01 October 2009

A flawed Act

Dr Grumble has never been entirely comfortable with the Mental Capacity Act. He preferred the law when it was vaguer. He always felt that if he acted in good faith and documented carefully the reasons for the decisions he had made the courts would protect him.

When the Mental Capacity Act was introduced Dr Grumble was specially trained by a barrister on what it would all mean. She made it quite clear that if Dr Grumble ever treated a patient against their wishes he would be guilty of assault. That's fine. Dr Grumble has never had any difficulty allowing patients to reject treatments they do not want even if it causes their death. Not usually anyway.

But there is one situation when Dr Grumble would be very uncomfortable about following the law and he put this to the barrister. He asked what would happen if a silly girl came to the Emergency Department having taking a potentially fatal overdose and declined treatment. Silly girls do this. They do it quite often. The next day they can feel different. So Dr Grumble has treated them against their will on many occasions and they have never in the past taken any action against him. But that was in the past when the vagueness of the law offered more protection and acting in good faith was always looked upon favourably.

Dr Grumble asked the barrister to clarify what the position would be following the introduction of the Mental Capacity Act if he decided to prevent the death of a young girl who refused to be treated having taking an overdose. The answer, insofar as lawyers will ever answer a question, was not reassuring. It seemed that even if the patient was depressed Dr Grumble would be required to let them die.

To allow a patient to die in such circumstances is so obviously wrong that Dr Grumble has decided to ignore the law in such a situation, save the patient's life and accept the consequences. If the patient dies they won't complain and if they live they are quite likely to be grudgingly grateful. And if Dr Grumble got it wrong they can always have another go at killing themselves. After all killing yourself is not that difficult if you really want to do it. The strange thing is that many people who try to kill themselves turn up in the Emergency Department where treatment can be offered. There is a reason for that.

Not all doctors are as brave as Dr Grumble. This was predictable

Some of Nutty's comments have been removed at her request.


Anonymous said...

I have to say - i don't really agree with you on this one - gone are the days when we as doctors should be paternalistic to the point of making all the decision for patients without involving them in the process. It is not always for us to decide which treatment is best or any at all. The case you highlight is one where the girl is 26, has attempted suicide many times before and only ended up in for pain relief and not to die alone. I know you can say that you could treat her depression and then she might not have done it again, however, we both know treatment of depression simply isn't that easy. It is quite rare to get an overdose that is potentially lethal where the patient is fully conscious, rational and competent to refuse treatment. In those rarer cases you normally have more time to talk to the patient and make an informed decision, remember these cases are grey areas and not black and white, so shouldn't be treated as such. (sorry for the long-winded response)


Dr Grumble said...

I do accept that there are patients with depression whose quality of life is so perpertually poor that a decision to kill themselves could be rational and reasonable and should be respected. Without knowing the details of this case it is impossible to know if she was one.

But there are some disturbing features. Why if you want to kill yourself do you turn up in hospital. The explanation she gave is not terribly plausible and we all know why people who purport to try and kill themselves turn up in hospital. Killing yourself if you are really intent upon it is not that difficult. People do it all the time. And it would not be too difficult to for someone of sound mind to research a comfortable method.

Patients like this are always sending us challenges of this type. It can be in their nature. They like causing a stir and they may assume that we will always find a way round the impediments they throw at us.

A great practical difficulty is that problems like this tend to arise out-of-hours. Decisions have to be made very quickly and I have no confidence that reading the situation correctly can easily be done by phoning the medical director and the psychiatrist on call.

But let us assume that the decison was proper in this case and that the law was correctly followed. What about the case of the 18-year old girl who is not depressed but is upset at her boyfriend leaving her? She is so upset she feels that her life will never be the same. She takes an overdose. It needs an antidote promptly. She tells you that her mind is made up and she wants to die. Her competence is not in question. You know and I know that there are other fish in the sea and that one day she will rebuild her life with another man. But like all people in this situation this is not even worth telling her. She sees the world through this one man whom she has lost forever. So, in accordance with the law, does ITU DOC allow her to die? And, if so, is he aiding and abetting suicide?

Anonymous said...

to answer your question i would probably treat the 18 yo girl in question. As to whether i would be breaking the law is another question. Just because she is over the age of 16 doesn't mean that she is competent to make a rational decision. Yes it is presumed so but if she has had alcohol along with her overdose she wouldn't be in a rational state of mind to decide. So i would most likely go ahead with the treatment, call for the on-call psych to formally assess whether she has capacity (and here for once the system helps us as it simply won't happen out of hours and will take quite a while during weekdays) in the mean time, it being an emergency you can go ahead with treatment.

If you were to be brought up for it in the future i doubt a peer panel would find what you had done enough to warrant being struck off.

If all you know about the case is that they are 18 not in a rational state of mind and having taken a life threatening overdose then the answer is treat. But as i've said before you've picked a very rare case (most don't take an overdose which is lethal, those who do aren't normally conscious enough to refuse treatment and many who have done something so silly normally aren't adamant about refusal of treatment by the time they get to A+E)

I think my point is that there can be cases where the decision to commit suicide is rational and shouldn't be stopped. I don't think we should simpy say everyone refusing treatment should be ignored, we're talking about rare grey case here which can't be generalised for what should be done.


Dr Grumble said...

Agreed - every case is different but the girl who is fully conscious and rational (though silly and upset) after having taking paracetamol in lethal quantities is less unusual than the case described in the newspaper.

Anonymous said...

This patient manipulated the NHS to be complicit in her suicide.

A doctor's duty is to his patient alone and the law. Hospital managers and any fashions and edicts of the day should be ignored.

This all smacks of the Nuremberg Defence of "I was only following orders."

Have we been so browbeaten as doctors in the past few years that we can't see the wood for the trees?

phatboy said...

It could be argued that if a person is so distraught, for whatever reason, that they are not thinking straight then that might constitute "an impairment of, or a disturbance in the functioning of, the mind or brain", which would allow treatment under section 2 of the Act.

I also wonder whether a future court will rule that an impairment need not prevent all rational decision making and may be limited to an impairment of the mind in respect of one area of decision making only. For example, the teenage girl who splits with her bf and takes an overdose, might be competent to make some decisions but not others. Don't know, it's just a thought.

Sam said...

If you put too much food on 'a plant' and it starts to shrivel, you run and wash it off the eccess nutrients and tend to it until you either save it or it dies ... but we will let a 26 year old die because the law says we can!

I shudder to think of what might happen if one of my own children 'temporarily' felt low because of what life throws at them and they react by doing something silly like writing a note asking the same as that 26 year old woman! Medicine has to consider the wider picture, that so many people are actually involved in this, so many family members and loved ones suffering eternally because a silly attention seeking note was written by a desperate young person.

I think this law sucks and if I was a doctor I would do all I can to save that young life! Not only was that woman's life wasted but I also wonder why nobody tried to do anything to help her with her depression after the 9 previous attempts at suicide? Why was she not sectioned and treated?!

This case highlights a BIG NHS failure in dealing with this case IMO as well as the need to revise the law to ensure that young life is not wasted in that tragic way.

As for the doctor who stood by and let her die 'in hospital', it was right to let him off the hook because the law 'currently' says so ... don't know if his concious will be so kind!

the a&e charge nurse said...

"which would allow treatment under section 2 of the Act" - no, I'm afraid that's incorrect, phatboy - the Mental Health Act has NO ROLE to play in the treatment of a physical emergency (such as self poisoning with antifreeze).

The law as it stands only permits health staff to impose treatment during a non-psychiatric emergency when a patient lacks capacity.
The doctor can adopt the doctrine of best interest- in other words due to a temporary or permanent form of incapacity the patient has made a decision about the their health they would not have otherwise made on a good day, so the doctor is authorised to protect them because of this deficit.

If a patient has taken an overdose of paracetamol then they will require a parvolex infusion over several hours - obviously this requires a cannula.
Should the patients arm be restrained for the duration or should they be chemically sedated?

Personally I would not hesitate to restrain a labile 18 year old following a potentially lethal paracetamol overdose unless she had a signed letter from God confirming she was of sound mind.

I have teenage daughters - the transition from adolescence to adulthood is a undoubtedly form of low grade mental illness in itself.

Treat now argue later that's what I say.
Anyway, it's enough for the doctor to BELIEVE a patient lacked capacity - there is no objective test to prove if they have got it right once we factor in the many variables that can impair capacity (such as the effects of alcohol or transient mood disorder, etc).

Dr No said...

Excellent post. My own thoughts (too long to publish here), for what they are worth, are here...

Julie said...

It wasnt going to be long before the Mental Capacity Act was going to cause bother like this. The area of interpretation round the phrase 'best interests' was the subject of long and acrimonious debate in the Commons when the bill was going through. In Scotland we have the Adults with Incapacity Act which is much clearer on these matters. The doctor has to act 'for the patient's benefit' and right of welfare attorney goes by default to the nurses and doctors treating the patient unless they have a named person for situations such as this. I think the Mental Capacity Act is going to have to go back to Parliament for amendment; this may be the case that does it.

the a&e charge nurse said...

You may well be right, Julie - there may be grounds to improve the framing of the legislation (MCA).

But the fundamental issue still comes down to how medical (and nursing) staff will INTERPRET these principles?

One authority has already commended efforts made by doctors in the Kerrie Wooltorton case;

Nutty said...
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Sam said...
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Dr Grumble said...

Nutty, assuming you are competent, is Dr Grumble wrong to try and bring people like you back to life following a suicide attempt?

Who do you want to look after you? Do you want ITU DOC who will follow your wishes to look after you until you die or would you prefer Dr Grumble who will keep you alive because he thinks there is a chance that in the future things may be better for you?

ITU DOC follows the law. Dr Grumble does what he believes to be in the best interests of his patient.

ITU DOC calls this paternalistic. Dr Grumble thinks that at times in our lives, competent or not, we all need protecting from ourselves and that looking after each other's interests is what being a human being is all about.

Who do you want looking after you? Is it the man who follows the letter of the law or the doctor who bends the rules in the interests of his patient?

Dr No said...

God (sic), this is a difficult one!

I have posted on this but as this is where the debate is happening I will add here:

What I think is going on here is a collision between two very important fundamental rights: the right to life, and the right to self-determination. Normally, of course, the two are aligned, but sometimes - as, for example in Kerrie Wooltorton's case - they are opposed and so collide. In that situation we are forced to decide which one has the higher ground.

It is a very difficult question to answer. My big big big worry is that those who put the right to life above the right to self-determination may be doing so ultimately not to satisfy their patients rights, but their own needs. They, quite rightly, place enormous value on the sanctity of human life, but this then distorts their ability to act in their patient's real best interests.

I know I would treat Dr Grumble's "silly girl". I know I could do nothing about the completed suicide that just got on with it and did it (because I wouldn't know about it until after the event). Where it gets horribly complicated is when a competent mind decides on suicide - and then places itself in the hands of doctors.

Witch Doctor said...

A clinician could easily argue that a patient who has attempted multiple suicides ineffectively, who presents at a hospital in an ambulance conscious but with a DNR letter pinned to her chest, is at least in part a manipulator, an attention seeker, and an actress - regardless of whatever other psychiatric diagnosis comes into the picture.

Believing this “diagnosis” to be correct, does that clinician allow a patient to die because they have decided to perform yet again on a hospital stage?

Dr Grumble said...

My thoughts exactly, WD.

The problem in real life is that when you find yourself in a difficult situation like this you may feel that you need to take advice or, more likely, somebody else informs the powers-that-be who give you the advice you did not want. Once management and the likes of Capsticks are involved you may find that you are prevented from doing what you believed to be in your patient's best interests even if you yourself are prepared to stand up in court and defend your actions.

The lawyers, unusually for lawyers, seem to regard this particular case as clear cut but I agree that it is likely that a different interpretation could have been made along the lines you outline.


Witch Doctor said...

There are a couple of other things that bother me about this case.

It needs to be remembered that she presented as an EMERGENCY and therefore required to be treated as such. That must surely over-ride self indulging oneself at that time in any prolonged legal and philosophical pontifications. It should have been clear to the consultant in charge within the first five minutes, that the law in this area is very complex and probably would have to be challenged. It should have been clear that such a challenge would take months to resolve and involve many people. However this patient was admitted as an EMERGENCY where time was of an essence. This is where common law and common sense should have kicked in. The instantaneous interpretation of common law would be to preserve life and argue about that later if necessary.

The other thing that bothers me is how the concept of “paternalism” is being demolished. If doctors are “forbidden” to be paternalistic, do they not try to use persuasion that what a patient is doing is not a good idea? Some patients appearing in A and E in this situation are yearning for a paternalistic approach. It might be a sign to them that someone cares.

I would not have involved the clinical director or any other administrator or lawyer regarding this patient while the clock was ticking in my ear. Consultants in charge of patients are paid a large salary to make difficult decisions about patients in their care. That is why they are there and they live with the consequences. Ask a colleague for medical advice by all means but don’t expect to have a philosophical hand holding session with a doctor-manager.

Dr Grumble said...

I couldn't agree with you more, Witch Doctor. Once again, my thoughts exactly.

Anonymous said...

I find your use of language in this post both sexist and patronising.

For one thing, the patient in question was a 26 year old woman, not a girl.

For another thing, why characterise those who feel the need to act on their suicidal impulses as 'silly'?

Perhaps this long-suffering woman had a lifetime of dealing with patronising consultants like yourself who treated her as a 'silly girl' and came to the conclusion that she was unlikely to get much in the way of help or respect from those in a position to offer it.

We can never know or ascertain the amount of suffering Ms Wolverton was going through but we can approach such patients with care, empathy and respect.

Dr No said...

Searching for another quotation, I came across a list of "Ideals" in my 1996 edition of the Oxford Handbook of Clinical Medicine:

• Don't blame the sick for being sick

• If the patient's wishes are known, comply with them

• Work with your patient, not your consultant

• Use ward rounds to boost your patient's morale, not your own

• Treat the whole patient, not the disease - or the ward sister

• Admit people, not "strokes", "infarcts or "crumble"

• Spend time with the bereaved; you can help them shed tears

• Question your conscience - however strongly it tells you to act

• The ward sister is usually right; respect her opinion

• Be kind to yourself - you are not an inexhaustible resource

They seem to me to be rather apt to the current debate.

I also came across another one about paternalism and playing God:

"Doctors are busy playing God when so few of us have the qualifications. And besides, the job is taken."

Oh, and the quote I was looking for:

"to cure sometimes, to relieve often, to comfort always"...

I am also unsure about the Witch Doctor's EMERGENCY argument. This wasn't the FIRST time she'd tried. Every one KNEW she was likely to try again. Wouldn't it have been BETTER to address the issue before she did have another go?

And I 100% agree about the fact that she presented to casualty raises a very big question about her intentions.

Dr Grumble said...

Over the years I have looked after many patients who have come back time after time again having taking overdoses. Addressing the issue is, in their cases, not a solution. However good the care provided these people often cannot be helped.

Presumably on previous occasions the patient did not refuse to be treated because, if she had, treating her would have been an assault. So how was anybody supposed to predict that on the next occasion this lady would arrive with a note saying that she did not want to be treated? It would have been more logical for her to have stayed at home which is the preferred place for most people to die.

The reality of the emergency situation is that you may have very little time. There are often quite short windows of opportunity when treatment may save a life. In that context I have great sympathy with Witch Doctor’s view that, if necessary, you take advice from a close medical confident and then do what you think is right in the patient’s best interests.

Death is a bit of a one-way step. If it is necessary to argue the law slow time it is best to do it with a patient who is alive and not a corpse. We have all seen court cases go one way and then another on appeal. As WD says there were arguments that could have been made which would have provided mitigation for the doctors responsible for giving the treatment.

Anybody who has worked in acute medicine knows that there are always patients pushing you to the limits. They react to the problems in their lives by putting hurdles in the way of doctors’ attempts to help them. They feel confident in doing this because they believe that most doctors will never abandon their patients.

That these poor people really want to be helped and not left to die is evidenced by their appearance in a hospital. I know we have been given another explanation for this but for me that is the most worrying feature about the sad case we have been reading about.

Anonymous said...

This is an extremely sad case. The young woman concerned had an emotionally unstable personality disorder. Her need for care and attention comes over in her advanced directive and must have been a motivating element which raises serious questions about her capacity.

Besides if she just wanted to die there are lots of ways to do this alone and quietly. Why use a method that requires an AD at all?

Dr No said...

For the avoidance of doubt, I would have treated Kerrie Wooltorton.

These people do manipulate their doctors, but 99 times out of 100 they are not doing it to be malicious. They do it because they know no other way - and sadly, sometimes the so called caring professions have actually been complicit in teaching them that that is the only way.

The key point about KW, and what makes her case so unusual, is that she both turned up at casualty and had a DNR note pinned to her chest, as the WD so aptly put it. That, plus the fact she had failed on several previous attempts, does, at the very least suggest ambivalence and so it is right to save her life first and then ask the questions later.

Putting aside the emergency presentation for a moment, I suspect KW may (I am not all that sure) have been what I call an expert overdoser (or in her case self-poisoner). They are expert in that they know how much to take and what to do to get to hospital. That, of course is why they keep on turning up - they know how just how far to go, but not too far. They get to know they can do it again and again. Every now and then one of them does get it wrong and dies. Allowing her to die - the doctors clearly had a choice in the matter - because of her previously unseen "living will" (a nasty phrase in my view) and an untested bit of law seems somewhat premature shall we say to me.

KW - if she was absolutely certain in her wish to die - was taking a great risk by turning up in casualty with a DNR note out of the blue - she must have realised most doctors would treat her. The logical (if we can call it that) thing to do would have been to make sure her "living will" was known about and accepted (however reluctantly) by her doctors. Of just do it at home. Or go to a country where they can do it. Just turning up and hoping the docs won't intervene is just plain bonkers.

What I am asking is: how did it get to this horrible situation in the first place? I cannot believe she was not known to the local mental health team. What were they doing?

Probably not a lot. Sadly, most of psychiatry hasn't got a clue to do with these patients. Once the pattern of overdoses and/or short detentions under the MHA has been established, it is very hard to break, particularly as most CMHTs are very risk averse (what they actually need to do is do a bit of positive risk taking). The door just keeps on revolving until something breaks.

The real answer is to stop the pattern before it even starts. But that's another story and will have to wait for another day.

Dr No said...

Oh, and I forgot to say - I support Dr Grumble's use of the word silly. Taking impulsive overdoses is silly, just like crossing the road with you eyes shut is silly. It is best to call silly things silly. As for girls - well, perhaps Dr G is of that generation where all woman under the age of 60 are girls - or gels, as he would probably say it.

Witch Doctor said...

Dr No, the common ground is in your last sentence.

“And I 100% agree about the fact that she presented to casualty raises a very big question about her intentions.”

Where there are big (or even niggling) questions about a patient’s intentions this surely puts the right to life ahead of the right to self-determination.

When, in my judgement, the right to life and the right to self-determination seem neck and neck, the right to life will win.

Multiple and frequent unsuccessful attempts at suicide may be interpreted differently. For me it would tend to indicate that a patient was not really serious about ending his/her life but others might draw a very different conclusion.

The other thing is that there is not really an opt out position for doctors in an emergency situation where no other staff may be available. Doing nothing is opting in.

Like Sam, I am very disturbed to think any of my children’s lives (or anyone of any age close to me) could end similarly with doctors standing by. My needs or not, I would be very angry and inevitably mistrust all doctors for good.

And that can’t be a good thing.

And listen, Dr No, I know women of 100 who think of themselves as girls! And they are too!

Witch Doctor said...

Sorry Dr No, I posted previous comment before properly reading all you said on the refreshed page.

You are a devil's advocate, you horror!

Dr Grumble said...

In fact I used the word 'girl' because that is what I meant. I was not referring to the case in the news but to the example I posed to the barrister of a younger patient, a girl, refusing treatment following a suicide attempt. I made the example female because that is mostly what we see. (Males tend to use more violent methods to commit suicide and tend to do the job more effectively.) I made the patient young, a girl, because of the importance of age when it comes to considering capacity.

If a girl of 10 refused treatment after poisoning herself I would ignore her but what about girls of 12 or 14 or 16? The point was to paint a scenario that is even more difficult than the one the doctors were faced with in this latest tragic case.

Dr No said...

WD, I know there are, I just chose an arbitrary age off the top of my head. I am now in deep fear that you will cast an ageing spell over me and I will end up like Dorrian Grey.

I think there is a lot of common ground. We are all clear that we would treat KW, and why we would do so (and then what we would do to the lawyers, medical directors and other lackeys out there).

The grey (sic) area is for me to do with a non-emergency presentation planned suicide by a competent individual who then involves his doctor. If we accept that we "comfort always" our patients (that was why I was looking for that quote, to get the wording right), then that places us in a really hard position. We don't appear to be able to "cure" them or "relieve" them, but we should always comfort them. The question is how to do that, and stay within one's own moral compass. I don't know the answer, but it seems an important question that is worth thinking about because, particularly with the MCA now in place, we may sooner or later come up against it. And, as we know, deciding such things under the pressure of an emergency situation is not a good idea.

PS wrote the above then refreshed that page only to see to more comments but am still going to post this because I think the question in the above paragraph is important: what are we going to do if and when faced with that situation?

Dr Grumble said...

Yes, Dr No. You too have worked out as our patients soon will that someone with capacity at the end of some terminal disease who wishes to end his life could arrive in a hospital having taken poison with a note pinned to his chest asking the doctors to keep him comfortable only. It would clearly be wrong to bring him back to life but helping him on his way would be aiding suicide and a crime. If the dose of poison was inadequate it could be awkward.

Dr No said...

They don't even need to have a disease, let alone a terminal one. They only need (in the absence of a mental illness) to have lost the will to live - maybe they've been made bankrupt, and money is important to them, or whatever - it doesn't matter.

Dr Grumble said...

Like my poor friend, Bill. He was a great guy who killed himself while a bit upset. He just hadn't thought it all through. I would hate to have to stand by and watch somebody like him die.

Witch Doctor said...

We are now wandering into the penultimate place on the road to voluntary euthanasia and so these theoretical examples cannot be considered without first considering the position and consequences of voluntary euthanasia.

There are hundreds of shades of grey there - all of them difficult. Now, I have watched several loved ones die in a bed in my own home and know how much I wanted to see an end to their suffering. No doubt pain relief and pneumonia hastened that end but putting a needle in a vein to end it there and then at a certain time of day or night would have been quite a different matter. Even if legal, these members of my family would have been unselfish enough not to expect me to have been in any way involved in their deaths or in any decision making in that regard.

Over the years I have deliberated on this a lot. Comfort and pain relief are as far as I could go. The reason? I truly believe in “creep.” I have no doubt – no doubt at all, that in the fullness of time, and it may take a long time, euthanasia will become involuntary and eventually and gradually move on to murder. Perhaps it is because I believe human beings are in fact quite dangerous animals.

I haven’t considered yet what I would do in the penultimate place that was your question.

Dr No said...

WD, I am absolutely in the same place as you are on this one. Creep over this is not conjecture - it is historical fact (Nazi Germany).

I don't think doctors should ever intentionally assist death. That is not a job for doctors (and if it is something that "has" to be done, then it is done by executioners).

They key for me is intent. I can give morphine for pain relief, even if I know it, as an unintended side-effect, might hasten death. What I am not prepared to do is an act that's primary intent is to kill. It is in the intent that the red line is drawn.

But that still leaves the penultimate place. This is an act of omission situation - we are omitting to do something that could save a life. To that extent, we are assisting in a death.

Morally - and legally - we would then be in a very difficult place.

Nutty said...
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Nutty said...
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Witch Doctor said...


I am truly sorry to hear about your troubles. I can identify closely with them since a young member of my family suffers 9 months of dark depression every year as a result of a serious brain injury. I can’t really talk about it more than this because of confidentiality reasons but I can understand all your frustrations very well.

All I can say is this. Beside me by the fireside I have a little magnetic plaque given to me by one of my children at the time the disaster hit the family. It sticks on to a piece of metal on the fire surround. It is not very clever nor is it emotional. It simply says: “If you’re going through hell, keep going.” It’s a Winston Churchill quote, I think. So we all just kept going and still are.


Dr No,

The problem I have with the penultimate place is that the thin black wavy line and the red indelible thick line are superimposed!.

Nutty said...

Thank you, Witch Doctor.

Sam said...
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Dr No said...

I think I have spotted the flaw in all this, and it is that Dr G sought a legal opinion.

For heaven's sake: we are doctors: as old as and equal to (if not better than) lawyers! Can we not make up our own minds?

Remember: all this started with Dr G being concerned about his counsel's advice. That suggests he gives weight to his counsel's advice.

Law and medicine are both professions. Neither has an absolute ascendancy. We should leave the lawyers to their games - and do what we do best - work for the best interests of out patients.

Nutty said...
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Dr No said...
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Nutty said...
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Sam said...
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Nutty said...
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Sam said...
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Nutty said...

I've had a funny old life. The silly thing is that it's easy enough to cling onto life when someone else is depending on you for theirs, but once you end up too ill to function as a full member of society, you have to scrape the barrel for reasons to go on. It's one thing to save someone else's life and another to save your own.

I think that it's good that people care. I just want others to understand that not everyone wants to keep suffering and that failure in suicide does not of itself equate to lack of intent.

Sam said...

"no matter how hard you try, you can't get them to understand. That's the curse of the saved suicide."

I am pro life Nutty .. but 'Quality' life, hence, in no way am I belittling your feelings, only I get a sense, from your choice of words, that there is still some hope to save you and help you out of your desperation. Not because I want to be rewarded at the end, but because I believe that 'humans' should care for each and that perhaps you have not experienced much love to help you get through life ... and that maybe if you did, that would change your mind about suicide ...

the a&e charge nurse said...

So, do those who refuse treatment (and sometimes die) play by a different set of rules providing their choice has sufficient RELIGIOUS authority?

Dr Grumble said...

You don't need to be religious to refuse blood (or any other treatment) and die as a result.

Actually I would be happier if an eccentric decided not to receive blood rather than a member of a religious group. My reason is that it always worries me that in a religious group there might be peer pressure. And if the patient lapses into unconsciousness you are reliant on the group members to know the patients wishes.

As you have pointed out, a&e charge nurse, you can't force treatment of a physical condition on a patient even if they are mad.

Dr Grumble said...

Law and medicine are both professions. Neither has an absolute ascendancy. We should leave the lawyers to their games - and do what we do best - work for the best interests of out patients.

I do agree, Dr No, though the law does have the final say in what is right or wrong.

The difficulty is that we are not always permitted to work for what we consider to be the best interests of our patients which is regarded as being patronising (see the hostile comment from the anonymous troll above).

Patients can refuse treatment that a doctor thinks is in their best interests. That is fine until one day a patient feeling unusually down decides to write a valid AD and tries to kill herself. Shortly after arriving in hospital she loses consciousness. Amongst the pills she has taken is paracetamol which may kill her if prompt action is not taken. It could be she is at the end of the road from some terrible disease or she could be just fed up. Only vague unreliable information is available and time is of the essence.

We know that we have treated many such patients in the past who have been grateful and made a full recovery. Fortunately the law of the land is clear so we don’t have to think too hard. We must let her die.

Somehow that doesn’t seem right to me.

the a&e charge nurse said...

My question really related to the tacit acceptance that religious ideology trumps the idiosyncratic world of individuals?

For example, if we look at some of the MSM reporting after the Kerrie Wooltorton case - there seems to be a barely veiled criticism of doctors for standing by while she died from organ failure?

Yet if a Jehovah's Witness bleeds to death there is an implied message that doctors have no right to interfere with god's business?

The point about peer group pressure is a very good one, Dr Grumble.

Dr Grumble said...

If you have a child refusing blood, is it what the child wants or what the child's family wants? That's another difficult one.

Dr No said...

The law, as they say is an ass, and the combination of the MCA and the Suide Act 1961 is a prime example.

As things stand, the MCA allows a sane, capacitous individual to initiate their suicide and then seek medical attention for pain relief etc with the explicit caveat that no attempt shall be made to save that persons life, even if a known effective treatment exists.

The Suicide Act says:

"A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years."

"Aid" means to assist; "abet" means to countenance, or sanction, an act. Electing to withold an available effective treatment is an act (an act of omission) which, in the case of a individual in the process of suicide, will aid and abet that suicide.

Whatever a doctor does, they will be acting illegally. If they save the life, they will be guilty of assault; if they let the individual die, they fall foul of the Suicide Act. And fourteen years is a long time to spend in jail...

Dr No has never taken the law too seriously. If is made by humans, and is just as fallible as humans. Often it gets it hopelessly wrong, as it has in the collision between the MCA and the Suicide Act.

What I am suggesting is that, as doctors, we do not have to be subservient to bad law. We are not acting as crackpot fanatics, we are acting as part of a noble profession that has a tried and tested moral compass that goes back thousands of years. Once we have worked out (for ourselves - we don't need a lawyer to do it for us) that the law is an ass, we are free to act as we should: in the best interests of our patients. Of course there will be huge debate about what "best interests" means, but that is a moral and medical argument, not a legal one.

Any proclamation - and acceptance - that the law is always King is the first step on the road to Dachau.

JD quotes Emerson in his post on this matter: 'Good men should not obey the laws too well.' Exactly.

Witch Doctor said...

A and E charge nurse

I remember the case you refer to in the Guardian although not all the details. You are absolutely right to bring up this anomaly. This conversation is not complete without referring to it.

Since not all he facts are known, consider a hypothetical but similar situation:

I would assume a young woman would not want to die and leave her children to grow up without her.

I would have warned her at the beginning of the pregnancy that although I would try if possible to observe her religious wishes, I would intervene in the unlikely event that her life was in imminent danger. That would be the contract. She might then choose to seek out an obstetrician of her own faith.

If she wanted to continue with the patient/doctor arrangement she would know the terms. I would encourage her not to bring an entourage of “minders” with her to the hospital since she was the patient - no one else (although I wouldn’t call them “minders” to her face)

If blood was necessary to save her from certain death then I would give it to her as in our agreement.

I would not cross my red line for the sake of any religion but she would know that from the beginning.

In an emergency I would not cross my red line either.

Dr No said...

The law is an ass Part II...

Going back to Dr G's original post, and the hypothetical young girl: perhaps it was a mistake to even seek a legal opinion, in so far that as a rule, involving lawyers usually complicates things. Not only is the law an ass on this: my view is that the lawyers can be assess too:

"The answer, insofar as lawyers will ever answer a question, was not reassuring. It seemed that even if the patient was depressed Dr Grumble would be required to let them die."

I cannot agree with our learn'd friend's opinion. One of the commonest features of depression is losing the ability to see a future, often to the extent of wishing to die or even explicit thoughts about suicide. Such thoughts, in the context of depression, are more likely to be a direct manifestation of that depression, rather than the sane and rational conclusion of a balanced mind.

In so far as this patient's thinking is distorted by her depressive illness, it cannot safely be assumed she has capacity. She has a relevant condition (her depression). When it comes to the four stage test of ability to make a decision, she will fail. She can probably understand and retain the information given to her (and can probably communicate her decision), but where she will fail is in being weigh the information. We cannot rule out that she gives undue weight to the negative (no future, I want to die etc) not because it is the case, but because her depressive illness makes her think so. The scales that are doing the weighing are broken. She lacks capacity - and can be treated under "best interests".

But - we are still left with the apparently sane capacitous individual who is not ill, but just plain old Fed Up, who initiates suicide and then seeks medical help the the DNR string attached.

I think what I would suggest is this: for the doctor to go along with this, it would have to be agreed in advance. In an emergency situation, where the doctor cannot know all the facts, because they are ignorant of all the facts, they are not compelled to comply with a living will which has, quite literally been dumped on them out of the blue. For God's sake, for all we know, a scheming relative could have pinned it to the patient's chest when no one was looking!

The planned, agreed in advance route allows the doctor to act within their conscience, as, for example, happens with abortion, or WD's pregnant Jehovah's Witness.

Dr Grumble said...

I cannot agree with our learn'd friend's opinion. One of the commonest features of depression is losing the ability to see a future, often to the extent of wishing to die or even explicit thoughts about suicide.

Of course you are right, Dr No, but the presence of mental illness does not necessarily mean that the patient is incapable of meeting the requirements of capacity.

Many patients arrive in hospital having poisoned themselves. That is the odd thing. They arrive and then refuse treatment. Some doctors break the law by giving it. Yet the advice is clear: you should let these patients die.

My guess is that this happens only very rarely otherwise we would have seen many more sad headlines. The fact that these patients appear in a place where treatment is given and then refuse it suggests that inside they want to put themselves in a place of safety where there are people they trust to do the right thing for them.

Unfortunately this is not something they can communicate at the time and the next day can be too late. They are actors in a play depicting their own demise.

Witch Doctor said...

Preserving your own Red Line is workable at the moment and the consultant in charge of a patient could probably justify his/her action in a court case if necessary. Even if unsuccessful in court, the consultant will still have the “privilege” of taking the blame and the consequences.

However, one of the things that I see might cause a problem in the future is the question “who is in charge of the patient?” This is one of the many reasons why I think the NHS should always be a service delivered by GPs in the community and consultants in hospital. Not led, not based, but delivered. In a hospital, every patient should have a consultant who is visible, and whose finger is continually on the pulse. Not that this will always be perfect and it is becoming increasingly difficult to achieve. However, anything other than this will over time develop into a fudge - ultimately the state, primed by suitable quangos and lawyers, will decide what is best and that is very dangerous territory for patients.

Dr Grumble said...

In the Grumble hospital Dr Grumble used to have his name at the head the patient's bed. There it was in big capital letter - DR GRUMBLE. The patients knew who their doctor was. They liked it. There was never any doubt about who was in charge. But things have moved on. The creep has started. Dr G no longer has his name over the patient's bed. The powers-that-be didn't like it. It didn't seem something worth fussing about so Dr G made no comment. It would have made no difference anyway. And what has been the consequence? The patients do not know who is in charge of them and worse not infrequently there is confusion amongst the staff too.

Antibiotic prescribing is determined according to a protocol. If you deviate from it you will receive an email telling you what you have done wrong. A colleague acting in the best interests of an elderly patient made a decision to allow her to die. The decision was countermanded within hours by the management. The patient was treated and died the same day. The consultant remains suspended.

The creep has already crept. Consultants are as WD has said paid well to make difficult decisions at all hours of the day and night but if the management had their way they would have it all protocolised. They do not even seem to grasp that there is no protocol to guide us most of the time. That's why we are needed.

Anonymous said...

Dr No
Oh, and I forgot to say - I support Dr Grumble's use of the word silly. Taking impulsive overdoses is silly, just like crossing the road with you eyes shut is silly. It is best to call silly things silly.


Your comment demonstrates a rudimentary grasp of borderline pathology. Impulsivity and emotional dysregulation are marked characteristics of this disorder.

What you trivialise as 'silly'impulses are very real and serious mind states to people who suffer with this disorder.

Similarly the frontal lobes are not fully developed in young people such as the teenage girls mentioned.

Calling the suicidal actions of such people 'silly' fails to take account of the limitations in emotional regulation and controlling impulsivity that teenagers and people with BPD face.

It's always better to adopt an empathetic patient-centred approach than a dismissive one.

Do you think calling patients 'silly girl' really helps them in any way or does it do something for you instead?

Sam said...

"gone are the days when we as doctors should be paternalistic to the point of making all the decision for patients without involving them in the process"

Sick people are vulnerable, hence can not make the right decision in that state of mind, even if they are not suffering from a mental illness. It is therefore not right to swing the pendulum fully to the other side and say that doctors should not administer a degree of paternalism when the best inteests of the patient demands it. Indeed, if I were in hospital and was given hard news about my condition, I would expect the 'professional' in charge of me to be compassionate enough to help me decide. Afterall, I am not a medicine man myself and that is why I am in hospital!

And yes, knowing who is in charge of you in hospital is reassuring for patients, I would go as far as to say it is even part of the treatment ... vulnerable people do not need the confusion of not knowing who is in charge on top of their affliction too! ... too much to cope with that will only be harmful tp patients IMO

Remember? 'First do no harm' is what medicine, as well as healing ... etc, is all about

Dr Grumble said...

Yes, Sam.

At a meeting just last week I met a friend who is a consultant in another part of the country. He told me he had developed a chronic illness that was preventing him from working. I asked him about the details of his treatment, the rationale etc. He just shrugged. He said that he was just doing as he was told even to the extent of seeing the specialist nurse in the same way as everybody else. He hadn't even googled it.

It may be unpopular to say so but some people are happy to be told what to do by professionals they trust. Some of us want to be looked after, guided and told what to do. It doesn't make me feel patronised.

Nutty said...

Is it possible to have the messages in which I gave out personal information deleted? I am not in the habit of asking this on people's blogs, but I allowed myself to be drawn and gave out sufficient personal information for me to be identified by some people.

Dr Grumble said...

Of course, Nutty. I will delete the ones I think you would want deleted. Let me know if there are others that need to go.

I was not actually at all comfortable with the way things were going and I can see Dr No wasn't either.

Dr Grumble said...

I have deleted most of your posts, Nutty. If I have left anything you are worried about let me know.

Thank you for your contributions. You have given us a patient perspective on this difficult area and we have a learned from your input.

Good luck.

Nutty said...

Thank you. I am sorry to have put you to this trouble.

Sam said...

Dr G "It may be unpopular to say so but some people are happy to be told what to do by professionals they trust. "

Providing I understand . fully .. and agree what that professional is offering as a solution, then yes, this would be the best way for me. I would not like to be either kept in the dark while others, I trust or not, made decisions for me .. or professionals explaining options then simply leaving it to me to decide on my own completely. The latter is because I do not have the depth of experience they have which is, hopefully, is also based on plenty of evidence. It is best to hold the stick from the middle IMO

Dr No said...

Anon at 13:31: if you read Dr G's original post, the hypothetical patient - the silly one - is not given a diagnosis - although depression is mentioned. There is certainly no mention of a personality disorder.

I understood Dr G to be describing an impulsive overdose in someone who did not have significant underlying pathology. This is the group to whom the word "silly" can be applied. Or stupid. Or whatever you want to call impusively and recklessly endangering your own life.

KW is altogether different: she had emotionally unstable personality disorder, effectively the same thing as BPD (borderline peronality disorder). These conditions are very complex and although they are impulsive, they are most certainly not "silly".

In the real world I might well say to the first patient "Don't you think that was a bit silly?" or words to that effect. It would never occur to me to call KW silly. She knew at first hand the misery of BPD and in the end it probably contributed to her death. I don't find that "silly" at all: I find it very very sad.

And I also know the people with BPD get a really bum deal in the NHS.

I may or may not do a "silly girls" and BPD post on my own website, where I will look into this a bit more.


Dr G - glad to see you have removed Nutty's personal details. You were right: I was not at all comfortable when Nutty was asked about age etc. This is a public site, for Heaven's sake.

And Nutty, if you read this, thanks again for your input - it was much valued.

Julie said...

One of the factors in this case, was the lack of time available. The doctors in question had to take a life/death decision quickly and it wasn't certain which one the patient wanted. Therefore if it had been me, I would have opted to save the patient. This way, if I had not acted according to their wishes, they would be able to take the decision to die again if that was what they truly wanted. But we will never know if Kerrie Woolterton got what she wanted, because the doctors let her die and that decision cannot be reversed. So if in doubt, save the life and argue later, that's what I would say.
In religious cases, the patient has usually made their views clear in advance. I would say the difference in religious cases is that it would probably come under the 'second effect' tag; a Jehovah's Witness refuses blood because they believe that consuming blood is against the Law of Moses, not because they want to die. In the same vein, a Catholic might refuse an abortion even if their life was in danger, not because they want to die, but because they do not want to kill their child. Intent is the crux of the matter here.
Nutty, I hope things work out for you and thanks for coming on here.

Sam said...
This comment has been removed by a blog administrator.
Dr Grumble said...

I have deleted some of your comments, Sam.

Let me know if you think anything else needs to go.

Sam said...

Perhaps the one I ask you to delete @ 21.34 and this one too, thank you Dr G :-)

Sam said...
This comment has been removed by a blog administrator.
Dr No said...
This comment has been removed by a blog administrator.
Anonymous said...

Can I just ask just what exactly the "useless" CMHT is to do with people who repeatedly take ODs etc and/or have BPD? Despite some valiant efforts there is no good, solid evidence that any treatment so far devised is of any lasting benefit.

Nutty said...


Anonymous said...

Over-rated , not widely available and uses a lot of resources ( training, groups, numbers of sessions, staff etc ) so unless there is a huge increase in these will be out of the question for the majority of people outwith the teaching hospitals and research centres. If you look carefully you will see the people providing "evidence" of its effectiveness are the same ones who devised and practice it. Oh and they are also quite charismatic which is not easy to achieve for the average mental health professional. There is no good evidence that it helps with the average patient in the average clinic, I'm afraid.

Nutty said...

I hadn't realised that.

Sam said...
This comment has been removed by a blog administrator.
Dr Grumble said...

Everybody please calm down. No harm has been done.

In the interests of peace I will delete the things that I spot that may be causing strife.

We can all learn from this.

Dr Grumble said...

I read a critique of this blog which said there was not enough interaction. I don't agree!

the a&e charge nurse said...

Well, let me add another interaction, Dr Grumble.

Is A&E, with it's culture of seeing, sorting and disposing of patients in the shortest possible time frame really the best environment for such complex deliberations?

Hassan's work 10 years earlier suggested that many doctors are ill-equipped to deal with non-consenting patients after a potentially fatal overdose.

When we are busy we can have as many as 50 (or more) patients in A&E at any one time, plus entourage - its hard enough to think, or hear each other speak some of the time, let alone decide who is competent to refuse treatment after self poisoning.

A decision is made then we all move on the next case - that's just how it is in A&E I'm afraid.

the a&e charge nurse said...

If link not working google this BMJ item;

"Managing patients with deliberate self harm who refuse treatment in the accident and emergency department".

Failure to assess adequately a patient's capacity to refuse treatment may have serious medicolegal consequences

T B Hassan, research fellow, A F MacNamara, senior registrar, A Davy, senior house officer, A Bing, senior house officer, G G Bodiwala, head of service.

Department of Accident and Emergency Medicine, Leicester Royal Infirmary NHS Trust, Leicester LE1 5WW

Correspondence to: Dr Hassan tajhassan@yahoo.com

Dr Grumble said...

Well, let me add another interaction, Dr Grumble.

I think we have broken the record number of comments already! But thanks, a&e charge nurse.

I think you posted this on JD's blog. It is good to have the link here too.

Some of the problems encountered in A&E are, of course, nothing to do with the Mental Capacity Act though it has in some circumstances highlighted our difficulties.

Unfortunately what the lawyers tell you to do is difficult advice to follow if it results in the death of a young patient. Most doctors do not like letting patients kill themselves when they know that most of them will one day get over their transient difficulties.

If you see someboby about to jump off a building and you drag them to safety the public would praise you. But it is an assault. Doctors do the same sometimes. They drag people to safety risking their livelihoods in the process. Though my feeling is that the public would praise us just as they praise a rescuer on a parapet.

the a&e charge nurse said...

Eagle eyed as ever, Dr Grumble - yes, I flagged this article on Jobbing Doctor's site.

While not a crusade exactly I have taken a great interest in this area following the case of a woman who died after a paracetamol overdose (this was many years ago).

There were all sorts of reasons for the sub-optimum care she received in A&E (patient arrived early hours of the morning, unclear to begin with wether it was an A&E problem, a psych problem, or both, poor hand-over to the day staff, inadequate level of observation, etc).

Incidentally, I would also commend the companion piece to Hassan's study - written by a barrister it follows on from where you first started this fascinating post.

"The law on managing patients who deliberately harm themselves and refuse treatment" (1999)
Barbara Hewson, barrister at law.


Hewson concludes, "Adults are presumed competent to refuse treatment, even in an emergency; but it is not easy to judge in practice what factors are capable of rebutting the presumption. Every case turns on its own facts. The detention of incompetent patients for treatment under a common law power of necessity is controversial, and likely to generate litigation under the Human Rights Act 1998".

I have searched but have yet to find a case against A&E staff for imposing treatment - if anybody has different information I would be very interested in seeing it.

Dr Grumble said...

Thanks, a&e charge nurse.

This is a passage that I think is of great relevance when somebody has decided to refuse treatment:

What matters is that the doctors should consider whether at that time he had a capacity which was commensurate with the gravity of the decision which he purported to make. The more serious the decision, the greater the capacity required.

This is, of course, exactly what we do in practice. If somebody refuses treatment and it is not that big a deal we take the view that a modicum of capacity is sufficient for us to happily go along with their wishes. But if they are making a decision that will likely result in their death we require a much greater degree of capacity.

I have to say that although I realise now that this is what we do all the time I had not quite appreciated that there are grades of capacity which need to be weighed against the gravity of the decision which is being made.

Witch Doctor said...

But I'll bet there's no guidance anywhere on grading capacity. Just as well really.

Dr Grumble said...

What you can conclude is that if somebody is set to refuse a treatment that will result in their death they must have the very highest level of capacity. Given the doubts raised by their turning up for treatment after poisoning themselves plus the likelihood that they are in some way mentally disturbed and the difficulties that might arise in assessing capacity when time is of the essence, it would seem that there is more room for manoeuvre than some would have you believe.

the a&e charge nurse said...

I think this case captures the concerns we as health professionals all share about making the right call when a patient refuses emergency treatment after a serious suicide attempt.

It seems a bit unfair to expect doctors to exercise the judgement of Solomon then be subject to criticism in the media, or threatened with legal action (as now rumoured in the Kerrie Wooltorton case) if ALL parties are not satisfied with the outcome.

As the old show biz saying goes - you can't please all of the people all of the time?

Dr Grumble said...

The safest default mode in the fog of the Emergency Dept is to save the life and worry about the consequences afterwards. Battery is a lesser crime than misinterpreting someone's wishes and allowing them to die as a result. In my book anyway.

That does not mean that I think that the system got it wrong in the Wooltorton case. I was not there. I do not know. But I would not like to see the effusive praise from the lawyers on the inaction of the doctors in this paricular case to colour the judgment of A&E staff when it comes to dealing with young girls who wish on the spur of the moment to kill themselves. We know that if you treat such individuals there may well be a happy outcome. The law really should recognise this. The best interests of the patient are what matters here not what the patient's own vacillating view happens to be at that moment.

We all need help, especially when young or otherwise mentally weakened, to make the right decisions for ourselves. There really is nothing wrong with a caring society doing that in this particular case.

I worries me that the people who tell us what to do on such matters have never seen the quirky reality of human behaviour seen on a daily basis in our A&E departments.

Dr No said...

WD - I think the grading of capacity is meant to be implicit in that the assessment is always time and situation specific: as in you might have capacity to decide not to brush your hair, but lack capacity to decide to sell your house.

I've spent a bit of time thinking about all this and posted my thoughts here (be warned, it's a long read!). In essence I suggest (a) there is a red line which doctors do not cross (b) doctors are not compelled to comply with verbal or written living wills in emergency situations (c) autonomy does trump life (sorry WD, but this is tentative - and there are precedents - so no spells please!) (d) a way through which allows doctors to act within their conscience.

The law over (b) could easily be resolved by inserting a clause in the MCA to the effect that the provisions of the Act over ADs do not apply in an emergency situation where time is of the essence (= death/serious harm will happen if action is not taken now).

Garth Marenghi said...

The law is an ass.

In the emergency situation I think one simply has to act first and ask questions later.

Whatever the ins and outs of the law in this complex area, it is a sad day when doctors cannot try to save life when they are in a bit of doubt as to whether the patient is competent and/or wishes to be treated.

Lawyers want things both ways, they want to generate work for themselves whatever they do.

Another big problem with advanced directives is to do with assessing competence at the time of signing the document and of fluctuating competence once the document has been signed.

The benefit of the doubt should always be given to the doctor who tries to save lives, it appears that the new laws erode this freedom of practice and that is bad for me, it is also bad for patients.