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Dr Colin Campbell Palliative Medicine Consultant Saint Catherine’s Hospice, Scarborough. Mental Capacity Act (2005) …..so give us an example from real life!. Listen to me!!. Advance Decisions. What life-prolonging treatments?. Antibiotics for life-threatening infections Haemodialysis

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dr colin campbell palliative medicine consultant saint catherine s hospice scarborough
Dr Colin CampbellPalliative Medicine ConsultantSaint Catherine’s Hospice, Scarborough

Mental Capacity Act (2005)

…..so give us an example from real life!

Saint Catherine's Hospice, Scarborough

listen to me
Listen to me!!

Saint Catherine's Hospice, Scarborough

advance decisions

Advance Decisions

Saint Catherine's Hospice, Scarborough

what life prolonging treatments
What life-prolonging treatments?
  • Antibiotics for life-threatening infections
  • Haemodialysis
  • Artificial ventilation
  • Artificial nutrition and hydration
  • Surgery? Chemotherapy?

Saint Catherine's Hospice, Scarborough

george sampson
George Sampson

A 39 year old man with Down’s syndrome who lives with his elderly parents.

One year ago, he was diagnosed with a carcinoma of the sigmoid colon.

A CT scan at the time had suggested a Duke’s C carcinoma (invading through the wall of the bowel to the adjacent lymph nodes, but with no distant metastases).

Saint Catherine's Hospice, Scarborough

so what did george do
So what did George do?

He vigorously rejected having a stoma or indeed any kind of surgery. He started chemotherapy but abandoned this after one cycle because he didn’t like needles.

He had to give up his job as a cleaner in a local warehouse.

He gets continuous pain in his side. His father says George is terrified of dying.

Saint Catherine's Hospice, Scarborough

george becomes acutely unwell
George becomes acutely unwell….

Over the last few days he has become less well with nausea, drowsiness, and he is noted to be passing less urine.

He doesn’t know where he is and becomes worried that he may be late for work.

Saint Catherine's Hospice, Scarborough

george is ominously unwell
George is ominously unwell

Blood tests show acute renal failure, and an ultrasound of his renal tract confirms that tumour has obstructed both ureters.

There is the option of having a life-prolonging nephrostomy fitted.

Without this he will die in the next 1 to 2 weeks.

Saint Catherine's Hospice, Scarborough

no 1 capacity
No 1: Capacity!!!

How would you assess George’s capacity to decide whether he should have a nephrostomy?

Saint Catherine's Hospice, Scarborough

how do you test for capacity
How do you test for capacity?
  • Impaired functioning of the mind
  • Also unable to do at least one of the following:
    • understand the information (which must be imparted in a manner which can realistically be understood, such as via an interpreter)
    • retain that information (even if only for a short period)
    • use or weigh that information
    • communicate the decision (by any means).

Saint Catherine's Hospice, Scarborough

capacity
Capacity

George is examined and found not to have capacity for this particular decision (nephrostomy)

Saint Catherine's Hospice, Scarborough

views of those close to george
…..views of those close to George

His mother says she is in favour of “letting nature take its course”

She says: “My son has had a long hard fight, and he’s suffered enough.”

Saint Catherine's Hospice, Scarborough

if george does not have capacity to consent to this treatment whose responsibility is it

If George does not have capacity to consent to this treatment –whose responsibility is it?

Saint Catherine's Hospice, Scarborough

no 2 weigh up benefits and problems of proposed treatment
No 2: Weigh up benefits and problems of proposed treatment

What are the benefits and problems for George in:

-having a nephrostomy fitted?

-not having a nephrostomy fitted?

Saint Catherine's Hospice, Scarborough

no 3 look for advance decisions and lpas
No 3: Look for Advance Decisions and LPAs

George has conferred Lasting Power of Attorney (LPA) on his father to act in his best interests, and this includes decisions involving his future medical care.

What would you need to do before accepting the LPA in this particular situation?

Saint Catherine's Hospice, Scarborough

slide16
Lasting Power of Attorney

George’s father says everything possible should be done to keep his son alive.

He’s had to fight for George all his life and feels that he’s faced prejudice from doctors because of his mental deficiency.

Saint Catherine's Hospice, Scarborough

no 4 act in patient s best interests
No 4:Act in patient’s “best interests”

Bearing in mind the requirements of the Mental Capacity Act (2005) how do you act in George’s best interests?

Saint Catherine's Hospice, Scarborough

what happened to george
What happened to George?
  • Nephrostomy tube was fitted
  • George felt much better within 4 days
  • During hospital stay, George developed a DVT. Treated with Tinzaparin, then Warfarin
  • Died of massive haematemesis 2 weeks after nephrostomy fitted

Saint Catherine's Hospice, Scarborough

brief take home points
Brief take home points
  • Must assess patient’s capacity first
  • Weigh up benefits and risks and burdens of proposed treatment
  • Look for
    • Advance Decisions
    • Lasting Power of Attorney

Saint Catherine's Hospice, Scarborough

brief take home points20
Brief take home points

4. Must act in patient’s best interests

  • Take into account all relevant factors
  • Relatives cannot give/withhold consent but may know what the patient might have wanted
  • May need to appoint an IMCA

Saint Catherine's Hospice, Scarborough