Working with doctors Working for patients

 

Introduction

Mr Hartley is 75 years old. He was diagnosed with Alzheimer's nearly a year ago. He currently lives independently but his condition has begun to deteriorate in the last six months, and his daughter, Clementine, is concerned about his future care.

Mr Hartley has come to see his GP, Dr Singh, with his daughter Clementine. He has been suffering stomach pain for several weeks which has recently worsened. Dr Singh has carried out a physical examination.

Dr Singh

Dr Singh

I think we're going to need to refer you for further investigation. How have you been coping since our last appointment, Mr Hartley?

Mr Hartley

Mr Hartley

I don't want to go into hospital...

Clementine

Clementine

He's in a lot of pain, aren't you, Dad? He's hardly sleeping at night which isn't helping with his state of mind, of course.

Dr Singh

Dr Singh

Well we can have a look at your medication and see if there's anything more we could do for the pain. In the circumstances I think it would be best if I refer you for an ultrasound scan to try and find out what's causing the pain.

Mr Hartley

Mr Hartley

I don't want to go into hospital!

Clementine

Clementine

He's been terrified of hospitals since mum died last year. But we've got to find out what's wrong, Dad - it might be something really simple, isn't that right doctor? We'll have the referral please.

Dr Singh

Dr Singh

It's a very simple investigation, Mr Hartley: you should be in and out in a couple of hours at the most.

Mr Hartley

Mr Hartley

I'd rather just stay at home. The pain's not too bad. It'll go...

Clementine

Clementine

Oh Dad you know that's not true! You hardly slept at all last night. You just don't remember. Make the referral please doctor. I'll make sure he goes to the appointment.

What should the doctor do...? (Select A,B or C)

A

Refer Mr Hartley for the ultrasound scan with his daughter's consent?

B

Politely ask Clementine to leave the consulting room so that he can talk to Mr Hartley alone to establish what his wishes might be, and whether he has capacity to consent to the referral?

C

Decide Mr Hartley - because of his Alzheimer's - does not have capacity to give consent for the referral and refer him for the ultrasound scan because it would be in his best interests?

Dr Singh

See what the doctor did

Dr Singh politely explains to Clementine that he really needs to hear from her father himself about what he wants. Mr Hartley is initially a little confused about what is proposed, and upset about the idea of going to hospital. However, Dr Singh decides that - with some extra support - Mr Hartley does have capacity to decide whether or not to have the ultrasound scan, and manages to persuade him that it would be in his best interests. Mr Hartley agrees to the referral.

References

64. You must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment. You must only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes.

65. You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with.
(Consent: patients and doctors making decisions together, paragraphs 64-65)

66. A patient's ability to make decisions may depend on the nature and severity of their condition, or the difficulty or complexity of the decision. Some patients will always be able to make simple decisions, but may have difficulty if the decision is complex or involves a number of options. Other patients may be able to make decisions at certain times but not others, because fluctuations in their condition impair their ability to understand, retain or weigh up information, or communicate their wishes.

67. If a patient's capacity is affected in this way, you must...[take] particular care to give the patient the time and support they need to maximise their ability to make decisions for themselves. For example, you will need to think carefully about the extra support needed by patients with dementia or learning disabilities.

68. You must take all reasonable steps to plan for foreseeable changes in a patient's capacity to make decisions. This means that you should:
a. discuss treatment options in a place and at a time when the patient is best able to understand and retain the information
b. ask the patient if there is anything that would help them remember information, or make it easier to make a decision; such as bringing a relative, partner, friend, carer or advocate to consultations, or having written or audio information about their condition or the proposed investigation or treatment
c. speak to those close to the patient and to other healthcare staff about the best ways of communicating with the patient, taking account of confidentiality issues.

69. If a patient is likely to have difficulty retaining information, you should offer them a written record of your discussions, detailing what decisions were made and why.

70. You should record any decisions that are made, wherever possible while the patient has capacity to understand and review them...
(Consent: patients and doctors making decisions together, paragraphs 66-70)

71. You must assess a patient's capacity to make a particular decision at the time it needs to be made. You must not assume that because a patient lacks capacity to make a decision on a particular occasion, they lack capacity to make any decisions at all, or will not be able to make similar decisions in the future.

72. You must take account of the advice on assessing capacity in the Codes of Practice that accompany the Mental Capacity Act 2005 and the Adults with Incapacity (Scotland) Act 2000 and other relevant guidance. If your assessment is that the patient's capacity is borderline, you must be able to show that it is more likely than not that they lack capacity.

73. If your assessment leaves you in doubt about the patient's capacity to make a decision, you should seek advice from:
a. nursing staff or others involved in the patient's care, or those close to the patient, who may be aware of the patient's usual ability to make decisions and their particular communication needs
b. colleagues with relevant specialist experience, such as psychiatrists, neurologists, or speech and language therapists.

74. If you are still unsure about the patient's capacity to make a decision, you must seek legal advice with a view to asking a court to determine capacity.
(Consent: patients and doctors making decisions together, paragraphs 71-74)