1. AMC Jan 2010 Your next patient needs treatment but Refuses to Travel

2. AMC Jan 2010 Objectives Recognise a patients right to refuse treatment Express what is mental capacity /incapacity Reinforce the decision making process utilising a simple Mental Capacity flow chart Clarify what is acting in a patients Best Interests Identify what is classed as an Emergency Situation Clarify the rationale around Restraint of a patient Clarify the types of Restraint

3. AMC Jan 2010 Patient Decision Not To Travel To Treatment Centre “When a patient refuses hospital treatment, the first fundamental question to be answered is that of whether the patient is mentally competent to make the decision to consent or refuse treatment”.

4. AMC Jan 2010 Capacity If a patient has the capacity to consent or refuse treatment, then the patient’s wishes must be respected, and he/she should not be transported to hospital. What is Mental Capacity?

5. AMC Jan 2010 What is lack of Capacity MCA says in 3(1)….a person is unable to make a decision for himself if he is unable: a)to understand the information relevant to the decision b)to retain that information c)to use or weigh that information as part of the process of making that decision, or d)to communicate his decision (whether by talking, using sign language or any other means).

6. AMC Jan 2010 Assessing Capacity Is there an impairment or disturbance in the functioning of mind or brain? (permanent or temporary). NO YES Impairment is not present, record refusal and arrange safety netting, the patient is deemed capable With all possible help given is the person able to understand the Information relevant to the decision? Lacks capacity Has capacity Are they able to retain the information long enough to make the decision? Are they able to weigh the information as part of the decision making process? Are they able to communicate the decision? or YES NO If the answer to 1. is YES and the answer to any of 2. is NO then the person lacks capacity under the Mental Capacity Act 2005. 1 2

7. AMC Jan 2010 Best Interests If the patient is not able to consent or refuse treatment, there is a duty to treat the patient in his/her own best interests. You must: involve the person who lacks capacity have regard for past and present wishes and feelings, especially written statements consult with others who are involved in their care there can be no discrimination

8. AMC Jan 2010 Emergency Situations Act allows care and treatment to be given as almost always in the persons best interests to give urgent treatment without delay Exception: when the person giving treatment is satisfied an advance decision to refuse treatment exists All staff involved in the care/treatment of a person who may lack capacity should record (PRF) why they had a ‘reasonable belief’ and how they determined ‘best interests’ decision making.

9. AMC Jan 2010 Group Task Break into three groups Discuss your management of the patient Feedback the group decision and justify 10 minutes

10. AMC Jan 2010 Scenario – Bess Bess is a 78 yr old widow who lives with her son and daughter in law. Bess has dementia, is hard of hearing and her ability to understand information varies day to day. In the last 2 weeks Bess has collapsed twice. GP thinks she may need a pacemaker so refers to a cardiologist for an assessment. On the day of the appointment you arrive to collect Bess, who insists that she has now recovered, doesn’t need any treatment and refuses to get into the ambulance.. What should the ambulance crew do? Discuss…..

11. AMC Jan 2010 Restraint Staff will be protected from liability if they: Reasonably believe the person lacks capacity That it needs to be done in their best interests That it is necessary to protect them from harm It must be proportionate and reasonable Consider: S135/6 Mental Health Act for removal to a Place of Safety

12. AMC Jan 2010 Types of Restraint Restraint can be overt: Wrapping in a blanket Straps on carry chairs and stretchers Restraint can be physical / mechanical: Held by one or more persons Use of equipment / withdrawing aids (zimmer) Restraint can be chemical: Medication /sedation Restraint can be psychological: Stating patient not allowed to do something

13. AMC Jan 2010 Any Questions

14. AMC Jan 2010 Summary A patient may not always need transportation Decisions not to transport must be supported by a full assessment and adequate safety netting Assessments of capacity and consent must form part of that assessment and be documented Decisions to act in the patients Best Interests must be documented In emergency situations act in ‘reasonable belief’ Common Law allows restraint to ‘prevent harm’

15. AMC Jan 2010 References Department of Health (2005). Mental Capacity Act 2005. London DOH. Department of Health (2008). Mental Health Act 2007. London. DOH. The Mental Health Act On-Line. Available at: http://www.markwalton.net/guidemha/index.asp. Accessed 15/01/2010. http://www.markwalton.net/guidemha/index.asp. Accessed 15/01/2010 The ‘Assessing Capacity’ Flow chart is based on a document produced by Hampshire County Council Adult Services Department. Assessment of Capabilities and Best Interests Decision Making.(2008) Managing the Psychotic Patient (2008) L. Lipton. Available at: www.emsresponder.com/article/article.jsp. Accessed 16 Jan 2010. www.emsresponder.com/article/article.jsp Hassan TB, MacNamara AF, Davy A, Bing A, Bodiwala GG. (1999) Managing patients with deliberate self harm who refuse treatment in the accident and emergency department. BMJ. 319:107–109. Stephenson.C; Baskind.R & Harris.C (2009). Transfer to hospital under the Mental Capacity Act 2005. Available from: www.rcpsych.ac.uk/publications/journals/pbinfo.www.rcpsych.ac.uk/publications/journals/pbinfo

16. AMC Jan 2010 Resources Advance Decisions to Refuse Treatment (ADRT) Modular Training Programme is available on website: www.adrtnhs.co.uk/. Mental Capacity Act Modular training Programme is available on website: www.kwango.com/derbsmcalogin. User name: Emas Password: beechdalewww.kwango.com/derbsmcalogin The full text of the Mental Capacity Act and the Code of Practice is available on website address: www.dca.gov.uk/legal-policy/mental-capacity