In an alternate dimension…
I find myself standing in front of the Coroner.
She says to me, “Did you consider that the patient who died may not have been competent to refuse transport? He was after all hypoglycaemic and septic. Why did you leave him at home instead of taking him to hospital?”
I reply, “Well our honour – I couldn't be sure. He knew what day it was, where he was and who was the prime minister. What I wasn't sure about was that he knew what would happen if he was left at home. *I* wasn't sure to be completely honest, there was something about him that I didn't like the look of, but I couldn't put my finger on it. I figured that he needed a doctor to give a full bill of health – not me.”
“So”, she asks me, “Don't you have capacity for consent tool for determining such things?”
“Yes Ma'am – but it's only really a guidance, it doesn't give us a checklist for things that we *feel* about a patient. It's very much a grey area and needs my judgement”.
“So, in your judgement”, she continues to ask, “Did you think that he was competent to refuse treatment?”
“I don't know – maybe he was 10% impaired – would that stand up in a court of law? I'm sure I could have filled in the competency either way, able to give consent, or not able to give consent. Either would have been a fudge”.
“And what do your guidelines say about people unable to give consent?”
“That I should use reasonable means to get the person to attend hospital – or get the police to assist me”.
“And why didn't that happen? Why did you leave him to die when you had such concerns about his health and some concern about his capacity to refuse treatment”. The coroner was asking me a lot of awkward questions.
“Well your honour – there are a lot of people out there who would rather err on the side of caution when it comes to consent. They would have us believe that everything is black and white and that we should always give people the benefit of the doubt when it comes to consent. After all it is only a matter of degree between telling a little white lie to someone to heading down the slippery slope of secret arrests in the night for people with communicable diseases”.
“So you left him at home.”
I gulped nervously, “Yes Ma'am”.
“To die?”, she raised an eyebrow.
“Well, I wasn't sure…”
“But he died didn't he?”
“Yes your honour”.
“You are a prat.”
I couldn't really argue with her, “Yes your honour – and I can't sleep at night”.
The coroner was unsympathetic, “Have you lost your job?”
“Yes your honour – the family complained and I was dropped like a hot potato. If I'd taken him into hospital then the family could complain and I'd have lost my job that way. But at least I'd be able to sleep at night.”
“And the patient would be alive?”
“Is that important your honour?”
I go away for a few hours and return to comments either congratulating me, or saying that I should lose my job. (Because if there is one thing London needs right now is one less ambulance staff). Still its interesting to read people's thoughts.
Part of it though is that my use of the word 'fudged' was a bit ambiguous…
To be clear, the capacity for consent assessment could have gone either way, I could have had an officer and a few police down to try and persuade the patient (something I would have done if my bluff hadn't worked, I was *that* worried about him).
I wrote the last post partly to highlight that it's not always black and white as to what we should do in any situation. At 11pm on a Saturday night there are very few people around to help out. There is no psychiatrist to turn to in order to sort out a formal competency hearing. There is no form full of boxes to tick that take into account my 'feeling' of a situation – that feeing that you get which cant' be expressed in an examination box two inches deep.
You have to make decisions that will let you sleep at night – which often nicely tie up with decisions that are in the patient's best interests. You have only a limited amount of time to make those decisions.
Would it have been better to wait around for the patient to collapse again and then wheel him out while unconscious? Wouldn't that have been against his earlier wishes? Or did he not really believe that he would collapse again.
At the end of the day, the balance of probabilities is that he didn't know that he could become fatally ill – I wasn't sure that he would become ill again. So if I performed a formal capacity to refuse check (and when I get back to work I'll scan one in and show you the form), and it could have gone either way. Truly a grey area.
So I persuaded a patient by telling a vague mistruth – I can't 'medically arrest' him, but the police (along with a few hours of paperwork and mobile phone use) would be able to. He got the treatment that he needed, and he got it a lot quicker than he would have if I'd gone down the 'proper' route – which may not have worked anyway. The 'medical arrest' part was also just a small part of my attempts to persuade the patient to attend hospital.
At no point did I think that he wanted to die.
Here is the thing – If I go to someone who has taken an overdose that will be fatal without treatment, and they refuse hospital, know that they will die and are not confused – then I can't 'kidnap' them. If they are in a public place then the police can place them under a Section 136 and we can force them to hospital.
If they are in their own home then we are to leave them to die.
Then we will get a complaint from the family and we lose our jobs, are up before the coroner and most importantly have to try to live with what we have allowed to happen. And for most ambulance services you are guilty until proved innocent.
I'm a liberal type of person, but I also know that I have more experience of illness than 'civilians' – that puts me in the position of having more insight than a lot of my patients. Persuading someone to come into hospital to see someone with more knowledge than me seems pretty benign. I'm not going to strap someone down to get them to hospital. I'm not going to roam the streets and drug people and drag them off to be experimented on. I'm not going to drive around squirting fire extinguishers into smokers faces because it's 'for their own good'.
What I will be doing is the best I can for people – so that I can sleep at night knowing that I helped them out.
…Until I read comments that make me ill with worry that I'm some sort of monster who shouldn't be allowed near children or something – seems I'm a sensitive soul after all. And that is nothing compared to the abuse that I get on the job.
This post was written after a few pints. I hope it doesn't read like a horrible mess when I look at it in the morning. I still think that calls for me to lose my job are a shade on the harsh side though – although if I wasn't an ambulance worker I would have a longer lifespan, relationships that might work, better health and possibly a job that pays me a lot more than £10 an hour.
Actually… anyone want to hire me?
My brother goes into hospital tomorrow to have some teeth chiselled out of his jaw under a general anaesthetic – so I'll be unreachable for much of the day. Please continue to argue in the comments box.