Dr Colin Campbell Palliative Medicine Consultant Saint Catherine’s Hospice, Scarborough

1. Dr Colin CampbellPalliative Medicine ConsultantSaint Catherine’s Hospice, Scarborough Mental Capacity Act (2005) …..so give us an example from real life! Saint Catherine's Hospice, Scarborough

2. Listen to me!! Saint Catherine's Hospice, Scarborough

3. Advance Decisions Saint Catherine's Hospice, Scarborough

4. What life-prolonging treatments? • Antibiotics for life-threatening infections • Haemodialysis • Artificial ventilation • Artificial nutrition and hydration • Surgery? Chemotherapy? Saint Catherine's Hospice, Scarborough

5. George Sampson A 39 year old man with Down’s syndrome who lives with his elderly parents. One year ago, he was diagnosed with a carcinoma of the sigmoid colon. A CT scan at the time had suggested a Duke’s C carcinoma (invading through the wall of the bowel to the adjacent lymph nodes, but with no distant metastases). Saint Catherine's Hospice, Scarborough

6. So what did George do? He vigorously rejected having a stoma or indeed any kind of surgery. He started chemotherapy but abandoned this after one cycle because he didn’t like needles. He had to give up his job as a cleaner in a local warehouse. He gets continuous pain in his side. His father says George is terrified of dying. Saint Catherine's Hospice, Scarborough

7. George becomes acutely unwell…. Over the last few days he has become less well with nausea, drowsiness, and he is noted to be passing less urine. He doesn’t know where he is and becomes worried that he may be late for work. Saint Catherine's Hospice, Scarborough

8. George is ominously unwell Blood tests show acute renal failure, and an ultrasound of his renal tract confirms that tumour has obstructed both ureters. There is the option of having a life-prolonging nephrostomy fitted. Without this he will die in the next 1 to 2 weeks. Saint Catherine's Hospice, Scarborough

9. No 1: Capacity!!! How would you assess George’s capacity to decide whether he should have a nephrostomy? Saint Catherine's Hospice, Scarborough

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

11. Capacity George is examined and found not to have capacity for this particular decision (nephrostomy) Saint Catherine's Hospice, Scarborough

12. …..views of those close to George His mother says she is in favour of “letting nature take its course” She says: “My son has had a long hard fight, and he’s suffered enough.” Saint Catherine's Hospice, Scarborough

13. If George does not have capacity to consent to this treatment –whose responsibility is it? Saint Catherine's Hospice, Scarborough

14. No 2: Weigh up benefits and problems of proposed treatment What are the benefits and problems for George in: -having a nephrostomy fitted? -not having a nephrostomy fitted? Saint Catherine's Hospice, Scarborough

15. No 3: Look for Advance Decisions and LPAs George has conferred Lasting Power of Attorney (LPA) on his father to act in his best interests, and this includes decisions involving his future medical care. What would you need to do before accepting the LPA in this particular situation? Saint Catherine's Hospice, Scarborough

16. Lasting Power of Attorney George’s father says everything possible should be done to keep his son alive. He’s had to fight for George all his life and feels that he’s faced prejudice from doctors because of his mental deficiency. Saint Catherine's Hospice, Scarborough

17. No 4:Act in patient’s “best interests” Bearing in mind the requirements of the Mental Capacity Act (2005) how do you act in George’s best interests? Saint Catherine's Hospice, Scarborough

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

19. Brief take home points • Must assess patient’s capacity first • Weigh up benefits and risks and burdens of proposed treatment • Look for • Advance Decisions • Lasting Power of Attorney Saint Catherine's Hospice, Scarborough

20. Brief take home points 4. Must act in patient’s best interests • Take into account all relevant factors • Relatives cannot give/withhold consent but may know what the patient might have wanted • May need to appoint an IMCA Saint Catherine's Hospice, Scarborough