link to post
Share on other sites

[highlight]but in the worst situation does this mean that the informed choice she made when she was conscious changes when she is stuporous or does it have the same effect of an advance directive. [/highlight]

Not as same as an advance directive

Share this post


Link to post
Share on other sites

[highlight]So in my case, even if my patient becomes unconscious with the overdose do i respect her decision while she was conscious....I can obviously reassess her capacity in regular intervals say every 6 hrs or so.....but do i intervene if she has already refused consent to it............. [/highlight]

If she has capacity and its assessed and documented, after that if she doesnt want any intervention, i guess we hv to accept her wishes and desires.

Share this post


Link to post
Share on other sites
[highlight]So in my case, even if my patient becomes unconscious with the overdose do i respect her decision while she was conscious....I can obviously reassess her capacity in regular intervals say every 6 hrs or so.....but do i intervene if she has already refused consent to it.............  [/highlight]

If she has capacity and its assessed and documented, after that if she doesnt want any intervention, i guess we hv to accept her wishes and desires.

Make it as official as possible though!! Like Advance Directives and stuff!! And get as many line managers, trust reps lawyers involved as possible.

Share this post


Link to post
Share on other sites
[highlight]So in my case, even if my patient becomes unconscious with the overdose do i respect her decision while she was conscious....I can obviously reassess her capacity in regular intervals say every 6 hrs or so.....but do i intervene if she has already refused consent to it.............  [/highlight]

If she has capacity and its assessed and documented, after that if she doesnt want any intervention, i guess we hv to accept her wishes and desires.

No. Because capacity is not all or nothing, and can change. You should reassess capacity whenever you are offering an investigation or treatment. You should take into account their previous wishes, but are obliged as a doctor to act in their best interests. If she becomes unconscious she then lacks capacity and you decide how best to proceed. Unless there is a specific advanced directive in place.

Share this post


Link to post
Share on other sites

If patient has capacity and has told u very clearly thats no intervention is needed...well documented in case notes, which becomes a legal document.If she becomes unconscious, would you still treat her ?

Share this post


Link to post
Share on other sites

It very much depends on the situation. The medical notes are a legal document, but they are not an advanced directive and do not hold the same legal power. You are still able to act as an autonomous decision maker and decide what is in your patient's best interest, in the absence of her being able to say at that time. If she really did not want treatment, then she should have gone to a lawyer first, and prepared an advanced directive to cover this eventuality. If she sues me when she recovers, then so be it. I'd feel more comfortable with that than being sued by her relatives if she died. Anyway, in this situation, i.e. for emergency treatment, then it isn't capacity legislation being used, it is Common Law.

Share this post


Link to post
Share on other sites
It very much depends on the situation. The medical notes are a legal document, but they are not an advanced directive and do not hold the same legal power. You are still able to act as an autonomous decision maker and decide what is in your patient's best interest, in the absence of her being able to say at that time. If she really did not want treatment, then she should have gone to a lawyer first, and prepared an advanced directive to cover this eventuality. If she sues me when she recovers, then so be it. I'd feel more comfortable with that than being sued by her relatives if she died. Anyway, in this situation, i.e. for emergency treatment, then it isn't capacity legislation being used, [highlight]it is Common Law[/highlight].

Didnt the MCA replace that?? Or actually enshrine that (case law) in law?

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!


Register a new account

Sign in

Already have an account? Sign in here.


Sign In Now
Sign in to follow this  
Followers 0