tag:blogger.com,1999:blog-25200961.post7103710290402423484..comments2024-03-14T09:50:40.819+00:00Comments on Dr Grumble: A flawed ActDr Grumblehttp://www.blogger.com/profile/04417731064007601504noreply@blogger.comBlogger92125tag:blogger.com,1999:blog-25200961.post-48166555889031530232009-10-22T17:47:35.452+01:002009-10-22T17:47:35.452+01:00The law is an ass.
In the emergency situation I t...The law is an ass.<br /><br />In the emergency situation I think one simply has to act first and ask questions later.<br /><br />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.<br /><br />Lawyers want things both ways, they want to generate work for themselves whatever they do. <br /><br />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.<br /><br />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.Garth Marenghihttps://www.blogger.com/profile/07373175498875348430noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-89411654826820210602009-10-06T15:28:24.818+01:002009-10-06T15:28:24.818+01:00WD - I think the grading of capacity is meant to b...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.<br /><br />I've spent a bit of time thinking about all this and posted my thoughts <a href="http://www.badmed.net/bad-medicine-blog/2009/10/playing-god.html" rel="nofollow">here</a> (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.<br /><br />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).Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-65433959513291483812009-10-06T09:56:21.512+01:002009-10-06T09:56:21.512+01:00The safest default mode in the fog of the Emergenc...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. <br /><br />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.<br /><br />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. <br /><br />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 Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-14440438326539760572009-10-06T08:54:42.110+01:002009-10-06T08:54:42.110+01:00I think this case captures the concerns we as heal...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.<br />http://www.telegraph.co.uk/health/5395232/Organ-donation-is-it-ever-right-not-to-save-a-life.html<br /><br />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.<br /><br />As the old show biz saying goes - you can't please all of the people all of the time?the a&e charge nursenoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-8998947616426341202009-10-06T06:42:50.603+01:002009-10-06T06:42:50.603+01:00What you can conclude is that if somebody is set t...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.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-60955892322216621132009-10-05T22:54:04.667+01:002009-10-05T22:54:04.667+01:00But I'll bet there's no guidance anywhere ...But I'll bet there's no guidance anywhere on grading capacity. Just as well really.Witch Doctorhttp://witchdoctor.wordpress.comnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-35657444004353198472009-10-05T21:24:44.418+01:002009-10-05T21:24:44.418+01:00Thanks, a&e charge nurse.
This is a passage t...Thanks, a&e charge nurse.<br /><br />This is a passage that I think is of great relevance when somebody has decided to refuse treatment:<br /><br /><i>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.</i><br /><br />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.<br /><br />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.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-74170380046140285072009-10-05T13:54:54.755+01:002009-10-05T13:54:54.755+01:00Eagle eyed as ever, Dr Grumble - yes, I flagged th...Eagle eyed as ever, Dr Grumble - yes, I flagged this article on Jobbing Doctor's site.<br /><br />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).<br /><br />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).<br /><br />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.<br /><br />"The law on managing patients who deliberately harm themselves and refuse treatment" (1999)<br />Barbara Hewson, barrister at law.<br /><br />http://ukpmc.ac.uk/articlerender.cgi?artid=425320<br /><br />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".<br /><br />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.the a&e charge nursenoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-71497977930859739622009-10-05T13:29:07.382+01:002009-10-05T13:29:07.382+01:00Well, let me add another interaction, Dr Grumble.
...Well, let me add another interaction, Dr Grumble.<br />*************<br /><br />I think we have broken the record number of comments already! But thanks, a&e charge nurse. <br /><br />I think you posted this on JD's blog. It is good to have the link here too.<br /><br />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. <br /><br />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.<br /><br />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.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-27800206292351274732009-10-05T12:29:52.272+01:002009-10-05T12:29:52.272+01:00If link not working google this BMJ item;
"M...If link not working google this BMJ item;<br /><br />"Managing patients with deliberate self harm who refuse treatment in the accident and emergency department".<br /><br />Failure to assess adequately a patient's capacity to refuse treatment may have serious medicolegal consequences<br /><br />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. <br /><br />Department of Accident and Emergency Medicine, Leicester Royal Infirmary NHS Trust, Leicester LE1 5WW<br /><br />Correspondence to: Dr Hassan tajhassan@yahoo.comthe a&e charge nursenoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-73310890533502133702009-10-05T12:09:56.780+01:002009-10-05T12:09:56.780+01:00Well, let me add another interaction, Dr Grumble.
...Well, let me add another interaction, Dr Grumble.<br /><br />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?<br /><br />Hassan's work 10 years earlier suggested that many doctors are ill-equipped to deal with non-consenting patients after a potentially fatal overdose.<br />http://www.bmj.com/cgi/content/extract/319/7202/107<br /><br />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.<br /><br />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 nursenoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-81138134752845744932009-10-05T07:59:15.314+01:002009-10-05T07:59:15.314+01:00I read a critique of this blog which said there wa...I read a critique of this blog which said there was not enough interaction. I don't agree!Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-71759341104749235712009-10-05T07:45:32.482+01:002009-10-05T07:45:32.482+01:00Everybody please calm down. No harm has been done...Everybody please calm down. No harm has been done.<br /><br />In the interests of peace I will delete the things that I spot that may be causing strife.<br /><br />We can all learn from this.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-25154854375339667942009-10-05T02:53:14.634+01:002009-10-05T02:53:14.634+01:00This comment has been removed by a blog administrator.Samnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-49416503596117968052009-10-05T01:19:21.742+01:002009-10-05T01:19:21.742+01:00I hadn't realised that.I hadn't realised that.Nuttynoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-81596028429397501782009-10-05T00:45:07.998+01:002009-10-05T00:45:07.998+01:00Over-rated , not widely available and uses a lot o...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-72019720119261781612009-10-05T00:02:16.664+01:002009-10-05T00:02:16.664+01:00DBT.DBT.Nuttynoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-57311179238037850812009-10-04T23:46:43.191+01:002009-10-04T23:46:43.191+01:00Can I just ask just what exactly the "useless...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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-12450927679242771882009-10-04T23:29:31.472+01:002009-10-04T23:29:31.472+01:00This comment has been removed by a blog administrator.Dr Nohttp://www.badmed.netnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-90081259655865413112009-10-04T22:53:33.267+01:002009-10-04T22:53:33.267+01:00This comment has been removed by a blog administrator.Samnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-89274017802080158942009-10-04T22:26:51.455+01:002009-10-04T22:26:51.455+01:00Perhaps the one I ask you to delete @ 21.34 and th...Perhaps the one I ask you to delete @ 21.34 and this one too, thank you Dr G :-)Samnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-16538036033190159052009-10-04T21:58:15.122+01:002009-10-04T21:58:15.122+01:00I have deleted some of your comments, Sam.
Let m...I have deleted some of your comments, Sam. <br /><br />Let me know if you think anything else needs to go.Dr Grumblehttps://www.blogger.com/profile/04417731064007601504noreply@blogger.comtag:blogger.com,1999:blog-25200961.post-60684723333895672222009-10-04T21:34:11.611+01:002009-10-04T21:34:11.611+01:00This comment has been removed by a blog administrator.Samnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-6219655080864304912009-10-04T20:53:15.919+01:002009-10-04T20:53:15.919+01:00One of the factors in this case, was the lack of t...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.<br />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.<br />Nutty, I hope things work out for you and thanks for coming on here.Juliehttp://juliemcanulty.blogspot.comnoreply@blogger.comtag:blogger.com,1999:blog-25200961.post-32300635944054187702009-10-04T20:21:27.042+01:002009-10-04T20:21:27.042+01:00Anon at 13:31: if you read Dr G's original pos...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.<br /><br />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.<br /><br />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". <br /><br />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.<br /><br />And I also know the people with BPD get a really bum deal in the NHS.<br /><br />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. <br /><br />———<br /><br />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.<br /><br />And Nutty, if you read this, thanks again for your input - it was much valued.Dr Nohttp://www.badmed.netnoreply@blogger.com