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Case studies

Case 1

Mrs M is 82 and usually very lively and alert. However, she has recently become very confused, probably due to a urinary tract infection. She is admitted to hospital where it is noted that she has an irreducible femoral hernia. The surgeons who are called to see her suggest immediate repair to avoid the risk of strangulation, but as Mrs M is unable to consent and there is no imminent danger (the hernia is not strangulated), it is decided to wait, in the expectation that she will regain capacity, and then seek consent to surgical repair.

Case 2

Mrs N is 86 years old and has had a stroke. Her speech is unintelligible and she dozes much of the time. She suffers a fractured neck of femur in a fall. The staff on the ward explain what has happened and that she needs an operation. Because she is unable to speak, the staff watch her body language intently to gauge her understanding and give her a picture board to help her communicate. Mrs N is able, through these means, to convince the staff that she understands what has happened and that she wants them to carry out the operation.

Case 3

Dr T is a newly qualified doctor working in gynaecology. Mrs V is admitted prior to a Uterine Artery Embolisation (UAE) and Dr T is asked to confirm her consent to the procedure, which she gave three weeks earlier in the outpatients’ department. Further questions and some concerns have occurred to Mrs V in the intervening weeks, and she particularly wants to know how the UAE will affect her chances of conceiving and carrying a baby to term. Dr T has only a sketchy, theoretical, understanding of the procedure, which he has never seen performed. He is therefore not competent to obtain Mrs V’s consent and must refer her questions to the radiologist who will be carrying out the procedure.

Case 4

Mrs D is 42 and has recently discovered a lump in her breast. She is told that malignancy cannot be excluded and an urgent referral to a specialist is required. She asks the GP to defer the referral, however, explaining that her daughter is currently preparing for important exams in five weeks’ time and she does not want to cause her any anxiety. Dr F, her GP, cannot understand how she can take such a risk but it is clear on talking to her that she fully understands the implications of her decision.

Dr F records his findings along with Mrs D’s reasons for not agreeing to an immediate referral.

Case 5

Mr H is a plasterer in his late 40s. He has been experiencing pain in his left knee, on and off, for several years, but this has been adequately managed with a combination of physiotherapy and NSAIDs. One day, he comes to see his GP, Dr J, complaining of intense pain and limited movement in his knee. Dr J, noting Mr H’s history and finding, on examination, that the knee is slightly swollen, recommends an intra-articular injection of Kenalog. As he is aware that Mr H is self-employed and needs to be able to return to work as soon as possible, he suggests that he administer the injection there and then.

Mr H is doubtful about having an injection straight into the joint, but Dr J brushes aside his doubts, saying that it will get him “up and running in no time”. He points out that it is unlikely he will get another appointment at the practice until the following week, which will only delay his recovery. Mr H reluctantly acquiesces, and allows Dr J to administer the injection. Unfortunately, he subsequently develops septic arthritis in the joint. Although this is successfully treated with antibiotics, he loses several more weeks’ work and decides to sue Dr J for compensation. His claim alleges invalid consent, not only because he had not been warned about the small risk of infection, but because he had felt coerced into making a hasty decision.

Case 6

Mr D has been admitted as a day case for colonoscopy for investigation of rectal bleeding. He finds the colonoscopy extremely uncomfortable and insists that the procedure be stopped. This happens just as the surgeon identifies a suspicious-looking lesion in the transverse colon.

The surgeon stops the procedure and then explains the situation to Mr D, who agrees to further sedation being administered so the colonoscopy can be continued and the lesion biopsied.