Working with doctors Working for patients

 

Introduction

Shannon Baillie is 27. She has a severe learning disability and has very little speech, but can make herself understood to her mother. Shannon hasn't eaten much for several days and her mother is worried there may be something seriously wrong.

Mrs Baillie has brought Shannon to the surgery to see her GP, Dr Oloko.

Mrs Baillie

Mrs Baillie

I thought it was just that Shannon was feeling a bit under the weather but she's been really agitated for about five days now and she's barely eaten anything. It's just not like her at all.

Dr Oloko

Dr Oloko

Are you drinking water, Shannon?

Mrs Baillie

Mrs Baillie

You have small sips, don't you Shannon? - but then she gets really upset and frantic - I think something must be hurting her.

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

A

Prescribe a low-dose tranquiliser and suggest Mrs Baillie waits a couple more days to see if Shannon's behaviour settles down?

B

Ask Mrs Baillie's consent to carry out a physical examination of Shannon?

C

Speak to Shannon to establish whether she has the capacity to consent to a physical examination?

Dr Oloko

See what the doctor did

Dr Oloko explained to Shannon that he needed to examine her to try and find out if anything was causing her discomfort. Shannon, communicating with her mother's help, understood that Dr Oloko wanted to examine her, but not why. Dr Oloko, concluding that Shannon did not have the capacity to make the decision, decided that an examination was a necessary step in assessing Shannon's condition and, with Mrs Baillie's guidance, that it would not cause Shannon distress. Shannon complied with the physical examination with Mrs Baillie's support.

After examination and some further questions, Dr Oloko suspected faecal impaction and felt that a hospital referral for further investigation and treatment if necessary would be appropriate. After discussing the best way of communicating with Shannon, and using the practice materials designed for patients with learning disabilities, Dr Oloko concluded that Shannon did not have the capacity to consent to the proposed course of action. He made a decision based on Shannon's medical needs, taking Mrs Baillie's views about Shannon's preferences into consideration,1 and made the hospital referral.

1. In England and Wales (under the Mental Capacity Act (2005)) and in Northern Ireland (under the Common Law), decisions must be made in a patient's best interests.
In Scotland (under the Adults with Incapacity (Scotland) Act 2000) any medical intervention must benefit the patient. Select the More Guidance tab for links to relevant legislation.

References

You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
a. adequately assess the patient's condition, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values. Where necessary, examine the patient.
(Good Medical Practice, paragraph 15a)

You must treat patients as individuals and respect their dignity and privacy.
(Good Medical Practice, paragraph 47)

You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients' language and communication needs.
(Good Medical Practice, paragraph 32)

You must be satisfied that you have consent or other valid authority before you carry out any examination or investigation, provide treatment or involve patients or volunteers in teaching or research.
(Good Medical Practice, paragraph 17)

How you discuss a patient's diagnosis, prognosis and treatment options is often as important as the information itself. You should share information in a way that the patient can understand and, whenever possible, in a place and at a time when they are best able to understand and retain it.
(Consent: patients and doctors making decisions together, paragraph 18a)

You should check whether the patient needs any additional support to understand information, to communicate their wishes, or to make a decision. You should bear in mind that some barriers to understanding and communication may not be obvious; for example, a patient may have unspoken anxieties, or may be affected by pain or other underlying problems. You must make sure, wherever practical, that arrangements are made to give the patient any necessary support. This might include, for example: using an advocate or interpreter; asking those close to the patient about the patient's communication needs; or giving the patient a written or audio record of the discussion and any decisions that were made.
(Consent: patients and doctors making decisions together, paragraph 21)

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.

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.
(Consent: patients and doctors making decisions together, paragraphs 66-69)

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. ...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)