(This is a post re-visiting the issues attached to a previous post – apologies if I’m repeating myself).
Jobs where patients have capacity issues really are difficult situations to be in. It is so hard to make what you think is the right choice for the patient. The worst of these positions to be in is where the patient is ill enough that they warrant a visit to hospital yet choose not to go and that there is a question mark over their mental capacity to make that decision.
In January I posted a blog entry entitled Mental Capacity and received a reply to it from Dorian – whom I suspect is very qualified in the subject. This is what he wrote . . .
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.
I’ve put this up as a proper entry. Not just because I thought Dorian was being an obtuse ‘kill-joy’ with his apparent head strong attack on what I believe should be seen as nothing more than a light hearted blog – but because I wanted to highlight his point of view as an interesting challenge to all of us working on the front line of the ambulance service.
With just one post, a highly qualified person in the field of Mental Capacity has started questioning our entire processes in the field. To me this simply emphasizes how hard it is for us to attempt to do the right thing in these awful situations, with little more than a green uniform and a keen sense of morals. But it also stresses how important it is for us to continue to cover all bases and avenues before making a decision which can ultimately effect, in one way or another, the liberty and freedom of another human being’s right to choose for them self.
So, my reply to Dorian was this . . .
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.
It’s really difficult to explain to a lay person or indeed a highly qualified proffessional within a specific area of the health and medical world exactly what it is we do and more importantly how ill prepared and trained we are for many situations we are sent to. It even causes a dilemma as to whether to ‘blow the lid’ on this or retain the reassurance we all feel that a proffessional who is highly trained is available at the end of a 999 call. Now don’t get me wrong, if your heart stops our little two man paramedic crew can give you practically the same treatment and drugs as a full ER department but that amounts to less than 10% of what we do. What if it’s the birth of a new born or a mental health patient experiencing a crisis, an ongoing chronic problem or a person deeply depressed and wishing to end there life? Are we expected to be a GP, a psychiatric liason, a midwife as well as advanced first aiders with the ability to administer life saving drugs and provide an emergency patient transport service??? It is bordering on inappropriate to send an ambulance to many calls we attend (sometimes because the local pharmacy could have prescribed calpol, but often because we simply dont have the appropriate training!) but who can we send and who else would be willing to go – perhaps we could ask Dorian to be on stand by, we could collect him at 4am and he could accompany us to a deprived area, where crews have been attacked to have a chat with a 20 stone suicidal patient and allow him to make an assessment of their capacity.
Im not being sarcastic either, I think it is appropriate to have ambulances specialising in mental health or at least blue light psychiatric liaison officers who can be requested to scene 24-7 to make such calls of judgment AND receiving centres with acute admissions. How many times have you been stuck on scene for hours because the police aren’t sure whether the person can be sectioned, you are not sure if they have capacity and no one from social services etc is available. I’m not having a go at Dorian, he’s probably right but until someone else takes responsibility we are the only Resourse available and we just have to do the best we can.
Blow the Lid!!! please……..