Once more I find myself concerned with Capacity and Consent.
Capacity and Consent are two linked words that govern how I can treat patients and it always needs to be at the forefront of my mind.
Capacity Is the ability for someone to understand what I am telling them and to be able to make a decision based on being able to understand the risks of choices that they make now.
Consent is my patient allowing me to do things to them, be that blood pressure measurements, giving them medicine or taking them to hospital.
For most of my jobs both capacity and consent are implied – someone calls an ambulance, I arrive, I do certain medical things to them and they do not complain and then I take them to hospital – the patient, for their part goes along with this and everyone is happy.
If a patient gives both consent and has capacity – everyone is happy.
If a patient refuses consent, but still has capacity – then I am less happy, but I will leave them alone (and write reams of documentation in order to 'cover my arse')
If a patient consents, but doesn't have capacity, I find myself acting in a parental role – in which I trust that I will do what is best for my patient.
However, If a patient refuses consent but doesn't have that capacity to understand what refusing treatment may do in the future I'm on a bit of a sticky wicket.
Take the drunk alcoholic who has sunk a couple of bottles of Jack Daniels, swallowed some pills and scrawled what he considers to be a suicide note (but is actually just some wavy lines as he is too drunk to write). He has then thrown himself down in the living room in front of his wife.
We arrive and, after he's already told us to 'fuck off' and taken a swing at us, he refuses to go to hospital.
I'm now dealing with someone who does not consent to treatment, but who – because of the effects of alcohol – can't be considered to have the capacity to refuse treatment.
He may get violent if I try to forcibly remove him to hospital – so I ask for police assistance.
The police may be able to forcibly remove someone to a 'place of safety' (normally an A&E dept.) under Section 136 of the mental health act, but the person needs to be in a public place.
My options come down to (a) Leaving him at home where he could die, and he probably doesn't really want to die, he was just temporarily suicidal because he's drunk, or (b) I drag him off to hospital against his will where he can then try suing me for kidnapping him against his will.
I'd like to think that the law was certain in this point, and while I have no doubt that I'm right and that the law would protect me, I may still lose my job.
(I direct you to the case of a nurse who lost their job after swearing at a patient after the patient had punched him in the face as evidence of how easy it is to lose your job, I also invite you to read my account of 'my first complaint')
So what did I do in this circumstance? Luckily for me the patient pretended to become unconscious after performing one of the least effective 'fits' I've ever seen, so we managed to cart him off to hospital.
If he hadn't decided to make it easy for me, well I'd have used the help of the police to forcibly remove him and worry about my job later – after all I'm more scared of the Coroner than my bosses.
The very next day I had a similar situation – someone so drunk that they could barely stand, teetering on the top of a long flight of stairs complaining of chest pain, but refusing to come to hospital because they wanted to have transport home.
He also said that he'd rather die than have to make his own way home from the hospital.
Again, his reasoning impaired by virtue of alcohol, I was left in a dilemma – do I leave him at home when he then dies and I'm up before the coroner, or do I 'trick' him into coming to hospital by saying that they will get him home, thereby risking a complaint and my job.
Once more the imaginary coroner sitting on my shoulder asking me why I left someone vulnerable at home to die won out, and I took him to hospital on the promise that tey would give him transport back home.
So yes, when a patient doesn't have capacity, but may well complain later – I'll take the route that has them less likely to die. Even if it does risk my job.