Dr Sarah Clarke contacted MPS when she encountered issues when an elderly patient tried to leave. She tells her story.
It was late afternoon when the ward sister bleeped me to inform me that one of my patients was trying to escape. Being based on a respiratory ward, I scanned my list, trying to guess which of my COPD patients was recovering quickly enough to sneak outside for a cigarette. I was informed that I had never met this patient before – she was 78-years-old, had been diagnosed with sepsis and was confused.
When I arrived at the hospital entrance I found the patient sitting down with a healthcare assistant and nurse. She appeared distressed and repeatedly stood up, expressing her wish to leave. She was barefoot, wearing a hospital gown and had a catheter in situ.
The nurse explained to me that immediately after receiving the patient to the ward, she had got up and left. They followed her, having been told that security were only available out of hours. I introduced myself to the patient and explained, as the nurse had done, that we needed her to return to the ward so we could give her intravenous antibiotics and make her better.
She seemed distracted, repeating that she wanted to go home and did not want to stay in hospital. She was unable to provide a reason for her wish to leave. Then, just as a taxi pulled up, she stood up, marched out of the hospital and got inside.
As I looked from the patient settling herself into the passenger seat, to the driver shouting at me to ‘get her out’, to the nurse and healthcare assistant staring at me in anticipation, I wondered where I stood ethically in all of this.
"As I looked from the patient settling herself into the passenger seat, to the driver shouting at me to ‘get her out’, to the nurse and healthcare assistant staring at me in anticipation, I wondered where I stood ethically in all of this"
I didn’t have time to figure this out. I took hold of the patient’s arm and firmly told the patient to get out of the taxi – exasperated I explained that even if we were to let her go home, she would need us to remove her catheter and find her shoes first. The patient relented; although whether it was due to me or the angry taxi driver removing his keys from the ignition, I’m not sure.
On arriving back at the ward I was able to read her admission notes. The patient had been brought in by her son with acute confusion likely secondary to infection. I called the psychiatry liaison team, to whom she was known, who agreed to urgently review the patient. I informed my consultant and also discussed the patient with the doctor previously managing her on the medical assessment unit, who explained that she had behaved similarly there. In the meantime the nurse had called the patient’s son who planned to come in.
The patient had 1:1 specialing provided by a healthcare assistant and she calmed down following a telephone conversation with her son. The psychiatry team assessed the patient and deemed her not to have capacity regarding her decision of whether to go home, advised to continue specialing and prescribed a PRN sedative.
On reflection I felt that I should have used physical restraint to prevent her from getting into the taxi. Although the situation unfolded far too quickly for me to make a proper assessment of her capacity, I have since established that there are specific situations when it is possible to restrain those with presumed capacity –
- In an emergency situation where a patient is deteriorating
- The patient is a threat to themselves or others and
- The patient may breach the peace or damage property.
In this instance it is possible that all three apply to this case to a degree.
Dr Sarah Clarke is a foundation doctor.
By Dr Clare Redmond, MPS Medicolegal Adviser
Doctors often find themselves facing extremely difficult decisions when dealing with patients who demand to leave hospital. This is only heightened when a patient appears confused, is physically violent, is actively determined to leave or is expressing ideas to harm themselves or others.
"If a patient has capacity and there is no evidence of mental disorder, then irrespective of the time of night, or the refusal to complete treatment, the patient is free to leave without restraint"
These situations frequently occur late at night, deteriorate in the space of minutes and give the doctor little time for full consideration of the facts of the case. Whilst every situation is unique, it can be helpful to have a framework in mind when faced with such dilemmas.
Some useful points to consider are:
- Whether the patient has the capacity to make a decision to leave the hospital at that time.
- Whether the treatment the patient needs requires hospital admission.
- Whether there is evidence of mental disorder (when use of the Mental Health Act can be considered).
If a patient has capacity and there is no evidence of mental disorder, then irrespective of the time of night, or the refusal to complete treatment, the patient is free to leave without restraint.
Even when a patient lacks capacity, the urgency of the situation must be assessed. The scenario we are considering here is one where there is an urgent need for treatment and a decision on the use of restraint must be made quickly. Where more time is available a full review of the medical records, including the existence of any Advance Decision, would be necessary.
If a patient lacks capacity to make the decision to leave hospital, then the Mental Capacity Act (2005) governs the decisions which can be made. There are two sections (5 and 6) of the MCA, which deal with acts of care and treatment and the use of restraint.
Restraint is only permitted if the person using it “reasonably believes that it is necessary to do the act in order to prevent harm” to the incapacitated person. If restraint is used it must be proportionate to the likelihood and seriousness of the harm. Remember that restraint does not have to involve touching a patient, but may involve locking the door or prescribing medication to sedate them.
In Dr Clarke’s scenario she was faced with an elderly confused patient, clearly medically unwell whose capacity she appears to have deemed impaired. Dr Clarke “took hold of the patient’s arm and firmly told the patient to get out of the taxi”. The patient acquiesced and returned to the ward. She was later provided with one-to-one nursing care and prescribed a sedative, two potential further forms of restraint.
In this, and every situation, clear documentation of the assessment of capacity, the risks involved of treating versus not treating the patient and a description of any restraint used (form and duration) is essential. This should help protect the doctor if there is any future investigation into the restraint required.
"Clear documentation of the assessment of capacity, the risks involved of treating versus not treating the patient and a description of any restraint used (form and duration) is essential"
It is preferable for staff trained in using recognised restraint techniques (security staff, some nursing staff) to restrain individuals, but this is not always possible. In the most extreme situations it is advisable to call the police when a patient is sufficiently agitated or violent that healthcare professionals and other patients may be put at risk.
If restraint is required in the longer term (or repeatedly) and not just for a brief period, then consideration must be given to whether staff at the hospital are depriving the patient of their liberty. These issues can be discussed with the team as a whole and a request made for a Deprivation of Liberty Safeguards (DoLS) assessment.
Whilst this advice is not intended to be all encompassing, hopefully it provides some useful tips to bear in mind the next time you are faced with an acutely unwell confused patient who is trying to leave the ward late at night.