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”
Ah. Problem.
“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?”
“January!”
“What year?”
“2012!!!”
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.
Binder
*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.
Long..but enough to put my head in full scenes of imagination to be in yr shoe by that moment…(apart from the ratty-dog…of course)…. anyway, interesting story and im glad it turn out to be good ending… long live Cassandra:) P/s: Feeling of having to settled on situations always giving a good sigh and rewarding smiles over your coffee! Hero of the day!
Hello. Interesting story with many positive aspects, notably your persistence and the eventual outcome. That said, I am surprised by the description of your attempt to assess the patient’s mental capacity. Without being there I can’t contradict your decision that the patient had capacity to make her own decision about accepting treatment but I am very concerned by your assessment. You seem to base yiur judgement abiut the patient,s capacity on her responses to a few random “orientation in time and place” questions lifted from the mini mental state examination. Does the London Ambulance Service not train paramedics in the use of the Mental Capacity Act decision-specific test of mental capacity? Use of that tool would provide a far more accurate assessment of the patient’s capacity, which in turn would inform your subsequent decision-making. I suggest that you speak to your manager about accessing appropriate training.
Thanks for the comments Dorian
Its good to get outside experience on these matters and your thoughts are greatly appreciated. I understand you are quite qualified and experienced in your field so it is useful to receive such positive thoughts.
However, it is difficult to express the full workings of what happened that day all in one small article – and, in a similar vain it is equally difficult to maintain its “light heartedness” for the blog – which, incidentally, is what I originally set out to do. So, albeit in the article it appears we only asked a few random questions, this is by far not the case. In reality they weren’t just a few random questions – I in fact asked at least three more questions which would make it “a lot” not a “few”. And they were intelligent ones based around things like the weather, colour of her wall paper, my chronic back problem (she was a nurse after all!) and what type of ugly breed her dog was.
The training on Mental Capacity has always been a tricky one but we do have certain guidelines to help and when these matters arise we tend to use a “Capacity Tool” to help the situation. This has a list of points and questions that are designed to help us make the right decision over the patient’s capacity. Things like, “does the patient fully understand the implications of their actions” or “is the patient REALLY happy with the colour of their wall paper” etc. If all the head questions are answered “Yes” then we can assume the patient has capacity to make their own decisions. However, unless it is clear cut, it can all end up being very subjective. And also, when you’re presented with a person who doesn’t even want to entertain your approach or system, inevitably you are left with only simple factors to base your decision on – namely your gut instincts. Don’t get me wrong, we’d love to just “mug” patients like Cassandra, by picking them up and carting them off to hospital to “help” them. But ultimately, if their choice is not to go, what else can you do. As far as I’m aware, its not against the law to kill yourself in this country.
Here’s a rather random example – if someone were to approach you (as a random individual), just as you are about to cross a busy (and potentially dangerous) road, and question your thought processes on why you’re crossing at such a dangerous section, would you even entertain their interjection? Lets say you didn’t (maybe because you were in a hurry to get across and buy a little chihuahua puppy and this person, dressed in a lime green Kappa tracksuit looked slightly odd and frightening – who knows, you choose), would that person be within their rights to question your mental capacity over you choosing to put your life at risk? After all, you could, at a very high probability, get maimed or killed in your attempt. Would your refusal to entertain their bombardment of inquisitive questioning also go in favour of proof of your capacity? Or would the individual be within their rights to say you’ve lost the plot and then forcibly remove you from the situation – with the aid of the police?
Now, I know this is a ridiculous analogy and in fairness Cassandra’s case is a lot different (our tracksuits are a darker green and not sponsored by Kappa). We tried to explain the implications of her decision and by all accounts she fully understood this and accepted it. Which is somewhat a bit better than fully ignoring Kappa man trying to stop you crossing the dangerous road. But, if we have exhausted all avenues in our approach as to a patient’s mental capacity we are left with only two options Dorian – to leave them there or forcibly remove them. We, as pre-hospital clinical practitioners, would rather not choose the former. But as professionals, we will always respect a person’s right as a human being to make their own choices – no matter how crazy they seem to us.
Putting all this aside I think our Capacity Tool is what you meant. So yes we did use it – as best we could . . . and as best we could in similar positions. But a lot of our work, at the end of the day, comes down to our professional decision making at that moment in time. And rest assured we always want to do what’s best for the patient.
I have however, taken your advice and approached my manager on accessing appropriate training. Amongst asking for the two year pay freeze to be lifted I’ve also asked whether I can be trained up on the FRU, HEMS, Emergency Care Practitioning and Paediatric Advanced Life Support. After a ten second bout of negotiations he’s finally agreed to send me on the inevitable Core Skills Training – which we all have to do. Still, if you don’t ask you won’t get.
I hope this in some way answers your concerns. I hope also, you are enjoying the posts – but please remember, the blog is supposed to be light hearted – nothing more.
Binder
I find the whole mental Capacity Act confusing and not at all user friendly. As Paramedics we are expected to pick up the baton of the failing mental Health system and adapt it into our front line services.I have had the PowerPoint presentation on the “new “mental Health capacity act and along with a sheet with a few tick box s suddenly I am now able to judge if someone has Capacity? unlike most of the people rating this system I have real concerns that we are leaving ourselves open to a law suit , we can not keep using the we did it for best intentions card as any good criminal lawyer would get an excellent return should they prosecute.
Cheers for the comment Richard
The MCA is a veritable minefield for us on the front line. I remember this job well as I was still quite new to the MCA and little had been done to train us all up on it. As you can probably read from previous comment (Dorian Davies) there is lots that can be picked at in that job – and lots that wasn’t mentioned due to “artistic licence”.
The LAS have come on leaps and bounds with the MCA. But it feels like with every move forward in learning more indepth reasoning, comes more complicated avenues to counter our decisions.
The introduction of the MCA tool which most trusts use now does help. But it’s a bit like our algorithms for Sepsis – you can make lots of patients fit the algorithm and say it’s sepsis when in actual fact it isn’t. The real “skill” comes in understanding (I shall call it for this purpose) the “pathophysiology”. So, understanding why there is a lack of capacity as compared to say, MHA or simply making poor decisions etc. Then it’s also understanding if they DO lack capacity then what is the best action for them.
If a person is severely ill then their mental ability to make a decision will most likely be impaired. This is why we have to make the decision for them. That one is, on the most, easier to deal with. But the tool would still be used – no matter how grey the outcome is with us!
Mental Health is a whole new different chapter. It currently stands that only should the patient display acute/sudden “irrational” behaviour to cause the self or others harm that could cost them their life, can we interrupt and use the MCA to deal with it. For example, I sat with a suicidal gentleman for a long while – known to authorities – he’d been drinking but was conversive and ok. It was only when, without warning, he leat from his chair and literally tried to jump through the open window did I intervene and then hold the MCA to him, calling on police back up to help extricate.
Now, each case is different. And each case has its own problems and each case is fraught with the risk of causing psychological and legal harm. I hate it. You’re right, we don’t have the correct training. We are expected to pick up the pieces. And MH in particular is being failed in this country.
What is the answer? I don’t know. What you can do is get on every MCA/MHA course you can and challenge everything. Understand the pathophysiology. Get ahead of the game and teach others. Cos it damn well ain’t gonna solve itself.
Cheers