Mental Capacity

Some jobs are just *hard*, not because the patient is heavy or even particularly ill but just because of the circumstances.

We were called to a care home, one of the good ones in the area which deals with people with learning difficulties, ('learning difficulties' is one of those politically correct terms that seemingly came from nowhere as a way to describe people who we used to call 'mentally handicapped'). The patient was a 50 year old man with a nasty case of pneumonia, the GP had been out to see him and had decided that hospital treatment would be in the patient's best interest. We were called to transport the patient to hospital.

Our problem was that the patient point blank refused to go to hospital. We tried persuading him, the staff tried persuading him, I tried reasoning with him and the staff even tried bribing him. I may have even thought about threatening him. He would sit there, coughing occasionally, and refusing to go.

What we have to determine in a case like this is if he has the 'capacity' to refuse treatment. I often tell patients that I'm not allowed to kidnap anyone and this is true. If you were to take a fatal overdose and refuse to go to hospital knowing full well what the overdose would do to your body then I couldn't force you to attend hospital*

However, this relies on the patient having the capacity to understand what a lack of treatment would do, in this patient's case I wasn't too sure. He'd been in and out of hospital for much of his life, he knew what would happen should he go there – but did he have enough understanding that without treatment there was a reasonable chance that the pneumonia could kill him?

If the patient doesn't have capacity then we can force a removal to hospital, normally with police assistance – this is something that we don't like to do as it isn't very nice on the patient, nor on their relatives. So we do everything we can to avoid this. It's not very good to have half a dozen coppers frog marching a sick person out to an ambulance.

Well, in situations like this there is/should be an officer around to come and advise us on what to do. It also means that we have someone who is paid more than me taking responsibility for the patient, so should that patient die I know I've done everything I can and it's the officers 'fault'. So I trotted out to the ambulance to radio Control to find us an officer.

I was waiting for them to come back to me when my crewmate, wheeling the patient on our carry chair, came trundling out of the house.

I was astounded, it had looked like the patient had no intention of travelling and yet my crewmate had managed to get him out of the house. In awe I asked him how he'd done it.

He told me that the carers had told the patient that they wanted to change his clothes, he did have a bit of a problem with drool being coughed down his jumper. They had stood him up, changed his top, put a coat on him and then sat him straight back down into our carry chair. Good thinking on their part and on the part of my crewmate. As he was wheeled out he realised what we were doing, he wasn't hugely happy but seemed resigned to going to hospital.

It's not nice to take someone to hospital against their will, but he really needed to go. Some people might think that it's bullying to do this, but without the mental capacity to understand what might happen to him, we sometimes have to be cruel to be kind.

*A simple version and there are tricks around this, some of which I've mentioned before.

18 thoughts on “Mental Capacity”

  1. That might be the legal term, but I think the currently PC-term here in the US is “developmentally disabled.””Learning disability” is already taken; it's used to refer to dyslexia and similar problems that interfere with learning but are unrelated to IQ.

  2. We have similar troubles with my sister. She has “learning difficulties” and has suddenly developed a fear of going through doors which are dark on the other side. It's a fear of the unknown.The astounding thing is, and it's something I cannot get my head around, she won't trust her mother who has taken care of her for 40 years when she says “It's perfectly OK on the other side. There are lights and everything”. We can't even drag her in. But when a perfect stranger (like the ticket person at a museum or another visitor) tells her it's OK she capitulates.

    We're sure it's a mixture of fear of the unknown and attention seeking from anyone but the people she lives with.

  3. I work in this field, in another part of the country. I probably would have done what your patient's carers did. We come up against similar problems every day with many of the people we work with. One chap springs to mind who has a less-than-sprightly swallowing reflex and trouble regulating his body temperature. He will happily put an entire sandwich in his mouth and then inhale bits of it if he's allowed to, so we have to take his lunch off him once he's got a decent mouthful, and give it back when he's swallowed it. If he gets too hot he will have a seizure requiring rectal administration of diazepam and then a trip to A&E, so when he gets a bit too warm his sweater needs to come off. Both of these procedures can p*iss him off royally some days, and he's a strong bloke.BTW we often get the 'Ooh, I couldn't do your job' response too, and we say 'learning disability' here.

  4. Firstly it's nice to have you back posting about subjects that get us all thinking.Secondly have you noticed how names keep changing we've had 'dullard” (got you out of the army), cretin, educationally subnormal, mental handicap, mental retardation and now the twee 'learning difficulties”.Of course what happens is that the names become derogatory and so someone decides to change them.

    Nowadays kids talk of someone having an 'eppy' ie a fit. I wonder how many of them know the derivation of the word. I doubt that many of them really want to take the mick out of epileptics.

    I know a very nice lady who looks after her handicapped daughter. The mum is in her 70s and the daughter in her 40s. Every year they come for 'flu jabs and the mum says that her other daughter thinks it is cruel to bring her sister along. The mum will do anything to prevent her daughter suffering and she considers a 'flu jab is beneficial.I always make a big fuss of the daughter and she never objects. I suppose if she really did object we wouldn't do it unless it was really important.

    It will be so sad when the mum isn't around any more and the daughter has to go and live in an institution.How will she understand that her mum isn't around anymore?

  5. I don't think anyone on Planet Earth would call this situation “bullying” but sadly you don't work on Planet Earth. You work on “Planet H&S/Rules and Regs” so you needed an officer and your colleague has sadly exposed both of you to accusations of what would it be ? Kidnapping ? I'm not saying the wrong thing was done – I think it damn clever actually and the right thing , just bemoaning that we have these discussions….

  6. I work at a place like this here in the US. Here it is still called Mental Retardation. I never liked the term retardation because my brother has Down's Syndrome and retard comes from retardation obviously. But, that is the legal term so it may be as it is.

  7. Be more dangerous not to have those rules though, and dangerous for a larger number of people as well surely? The Victorian melodrama staple of troublesome wives and relatives admitted to asylums is hardly a direction we need to go in, nor is the Soviet technique of forcing dissenters to receive psychiatric “care”!I think this was very clearly the right thing since, if the chap had been capable of making an informed decision, he would have known not to sit in the carry chair.

  8. In the mid-nineties I had an ex with OCD and a serious fear of the dark. I can't say my ex would NEVER walk through a dark doorway, but suffice to say an excuse would appear if there wasn't a light-switch within reach.Maybe sounds stupid, but have you tried talking up how great hand-held torches are for a while, then giving her one?

    Worked for my ex, better than I'd hoped – I threw in imagery about X-Files agents, lightsabres, “light defeating evil” and though said ex is a switched-on software engineer – it did the trick!

    Fear comes from a belief, irrational or not, of loss of control and power – and the ability to conquer it comes from a belief we're capable – or no-one would ever abseil or parachute out of a plane.

    I hear you on the attention seeking but after thinking (on the back burner) about your post, and my ex, thought I should post this, and if it's useless then it's useless, and I hope I'm not being offensive adding it. :o)

  9. I doubt the daughter will ever fully understand that her Mum has died (when the unfortunate time comes). I suppose the daughter will end up thinking that her Mum has gone away, for example on a long holiday…My girlfriend works/worked at a respite home, and one of her charges was a 90year old who just couldn't grasp the idea of dying. Up until her last days, she always used to talk about people “going away”, as if they'd come back. Apparently it was incredibly sad. She too had “learning difficulties”.

    Also, are they called “Institutions” now? That conjures up images of Victorian Mental Hospitals, etc in my mind…

    Regards

    Nick

    http://nickhough.blogspot.com

  10. “Retarded”, just like “spastic” and “crippled” (and I'm sure you can think of loads more), started off as a medical term used by the care/medical types who provided care for those people. Over time the word came into common usage as an insult.It's hard but important to remember that we can't rewrite every piece of legislation, medical text, historical account, etc, simply on the basis that some playground-mentality jerks have twisted the comonly-used words around.

    People do still try to do it – like when The Spastic Society rebranded as Scope – but I'm not convinced as to how much “being PC” helps. Often the fuss about what is the correct term to use of (random example) a person with depression, draws a bit too much attention away from how to actually make life better for that person.

  11. This post made me think of my granddad – he passed away last saturday. He was in the dementia ward of a residential care home. We knew his time was coming, he was very weak with pneumonia and had suffered a few strokes. Im thankful (?) no ambulances were called or resuscitation attempted. He was 82, so clearly your guy was a lot younger. Also, I just want to say the staff in the home looked after my granddad amazingly, we often only hear of neglect in care homes. My nan is still in the home and she is being well cared for by the current staff.

  12. On a slight tangent – at work we cant use the phrase “Brain storming” because epileptics and people who have grand mal seizures could be offended by it, I think thats going a bit too far from the PC camp though…

  13. Werllll I'd suggest that getting someone to hospital is not as far down the line as sectioning them. But my general point is that whilst we do need some “rules” in part for the guidance and protection of those who have to implement them; they now act as too finite a box to work in.

  14. If they can produce an epileptic who has actually been genuinely offended by use of the term “brainstorming” to describe an ideas session, I'll give them a fiver.

  15. actually, I read some studies when at university that showed me to my satisfaction that changing the language people use to describe people or anything can indeed have positive effects on the way the think about them or at least reduce some negative stereotypes they associate with them. when you first see people doing it it seems ridiculous I know, but there's good reason to believe it works and it annoys me when people say “it's political correctness gone mad” and so on.

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