tag:blogger.com,1999:blog-25200961.post6535532680670058181..comments2024-03-14T09:50:40.819+00:00Comments on Dr Grumble: Any clinician will tell youDr Grumblehttp://www.blogger.com/profile/04417731064007601504noreply@blogger.comBlogger60125tag:blogger.com,1999:blog-25200961.post-76886279261031409222010-01-31T07:11:41.498+00:002010-01-31T07:11:41.498+00:00Thank you, Kiwi Survivor. You have put your point ...Thank you, Kiwi Survivor. You have put your point very well.Dr Grumblehttps://www.blogger.com/profile/02459592334604944530noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-86924481261345096912010-01-31T06:45:30.131+00:002010-01-31T06:45:30.131+00:00I have visited A&E more times than I can remem...I have visited A&E more times than I can remember (literally - I gave myself short-term memory loss) for overdoses. At the time, I wanted to die more than anything else in the world. I have enough reason - I was abused as a child and abandoned - but even when I pleaded with the staff to just let me die, they still saved me. And I believe they were right. I was screaming for help; I just didn't know it at the time. The fact that the help hardly ever appeared is a subject for another time.<br /><br />I believe that if I had truly wanted to die, subconsciously as well as consciously, I would have chosen something more reliable and permanent. Walk in front of a train or something. But I didn't, and really all I wanted was for the pain to go away, not the world.<br /><br />For goodness' sake, she called an ambulance. She was imposing her fate on the conscence of others, which is brutally unfair. The natural instinct of the human being is to do all in their power to save another in distress, and her survival was predicated on this instinct. Perhaps she was even relying on it, as her illness twisted her in ever more complicated knots. I cannot place any blame upon those who attended her, because they were put in an untenable position. But I also think that if someone who had been in her position was in attendance, they would have made the decision to save her. I would.Kiwi Survivornoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-54925469856619873762009-12-19T15:25:53.327+00:002009-12-19T15:25:53.327+00:00If the coroner and the court had come out at the e...If the coroner and the court had come out at the end of their deliberations and said, 'The clinicians misinterpreted the intentions of the MCA, for which we do not blame them, but we do not want this to occur again and make it clear that the MCA cannot be used like this,' then I would feel a lot easier about this. OR if they had said, 'The clinicians should have used the Mental Health Act in this case rather than the MCA,' then I wouldn't have a problem. It's the fact that the coroner and the court have said that that the clinicians took the correct decision that bothers me. It implies that the MCA a) was the correct act to use b)that the correct conclusion was reached using it. I really wish I could see a transcript of the judgement somewhere; it would help. But not even that's available and in such a vital case as well.Juliehttps://www.blogger.com/profile/10556587747031166439noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-92180849284793589852009-12-19T15:22:44.079+00:002009-12-19T15:22:44.079+00:00" is it bad law or bad interpretation of the ..." is it bad law or bad interpretation of the law?"<br /><br />Both, because a law that allows itself to be misinterpreted is flawed<br /><br />And I agree with you anonymous, this young woman had no capacity to decide nor would she have gone to hospital if she really wanted to die<br /><br />Hence, if she would have been treated and her life was saved had their been no Capacity Act 2005, then that act is, again, flawed because laws are not made to harm but to protect from harm ... this act just did the opposite.<br /><br />(Allowing a terminally ill patient to choose to die is still protecting that individual from harm, in the form of having to endure extreme suffering and pain if not allowed the choice, while in this case this senario did not exist)Samhttps://www.blogger.com/profile/09558370387772079822noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-55257110164532684752009-12-19T14:27:41.106+00:002009-12-19T14:27:41.106+00:00My feeling is that the law pushed the doctors in t...My feeling is that the law pushed the doctors in the KW case into allowing Kerrie to die. The hospital's solicitors were involved and we know that there are many lawyers who take the view that legally the management of the case was correct.<br /><br />Her life had been saved nine times in the previous year. What had changed in that time? It was the introduction of the Mental Capacity Act which enabled the hospital solicitors to read across from statutes when previously they would have been reliant on much vaguer case law - which would probably have meant that doctors wouldn't even have consulted the lawyers.<br /><br />According to the Telegraph: "Experts said that before the new laws came in, doctors faced with a similar case to Miss Wooltorton’s would have been likely to insist the patient be treated."<br /><br />If that is the case the law is surely a bad one. But is it bad law or bad interpretation of the law? If KW had really wanted to die does it really make sense that she appeared in the hospital - as she had done on every one of the nine previous occasions when she was treated? Nobody in their right mind would go to hospital if they didn't want treatment. Which means that KW was not in her right mind. In other words there must have been enough doubt about KW's capacity to have permitted her treatment. This should have been apparent to both the lawyers and the doctors involved in the decision making.<br /><br />The problem was caused by a new law which was poorly interpreted.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-61491249937567793512009-12-19T11:49:23.773+00:002009-12-19T11:49:23.773+00:00Shrink - Sam makes a good point, and one that Dr N...Shrink - Sam makes a good point, and one that Dr No and Witch Doctor (sadly currently not with us) would agree with: some people cannot be trusted. That is the lesson of history.<br /><br />I have always felt (this is no criticism, just observation) that you are of the Julian of Norwich (!ironic) way - eg your "About Me":<br /><br /><em>I work with fantastic people. All is well with the world, in my wee corner of it. I am happy.</em><br /><br />The trouble is that there are other wee corners, where things are not so well...<br /><br />I don't think (as yet) you have expressed a view on how you would manage a patient like KW. It would be very interesting to hear what your approach would be!Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-89203779878794208212009-12-19T11:35:35.042+00:002009-12-19T11:35:35.042+00:00"The law supports good practice, rather than ..."The law supports good practice, rather than clinical care being compromised to support direction of a rigid law.<br /><br />Clinicans get to work as they wish, the law supports a range of sensible parctice (rather than directing one absolute How It Shalt Be) and everyone can win.<br /><br />I like it."<br /><br />You're taking the argument back to square one The Shrink! This is what this whole debate is about; this law allowed room for manouver which led to the death of a physically healthy 26 year old 'In Hospital' while the doctors who could have saved her life stood by and allow it to happen!<br /><br />When things like that happen, one understands why laws 'have to be' rigid when it comes to matters of life and death; because while you may act sensibly, others won't<br /><br />This law is flawed! Big time!Samhttps://www.blogger.com/profile/09558370387772079822noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-49458558387907004162009-12-19T00:54:00.556+00:002009-12-19T00:54:00.556+00:00I think there's too much choice in the MCA, Sh...I think there's too much choice in the MCA, Shrink.<br /><br />If they had opted to keep KW alive, that probably would have been allowed. But they chose to let her die and that was also allowed and judged as a correct decision.<br /><br />What bothers me is how much of this decision was due to management being fed up with a regular self harmer clogging up A&E. If this had been KW's first time in A&E, would they have stood back and let her die? I'm not sure that they would.<br /><br />Ironically, it's the one 'inflexible' feature in the MCA that led to all the confusion. ADs now have a statutory, rather than an advisory status, and at the time, the discussion was round whether KW's note was an AD or not. It wasn't, and it may be in future that it will not carry this kind of weight; on the other hand it may fall under 'patients wishes and feelings'.Juliehttp://juliemcanulty.blogspot.comnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-19744786679551942802009-12-18T19:10:07.729+00:002009-12-18T19:10:07.729+00:00A&E Charge Nurse, in the KW case they chose to...A&E Charge Nurse, in the KW case they chose to do things in a certain way. I'd suggest that they could have done things differently, but still been congruent with the MCA 2005. Practice can be supported by the MCA 2005, rather than the MCA 2005 directing specific decisions/outcomes on specific issues of clinical care.<br /><br />It's a grey area, healthcare professionals are used to living with uncertainty (in diagnosis, prognosis and most elements of practice) so it's not too challenging to formultate (and consequently frame things) in the way you'd wish, that's in your patient's best interests.The Shrinkhttps://www.blogger.com/profile/10009039342346247138noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-78299132871705811662009-12-18T18:33:04.297+00:002009-12-18T18:33:04.297+00:00A&E Charge Nurse - "Basing life and death...A&E Charge Nurse - "Basing life and death decisions on such a narrow time frame seems to be a dangerous flaw within the MCA " - I agree - it is but a snapshot. Hence my suggestion (back on BadMed) that the answer might be an additional test in the case of life-threatening refusals to establish that the decision is a settled decision, and not a whim of the moment. I can also see other advantages to adding such a test in such cases...Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-21905809181650894002009-12-18T18:07:08.451+00:002009-12-18T18:07:08.451+00:00"Clinicans get to work as they wish".
W..."Clinicans get to work as they wish".<br /><br />Was this really true of the doctors in the KW case, Shrink?<br /><br />Having listened in detail to the views of Dr No & Dr Grumble it seems to me they are both arguing that the issue of imposing, or not imposing treatment (following assessment of capacity) is based on too narrow a time frame?<br /><br />Put simply experience tells us time and time again that a significant number of patients change their minds (about wanting to commit suicide) and are grateful that they have been supported by medical staff during a crises (even if medical staff have behaved paternalistically).<br /><br />Basing life and death decisions on such a narrow time frame seems to be a dangerous flaw within the MCA and one that contributed toward the death of a young woman like KW?the a&e charge nursenoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-21105734158134392552009-12-18T16:33:02.541+00:002009-12-18T16:33:02.541+00:00"I think the trouble with the MCA is that you..."<i>I think the trouble with the MCA is that you can interpret it any way you please.</i>" - Julie<br /><br />"<i>I agree it's grey: but that is what we need. Strict rules aways fail because there is always the exception that breaks the rule.</i>" - Dr No<br /><br />That's why I like it. You can apply a common sense approach, interpreted in a range of ways, that's congruent with the MCA 2005, so your practice is lawful.<br /><br />The law supports good practice, rather than clinical care being compromised to support direction of a rigid law.<br /><br />Clinicans get to work as they wish, the law supports a range of sensible parctice (rather than directing one absolute How It Shalt Be) and everyone can win.<br /><br />I like it.The Shrinkhttps://www.blogger.com/profile/10009039342346247138noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-21545719803984422062009-12-18T13:09:13.712+00:002009-12-18T13:09:13.712+00:00Having furthered reviewed the BMJ's Rapid Resp...Having furthered reviewed the BMJ's Rapid Responses linked to above, and the cases mentioned above, I continue to think that where there is uncertainty (ie where we do not have an obviously sane and capacitous individual with a settled intent to commit suicide); the balance swings in favour of treatment.<br /><br />While it is true the courts have decided both ways (which in and of itself strongly suggests the matter is not settled), there is a bias in favour of treatment. Even the notable well known exception - Re C (Adult: Refusal of Treatment) ([1994] 1 WLR 290) - was grey: part of the patient's delusional system had him as a great doctor competent to make his own decsions...<br /><br />My earlier comment (16:20 yesterday) was carefully worded: can, not must; could, not should. These areas are so grey that there needs to be room for the individual discretion of the doctor at the bedside. An absolute, definitive legal answer to all cases is too rigid (hard cases make bad law - although for doctors it is ironically the probably the other way round - hard cases make better medicine - because we can learn from them).<br /><br />Section 63 of the MHA (as amended) reads:<br /><br />63 Treatment not requiring consent <br /><br />The consent of a patient shall not be required for any medical treatment given to him for the mental disorder from which he is suffering, not being a form of treatment to which section 57, 58 or 58A above applies, if the treatment is given by or under the direction of the approved clinician in charge of the treatment. (S57/58 being drastic treatment that requires a second opinion)<br /><br />The key point is what constitutes the borders of "the medical disorder from which he is suffering"? It can - and has - been argued that a physical condition that causes of results from the mental disorder is part of that disorder. I fully appreciate this is all semantics - but it is that semantic laxity that allows us to act.<br /><br />A couple of quotes from the Rapid Responses sum up what I believe to be the common - and correct - medical opinion:<br /><br />"However, it would be the worst sort of defensive medicine to fail to provide the life-saving treatment that is a distressed young woman’s human right, because of a fear of the remote possibility of falling foul of the law of battery."<br /><br />"The way I teach it to my trainees is as follows: I would rather be sued for battery than for wrongful death."<br /><br />Dr Curtis's stringent assertions are the exception, not the rule.<br /><br />Another interesting point is made by a philosopher/lawyer (where are the sensible ones this time round?):<br /><br />"...one cannot safely move from the fact that X insists that she wants to die and/or the fact that she refuses treatment which would thwart her (alleged) desire, to the conclusion that X does genuinely want to kill herself and/or that she did intend to kill herself by means of the overdose. She might have intended any number of things...It is difficult to accept that anyone genuinely wanting to commit suicide - which, again, is not the same as genuinely 'wanting to die/be dead' - would run the risk of frustrating that objective by putting himself in arm's reach of nurses and doctors..."<br /><br />Again - the uncertainty dominates.<br /><br />These Rapid Responses were posted a decade ago. It seems a pity we haven't really moved on very much - apart from getting to the point where a woman in her twenties was allowed to die...Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-55230251155555245632009-12-17T22:58:28.931+00:002009-12-17T22:58:28.931+00:00I agree it's grey: but that is what we need. S...I agree it's grey: but that is what we need. Strict rules aways fail because there is always the exception that breaks the rule.<br /><br />What we have here is an argument between state rules (law) and professional discretion. When I take my overdose, I hope I will be managed by a discrete profession, and not by a government rule.Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-63405564694396642192009-12-17T22:20:40.153+00:002009-12-17T22:20:40.153+00:00" ......... you can treat a physical disorder..." ......... you can treat a physical disorder under the MHA as long as it is related to the mental disorder that is causing the detention".<br /><br />Yes and no, Dr No - according to one consultant, psychiatrist, Dr Curtis, " .......an overdose is not a symptom of mental disorder, but a consequence of mental disorder. The Mental Health Act allows one to treat the causes (e.g. thyrotoxicosis) and symptoms of mental disorder. The latest edition of the Code of Practice makes this very explicit, and recommends that if there is doubt legal advice should be sought".<br /><br />There is a fascinating debate on this topic here;<br />http://www.bmj.com/cgi/eletters/319/7202/107<br /><br />x3 cases are sometimes cited to illustrate these complexities;<br />i. In addition to B v Croydon HA ([1995] Fam 133), which is mentioned by Mumford & Mumford (11 July 1999), there are at least three cases which bear upon Hassan et al's well-constructed hypothetical scenario. The solution to the problem, however, seems to require that we do not overlook how the circumstances of Hassan et al's would-be suicide differ from those of the patients in some of the best-known and most important consent cases.<br /><br />Re C (Adult: Refusal of Treatment) ([1994] 1 WLR 290) concerned a patient who was diagnosed as a paranoid schizophrenic. C, who was a diabetic, developed gangrene in his foot, but refused to consent to amputation. Was his refusal 'valid'? If C lacked sufficient capacity to make a genuinely autonomous decision, then nonconsentual treatment would not have been unlawful. Why? Because the doctors could justify their otherwise unlawful touching in terms of acting in the patient's best interests, consistent with Hunter/Bolam principles. As it happened, the court found that C was capable of making a meaningful judgement about this aspect of his medical care. Treatment in defiance of his competent refusal would have attracted liability.<br /><br />Re W (A Minor) (Medical Treatment: Court's Jurisdiction) ([1993] Fam 64) centred on the fate of an anorexic 16-year-old female, who refused attempts to feed her, and who failed to be persuaded that relocation to a specialist hospital would be to her benefit. The court in this case held that the disorder in question significantly diminishes capacity for rational choice - i.e., such acute, transient diminution of the capacity for genuinely autonomous decision-making is 'part of the condition of anorexia nervosa itself' (Davies M 1998 Textbook on Medical Law, 2nd ed., London: Blackstone Press, p.136), and force-feeding is in such cases an ineliminable (if unfortunate) part of autonomy-restoration treatment. In any case, the immanent threat to her health and life - and her diminished capacity for informed choosing - meant that the imposition of such treatment as was indicated was not unlawful, even in the absence of her consent.<br /><br />St George's Healthcare NHS Trust v S (1998) (The Times Law Report 8 May 1998) required the courts to face squarely the issue of a refusal to undergo a caesarean section, where this was clearly indicated (foetal/maternal life was at risk). Despite her protests (S insisted upon a vaginal delivery - preferably in a barn in Wales) S was sectioned under the Mental Health Act 1983, and the caesarean was carried out.the a&e charge nursenoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-18080569759303884512009-12-17T16:20:06.960+00:002009-12-17T16:20:06.960+00:00Julie - you can treat a physical disorder under th...Julie - you can treat a physical disorder under the MHA as long as it is related to the mental disorder that is causing the detention. So - if KW had been detained, then the MHA could have allowed treatment of her self-poisoning which arose from her mental disorder. If she was not detainable, then she could not have been treated under the MHA. The relevant section is S63.<br /><br />The other things is that if either act might apply, then the MHA normally trumps the MCA.Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-41112926704325844102009-12-17T15:03:06.840+00:002009-12-17T15:03:06.840+00:00I think the trouble with the MCA is that you can i...I think the trouble with the MCA is that you can interpret it any way you please. On the one hand, you could say that KW didn't have a valid AD and so you act in the 'best interest' of the patient and treat. Or you take the view that 'because a patient makes an unwise decision does not make it an invalid one' and as she has asked for treatment to be withheld, you follow that. Either decision is equally valid under the MCA and that is bad law.<br /><br />One thing that I did not realise, is that the reason that KW was not treated under the Mental Health Act, was because the condition that was to be treated was a physical one (the effects from the overdose). This meant that it had to be dealt with under the MCA, even although it was KW's mental condition that led to the overdose. This is important, because under the MHA you can give treatment against the will of the patient; under the MCA you cannot. I think the MCA needs to go back to Parliament for amendment. Some of the everyday stuff re consent is ok, but on matters such as this it's confused and unclear.Juliehttp://juliemcanulty.blogspot.comnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-15301549315799164152009-12-17T12:46:00.114+00:002009-12-17T12:46:00.114+00:00There is an excellent comment here by the Shrink. ...There is an excellent comment <a href="http://www.badmed.net/bad-medicine-blog/2009/12/human-frailty.html#comment-290" rel="nofollow">here</a> by the Shrink. His essential point is that the Mental Capacity Act is a good act and the problems are with its interpretation. Dr No essentially agrees. And so does Dr Grumble.<br /><br />Given how common it is to find oneself dealing with somebody who wants to kill themselves it is disappointing that this situation is not one of the examples explicitly dealt with in the Code of Practice. The Code does suggest that someone being suicidal raises questions about their capacity but against this we have lawyers and coroners and ethicists praising doctors for their approach in the KW case which superficially appears somewhat similar to the everyday cases we see in the Emergency Department.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-14283238011338943442009-12-17T02:54:04.038+00:002009-12-17T02:54:04.038+00:00'Only reasonable if you've decided that ou...'Only reasonable if you've decided that outcomes of a certain sort are the parameter by which moral decisions ought to be judged. If you don't accept that, then you'll disagree. So there's a metaethical dispute at the core of things here - one to do with whether the consequentialists or the non-cons have got their moral theory right. And to settle that, you can't go pointing to the consequences in a given situation without begging the question.'<br /><br />Ah, I see we're onto dear old Euthyphro or a variation of it anyway.<br /><br />'Is the pious loved by the gods because it is pious, or is it pious because it is loved by the gods?'<br /><br />Or to put it in the terms of this argument 'Is a judgement approved by law because it is moral, or is it moral because it is approved by the law?'<br /><br />If you take the view that judgements are moral because they are approved by the law/ethicists/whatever, then Dr No is indeed begging the question, as are you. In such a situation, there is no such thing as right or wrong; only the majority opinion. If on the other hand you take the view that there is such a thing as right and wrong regardless of what is in fashion, then Dr No is not begging the question; he has simply decided that the law is an ass and stuck to the more reliable principle of 'First do no harm.'<br /><br />Underpinning your argument Enzyme, is a tacit assumption that objectivity is 'right' and subjectivity is 'wrong'. I think you should examine that assumption. It is possible to be 'objective' in a discussion such as this. It is not possible to be 'objective' in the real world; a decision has to be taken one way or the other. Life is subjective and as we say in Scotland, 'Things maun be some wey'.<br /><br /><br />'metaethical'<br /><br />I'll use that as my 'am I pissed' test next time I've had too much...Juliehttp://juliemcanulty.blogspot.comnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-28568532547946995862009-12-16T23:04:32.627+00:002009-12-16T23:04:32.627+00:00Enzyme commented as I was writing one. Julie's...Enzyme commented as I was writing one. Julie's "Dr No's critisism of deontology boils down to; 'Deontology is not flexible enough to deal with the variety of situations that cross our path and can end up leaving a 26 year old dead.'" is 100% right. Dr No has always distrusted rules (and so deontology) for 1001 reasons (not least the one of who makes the rules) but the clincher for Dr No is deontology is first cousin to Nazism. Once rules matter more than people, and what happens to people, then anything goes.<br /><br />Achtung!Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-76789173399903629452009-12-16T20:38:32.680+00:002009-12-16T20:38:32.680+00:00Anon - interesting that the idea of "disposit...Anon - interesting that the idea of "dispositional autonomy" is already out there. But I can see it stumbling a bit when the dispositional clashes with the current autonomous choice unless one bites the bullet and accepts that autonomy is not always aligned with best interests.<br /><br />What would I change? I've written a reply to a comment on my blog that <a href="http://www.badmed.net/bad-medicine-blog/2009/12/human-frailty.html#comment-291" rel="nofollow">covers this in more detail</a>, but in essence my view is that when the capcitous individual refuses treatment and in so doing is likely to lead to their death then there needs to be an additional test that shows that their descision is a <em>settled</em> decision.Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-32367128069322421272009-12-16T20:28:37.191+00:002009-12-16T20:28:37.191+00:00Julie - Only reasonable if you've decided that...Julie - Only reasonable if you've decided that outcomes of a certain sort are the parameter by which moral decisions ought to be judged. If you don't accept that, then you'll disagree. So there's a metaethical dispute at the core of things here - one to do with whether the consequentialists or the non-cons have got their moral theory right. And to settle that, you can't go pointing to the consequences in a given situation without begging the question.Enzymehttps://www.blogger.com/profile/05832199852295429281noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-91304193404911080422009-12-15T22:21:58.578+00:002009-12-15T22:21:58.578+00:00Excellent reply you have linked to, Dr No. It brin...Excellent reply you have linked to, Dr No. It brings up the concept of 'dispositional autonomy' which is an attempt to look at the previously stated wishes of someone when they are unable to currently make a decision - looking at their overall 'life direction' / goals / etc. This concept can and should be used in these situations and I think does have some ethically justifiable weight behind it. Agree the law is fine superficially but (being a deontological construct) falls down in these difficult situations. On the other hand, what would you change it to? Hard cases make bad law and all that....Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-23317282579431635612009-12-15T20:47:21.955+00:002009-12-15T20:47:21.955+00:00My latest reply to Enzyme became more a post in it...My latest reply to Enzyme became more a post in its own right - so have posted it <a href="http://www.badmed.net/bad-medicine-blog/2009/12/human-frailty.html" rel="nofollow">here</a>. It is the best I can do to show <em>how and why</em> the MCA is fails - and so how and why those who seek its shelter have got it wrong.Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-62110028490122530462009-12-15T11:32:24.632+00:002009-12-15T11:32:24.632+00:00The bottom line, Enzyme, is that doctors and nurse...The bottom line, Enzyme, is that doctors and nurses (in the main) have great difficulty standing by while a patient in crises tries to kill themselves.<br /><br />For this reason we will look for a set of principles (or philosophical theory) supporting our position.<br />The 'best interest' paradigm is an extremely useful framework in my opinion.<br />http://www.ethics-network.org.uk/educational-resources/mental-capacity-act-2005/best-interests<br /><br />Personally I think it is difficult (if not impossible) to PROVE with absolute certainty in every case that a patient, by virtue of being in a 'crises', was not overwhelmed, at least temporarily, thus impairing capacity?<br /><br />Surely if there is doubt we must act in the best interest of the patient - in A&E we have no more than 4 hours to address these delicate issues.the a&e charge nursenoreply@blogger.com