Warning: This is a very long blog entry
The Mental Capacity Act of 2005 states that “a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.”
Seeing as we have a ‘duty of care’ for the well being of patients this means that if a person is injured or sick and lacks the mental capacity to make the “right” decision for their well being – we may have to step in and use force to help and/or remove them.
In this job we often come across patients who lack capacity. If their lack of capacity is obvious then the decision to remove and help the patient is easy enough – but still not nice. An example of this might be a 90 year old lady with a urinary tract infection which has given her a raging temperature and made her delirious. When asking her what day it is she might reply by saying, “I am a tomato” and then attempt to stick a fish in her ear. This lack of capacity is clear cut and simple to deal with.
The big problems arise when we are presented with patients where;
a) Its difficult to determine whether they have mental capacity or not and
b) They don’t want to do anything that you or anyone else would deem in the best interests for their health
This is arguably one of the worse ethical positions for any Paramenace or Technician to be in. It can become very ugly and not nice and ultimately its exhausting for all involved . . .
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I peered over the railing down at my crew mate. She was leaning against the wall by the front door of a granny flat listening to the voice coming from within. She glanced up and laughed at my appearance. My hair was dishevelled and scratches covered my arms and face along with mud and sludge. I spat out a couple of leaves and caught my breath.
“No luck that way” I motioned to the back garden.
We’d been here for ages and had still not gained entry to the flat. This was fast becoming a difficult position to be in. An hour and half earlier and it was a different situation . . .
The call had come down as “Collapse Behind Close Doors”. Albeit a neighbour was able to talk with the patient it was apparent they could not get their self up to open the front door. This meant – ‘granny down’! After talking with the neighbour we obtained the history – a seventy two year old lady with rheumatoid arthritis and osteoporosis had fallen over and couldn’t get herself back up. She lived on her own and appeared to be locked in. No one else had any keys to her home!
By all accounts this appeared to be a simple job. We’d establish what injuries the patient had, get her permission to force an entry, help her up, check her over and either take her to hospital or leave her be – with a nice cup of tea and some toast. Bish bash bosh, job done – cue sunset and tune of “In the City” by The Eagles, for us to walk off into.
I knocked on the door and could hear the frail voice, clearly in distress, on the floor.
“What’s your name my dear?” I shouted.
“Cassandra* . . . oh dear” Came back the little Jamaican voice.
“What’s happened Cassandra?”
“Nothing. I’m fine. Please go away”
“What do you mean nothing Cassandra. Are you hurt?”
“No I’m not. Now please just leave me alone” She sounded upset.
“Your neighbour is concerned for you Cassandra. He says you’ve been on the floor since yesterday evening. Can you get up?” I strained to listen for her response.
“What nonsense is that . . . I’m fine. He has no right to do that . . . oh dear”
“Can you get up at all Cassandra? Just so we can check you’re ok?”
“Yes I can”
There was a long pause of nothing happening.
“Are you trying to get up at all Cassandra?”
“No. Leave me alone. I’m fine. Go away!”
And so the conversation continued. We could clearly hear the patient was on the floor and it was plain to us that she was in some form of painful distress. Yet she didn’t want our help. The neighbours confirmed she was a tiny frail woman with knotted hands stick like legs.
After much questioning we decided that her mental capacity was questionable, as lots of her answers to our questions were not consistent. The description of her also suggested that she could not get up off the floor, whether she wanted to or not. However, she was adamant she did not want our help and was becoming more and more upset by our presence outside. But because of her predicament we had to assume she was in potential danger – albeit, not imminent – and therefore we made the difficult decision of forcing an entry.
My crew mate stayed by the front door to talk with the patient whilst I went round the back with the police to see what we could do.
Her back yard was like the heart of the Peruvian jungle – immensely over grown and not looked after. Barbed wire lined the top of her flimsy wooden fence and thick rose bush thorns interlaced them. Albeit the fence was only face height, it was so fragile and rickety it appeared that any attempt to scale it would result in its collapse and subsequent entanglement and consumption of the person struggling to do so.
With the help of a step ladder, a Leatherman multi-tool and a crow bar we succeeded in scaling the fence and fighting our way through the undergrowth to the back door beating off spiders, snails, slugs, thorns, pots, broken bottles, sludge, dog and cat poo, mice, badgers, snakes, elephants and the occasional ancient hidden Japanese General refusing to believe that the war was over. Here, the police managed to pry open a window to the back kitchen. Looking in it didn’t appear to be much different than the back yard. The small room was stacked floor to ceiling with dog and cat food tins – some open, some not. Stacked around them were all manner of objects that seemed to have no purpose other than filling the spaces not taken up by the dog and cat food!
After moving enough clutter to allow entry I climbed through the window. Remembering a time in my life when I was supple and agile enough to do so, I attempted to jump down through the mess. Landing flat on my face, my pride was hurt further with several piles of tins collapsing on top of me. Jumping up as if nothing had happened I brushed myself down and picked my way to the kitchen door. Through a small window in the door I could see our patient at the far end of the house sitting awkwardly on the floor. Brilliant, I thought, we’re in. Keeping my eyes on Cassandra I pulled the handle.
It was locked. Oh for gods sake – really?! After all this!!!? A quick scan of my surroundings suggested it was pointless trying to force this door as it opened toward me and there wasn’t enough room to try.
I looked back at the police officer who’s head was poking through the window watching my progress. He let out a sigh.
So, back at the front of the house, I peered over the rail down at my crew mate.
“No luck that way” I spat out the leaves, “we’ll have to go in through the front door”
The police gained entry quickly and without causing too much damage and then stepped back to let us through. The patient was sat crumpled up against an inner door. She was practically naked and was literally a bundle of arthritic bones wrapped in skin – emaciated and clearly dehydrated. The house had long been left to deteriorate and there was barely enough room to move anywhere and the smell of pet food, both fresh and rotting, filled the stale air.
We immediately set about checking Cassandra over and it quickly became apparent that her obs were border line normal. But looking at her you could tell she was in immense pain and there was no chance she was getting up off the floor on her own. She was also still upset and wanted us to leave. I therefore started to determine whether she had capacity to make these decisions.
“What day is it Cassandra”
“Tuesday” She answered this correctly and as quick as lightening. After I’d worked out what day it was I moved on.
“What month is it?”
She was on the ball and I was being beaten at my own game.
“What’s the capital of Syria?” I winced.
“What a stupid question! Go away and leave me alone! I have capacity. I used to be a nurse you know. This is not fair – please, PLEASE go away!”
She was right. She did have capacity. And what’s more, she knew about capacity which suggested that she had probably been a nurse also. To finish with I had to make sure she understood the implications of us leaving her where she was.
“Cassandra, I need you to listen carefully. If we leave you here do you know what will happen?”
“I’m not interested! Go away!”
“Cassandra! If we leave you here you may well die. Do you understand that?”
“Of course I know that! I’m seventy two years old – look at me! Do you think I care about that anymore!? Now please – leave!”
Now we really were in a predicament. And to be honest, this was breaking both our hearts. Cassandra had clear mental capacity to make her own decisions and was choosing to sit there and (eventually) die. By law, we could do nothing to stop this and had to respect her resolution.
At that moment a long haired Chihuahua-resembling-ratty-dog-thing bounced into the hall and proceeded in pasting the entire contents of its mouth over our hands and bodies. It looked skeletal and gaunt – but then again, all Chihuahua type dogs look like that to me. I shooed it away.
We decided to phone our “Clinical Support Desk” (a.k.a. Google Desk) and ask their opinion. It was in vein as they confirmed what we already knew, but were trying to deny – which was that we had no jurisdiction over her decision. We had to leave her.
I knelt down in front of our patient and took her hand, “Ok Cassandra, we’re sorry. We’re going t . . . ”
At that moment I felt a strange wet sensation down by my crotch. Looking down, the ratty-dog-thing was frantically licking my private parts. I grabbed it and “assisted” it to one side.
” . . . we’re going to leave you. But can we at least help you up and make you c . . .” The ratty-dog-thing was back licking my crotch. I stood up, ” . . . comfortable?”
“Yes. Please Cassandra . . .” My crew mate now stepped forward, “please, let us get you up from here. You’re in so much pain – its upsetting us as well”
As my crew mate continued to persuade our patient, I concentrated on defending my honour from the sexual advances of the ratty-dog-thing until eventually I heard Cassandra utter the golden words, “OK then, please”.
To get her up, onto our carry chair and moved back a few paces took a further half an hour and lots of screaming in pain. Eventually we stopped further down the hall way and crouched down to talk with our patient. Well, my crew mate crouched – I stood and continued to kick at the sexually overzealous ratty-dog-thing.
After another thirty minutes of persuasion – we’d nailed it. Cassandra had agreed to come with us. This was fantastic news! Not only because she would receive much needed medical treatment but also that she’d made the decision herself. For the first time since we’d made contact with Cassandra she appeared content.
Now all we had to do was get her out. There was no way we were getting a line in our patient so we gave her drinkable Morphine instead. And, after making her as secure as possible on our chair – and with the ratty-dog-thing in tow jumping at my knackers – we made our way out of the house and onto the ambulance.
A police crew had remained on scene all this time and as we transferred Cassandra to our trolley bed we spied the officers running around the street trying to chase down the ratty-dog-thing. Cassandra smiled – I suspect for the first time in a long while.
“Will they look after my dog?” Her voice was now quiet and sweet and with a full Jamaican accent. Seeing Cassandra smile we both turned away and started to scratch at the sudden ‘itch’ around our eyes and cheeks.
One of the officers poked their head round the door, “Don’t worry Cassandra, we’ve arranged for the RSPCA to look after your dog until you return home – ok?” She smiled again, and this time laid back, closed her eyes and relaxed.
With the help of the Morphine she eventually dozed off and we imagined it was the first proper sleep she’d had in weeks, possibly months. On arrival to Hospital we explained the story to the nurses who, after listening intently, went to work and made Cassandra as comfortable as they could.
We had been on scene for six hours and it ended up being our off-job. As jobs go, it was difficult and interesting enough to warrant “earning your pay”. But if Cassandra had continued to refuse help, we would have had no choice but to leave her there. It would have broken our hearts and gone against everything we believed in. And ultimately she would have died, there on the floor. This, like many other bad jobs, would be put down to experience and have to be chalked up as just another bad day – as is sometimes the case.
But thankfully it wasn’t – and I think we can chalk this one up as a good day after all. I hope.
*Not her real name of course.
NB – I apologise that this was a long one. Its difficult to get across all the emotions that happen in such a long job and I’m sure I could have shortened this with the right editing. But you know what? In the end I couldn’t be arsed – sorry.