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Not such a minefield. This lady would be likely to suffer a horrible death if left untreated, and it is certain that was not what she intended. If there is any hint of a depressive illness (good grounds for suspicion from her own words, plus suicidal intent to boot), there would be very little legal risk to a doctor who treated her against her wishes, but in her best interests. It would be wise to get a second doctor to record agreement with your course of action in the notes. However, if you were forced by urgency or the physical situation (eg being outside the hospital) to make the decision alone, you would still be entitled to support from your Trust.
I had a similar pre-hospital case in Hampstead many years ago in which a man cut his throat and refused to go to hospital in an ambulance. He was holding on to the (very red) bathroom door frame, and I was called out to see him. On finding that he was not open to reason, I took on the responsibility of assigning one ambulanceman to each limb (we had two crews by now), and forcibly took him to hospital while holding a pad on his neck. On recovery, he expressed his gratitude to me for taking the decision out of his hands. OK, it seems paternalistic, but there are no second chances for such patients. Failure to consider depression would arguably be negligent.
As Sir Donald Irvine (GMC) said to me the other day at a conference, carrying the can "is called part of being a doctor". If you have the courage to do the right thing, acting in what you genuinely believe to be a patient's best interests in an emergency, it is highly unlikely that you would face legal action, and virtually no chance that it would succeed. More elective issues are different, and are best sorted out by judges (example - the Recent Jodie/Mary case).
I realise that the above is partly (informed) opinion, but generally the law recognises such ethical dilemmas and it is FAIR to doctors.
Rob Cocks
(A&E adviser to the Public Complaints Committee in Hong Kong, and Medical Director of the NHS Litigation Authority as of January 2001)
-----Original Message-----
From: Gautam [mailto:[log in to unmask]]
Sent: Friday, November 10, 2000 6:31 AM
To: [log in to unmask]
Subject: Re: scenario
In message <[log in to unmask]>, Simon
Bell <[log in to unmask]> writes
>Here it is......?the first real time scenario.
>An old chestnut I know of an OD in a patient who
>refuses treatment.
>I came on duty to find an 81yr old lady who took
>paracetemol in a serious attempt to end her life. The
>SHO managed to get a level from her which was 47 at 14
>hrs. (why she waited overnight I am not sure)
>This lady refused any treatment.
>I had a chat to her and she clearly says, I have no
>husband, no visiting relatives, I have been unhappy
>for years, and it is time for me to go...I am 81 and
>it's time to die.
Time for the lawyers to make some money again. Legal minefield.
Always try gentle pursuasion, then try it again. Be careful not to cross the threshold of harranguing the patient: the patient's decision must be voluntary to be valid.
If she was competent to make an informed decision and that decision was that she didn't want treatment, I wouldn't treat her. There are guidelines based on case-law regarding competence to consent to (or decline) treatment, which I think are fairly straightforward (!)
If she became unconscious, there is a school of thought that says you could treat her, unless the previously expressed witholding of consent was of sufficient strength to qualify as an advance directive (again there are established criteria). You could argue that she would have changed her mind had she remained conscious, unless it was clear that this was a long-held, well-informed decision on her part (advance directives again). The fact that she came to A&E (voluntarily?) suggests that at least part of her may not want to die, unless she established that she wanted only symptomatic "terminal" care.
As far as sectioning, she could potentially be sectioned on the grounds of depression, which can then be treated (if needs be without consent), and I think the MHA allows for "forcible" treatment for certain life-threatening consequences of the mental illness (anorexic patients can be force-fed under section). As a rough rule of thumb, don't ever get involved in using the MHA in A&E, use common law instead, as a last resort. Involve psychiatrists to assess competence if in doubt, or potential serious consequences, or if patient is mad and needs sectioning.
Common law can only be invoked for immediately life-threatening conditions, where consent is not obtainable (implied), or there is some doubt about capacity to withold consent to treatment (the apprently drunk combative head injury being a classic example). If there's time, hand the question over to the Trust lawyers to ask the courts to decide (Court Orders can be obtained fairly urgently).
If your lady suddenly got up and tried to take her own discharge, would you let her go, or physically restrain her (invoking common law) until assessed by shrinks regarding sectioning?
In the emergency case, as long as you are prepared to prove in court that you were acting in the patient's best interest as you perceived it at the time, it is easier to defend against a charge of battery (treating without consent) than negligence (not treating when you should have).
There must be some lawyer-medic types lurking: come on guys and gals, help us out here.
Dr G Ray
Staff Grade
A&E
Sussex
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