While working in psychiatry Dr Sarah Clarke sought MPS advice about mental capacity issues in relation to her patient Mrs H. Here’s her story
Mrs H, a 69-year-old woman, was transferred to the Emergency Department (ED) from a local psychiatric unit as there were concerns that her renal function was deteriorating as a consequence of her poor oral intake and the removal of her long-term catheter. Mrs H had been detained on the psychiatric ward under Section 3 of the Mental Health Act for treatment of her schizophrenia.
The ED carried out initial tests that confirmed her creatinine had increased to 550 from her usual baseline of 390 and a urine dipstick showed signs of infection. Mrs H refused to be examined or to be catheterised; her history was taken from the psychiatric team referral letter and previous clinic letters. A provisional diagnosis of acute on chronic renal failure secondary to urinary retention, urinary tract infection and dehydration was made.
She was referred to the oncall medical team whose plan was to examine and catheterise her once she had settled, liaise with the psychiatric team and contact the tertiary care renal physicians for further information. Mrs H was admitted to a side room on the ward. She continued to refuse to be examined.
Mrs H refused to speak to the team during the ward round and frequently went to the bathroom, often appearing distressed. At all times on the ward she accepted oral medication and the team were able to treat her urinary tract infection with antibiotics.
After discussion with the tertiary centre it was confirmed that she had been offered dialysis, but had declined this. There were concerns about her capacity and therefore she was assessed in accordance with the Mental Capacity Act (MCA). Whilst it was determined that she did not have capacity to decline dialysis, a decision was made that it would not be in her best interests to try and impose this on her.
Unfortunately, Mr K did not settle on the ward, so she could not be examined or catheterised, and the nurses were unable to monitor her observations. The psychiatric team advised regarding the dose of olanzapine and whilst they were of the view that she was safer being managed on a medical ward, I was concerned that we were doing too little to manage her medical problems.
Section 3 of the Mental Health Act allows a patient to be admitted for treatment of a mental health condition; it does not extend to the treatment of other medical conditions, such as Mrs H’s renal failure. I knew that Mrs H was aware that she had ‘bad kidneys’ and it had been explained that she may die without intervention. On a few occasions Mrs H informed staff that she did not agree to the proposed tests etc as they were too personal in nature, at other times she would refuse to speak at all.
After careful consideration, it was decided that at this time Mrs H did not have the capacity to make the decision about dialysis or other aspects of her medical care.
It is important to maintain communication between teams, review the situation as it evolves and ensure that staff are confident that they are working within their competencies
We then had to consider what was in Mrs H’s best interests. If dialysis was not an option then a return to baseline renal function would be the most we could achieve. Would it be preferable to concentrate on keeping her comfortable? She had begun to start passing small amounts of urine and was less distressed. In order to take her bloods, perform an ultrasound and catheterise her, we would need to restrain her. Physically restraining patients is a challenging experience for everyone involved and has to be justified; Mrs H had a history of aggression and we would need to be careful when using any sedatives because of her renal function. We decided that this course of action presented too much of a risk to Mrs H.
A consultant psychiatrist reviewed her at this stage and suggested starting a regular low dose of clonazepam. Mr K was well known to the psychiatrist and they had a good relationship. Consequently, Mr K consented to having a blood test and agreed to an ultrasound, although when the time came she refused to go to the department. Unfortunately, the blood test showed a further deterioration – her creatinine was 605 and she developed hyperkalemia for which she accepted oral calcium resonium.
There was a discussion about whether Mrs H should be referred back to the psychiatric unit on the basis that they could offer similar care that was being provided on the medical ward and there was a possibility that she may become more compliant with medical management. However, after further discussions with the psychiatric team, it was confirmed that they did not consider that her schizophrenia was likely to improve and they suggested that we attempt to slowly build our relationship with her.
I decided that I would try to do as they advised and I spent some time talking to Mr K about aspects of her life unrelated to her health. I realised that I would often have this sort of conversation when I was carrying out observations on other patients, but this is something I had never had the opportunity to do with Mrs H. Whilst she still refused any intervention, she did ask my name at the end of the conversation and I felt that I may have achieved something.
Mrs H’s urine infection resolved after a course of antibiotics, her oral intake also improved and she reported feeling much better. Three weeks later Mrs H still occupies the side room and there is no consensus about who is best placed to look after her. I have thought about this issue whilst Mrs H has been with us and I do not think that either a medical or a psychiatric ward is the best place for her. In my view she would be less distressed in her home although it is clear that she would need a lot of medical input in the community. Certainly she would benefit from care being delivered by those she trusts and given the chronic nature of her conditions, she will always require joint medical and psychiatric input.
By Dr Jayne Molodynski, MPS medicolegal adviser
It is clear that Mrs H provided a number of challenges to the teams looking after her and it can be difficult to determine who is best placed to look after patients with psychiatric and medical conditions. It is important to maintain communication between teams, review the situation as it evolves and ensure that staff are confident that they are working within their competencies.
Capacity is decision specific and the MCA requires healthcare professionals to assume a patient has capacity until it has been proven otherwise
This case study highlights the importance of assessing capacity. Capacity is decision specific and the MCA requires healthcare professionals to assume a patient has capacity until it has been proven otherwise. The GMC states that doctors must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with. Whilst ultimately, it was decided that Mrs H did not have the capacity to make a decision about dialysis, it was imperative to make a formal assessment and it was good practice to reconsider this issue after she had been admitted.
In certain cases capacity can fluctuate and consideration should be given to whether a patient’s lack of capacity is temporary or permanent. It is advisable to weigh up which treatment options would provide overall clinical benefit for the patient and what options, including the option not to treat, will be the least restrictive to the patient’s future choices.
Best interests extend beyond medical issues and when making a decision the team need to take into account any information about the patient’s past and present wishes, feelings, beliefs and values, which is why obtaining the views of people close to the patient is important.
Prior to making a decision in a patient’s best interests it is necessary to clarify whether they have made an advance statement or appointed a lasting power of attorney who can make decisions on their behalf. If the patient has no family, an Independent Mental Capacity Advocate (IMCA) can be appointed to represent and support the patient.
You must have objective reasons for any decision you make and the records should reflect that you have considered all the circumstances relevant to the decision in question.
If it is unclear whether a patient has capacity or what action should be taken in their best interests, then an application can be made to the Court of Protection. Should you ever find yourself in this position it would be advisable to speak to a senior colleague, or contact MPS for detailed advice and guidance.
- GMC guidance, Consent: Patients and Doctors Making Decisions Together (2008)
- Mental Capacity Act, Code of Practice, (2005)