Endgames Case Report

Caring for a woman with intellectual disabilities who refuses clinical diagnostic investigations

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.f7645 (Published 03 January 2014) Cite this as: BMJ 2014;348:f7645
  1. Pauline Heslop, senior research fellow1,
  2. Anna Marriott, research fellow1,
  3. Matthew Hoghton, general practitioner12,
  4. Marcus Jepson, research fellow1,
  5. Antonia Noble, barrister3
  1. 1Norah Fry Research Centre, School for Policy Studies, University of Bristol, Bristol BS8 1TZ, UK
  2. 2Clevedon Riverside Group, Clevedon, UK
  3. 33 Lower Hampen Cottages, Cheltenham, UK
  1. Correspondence to: P Heslop Pauline.Heslop{at}bristol.ac.uk

A 56 year old woman with moderate intellectual disabilities who lived in a residential care home presented to her general practitioner with iron deficiency anaemia, weight loss, and dyspepsia. She had severe osteoarthritis of one hip as a consequence of untreated Perthes’ disease, which necessitated her using a wheelchair. Her vision was severely impaired and her speech was unclear. She was able to make day to day decisions about her choice of food and clothing but required a full assessment of her capacity to make more complex decisions. Her behaviour was described as “difficult” at times, and she had severe anxiety about medical consultations and interventions.

A “fast track” referral was made for an endoscopy, but she refused to attend. Two months later her haemoglobin had dropped to 68 g/L and faecal occult blood testing at that time was positive. She was referred for an ultrasound scan of her abdomen but again refused to attend.

Questions

  • 1 The Mental Capacity Act states a presumption of capacity unless proved otherwise. When people refuse examination or clinical diagnostic investigations, how should a doctor question the assumption of capacity?

  • 2 Everything that is done for (or on behalf of) a person who lacks capacity must be in that person’s best interests. What should a doctor consider when deciding what would be in this woman’s best interests?

  • 3 If a patient resists examination and treatment that has been agreed to be in his or her best interests, what should a doctor do, and what safeguards are available for the person?

  • 4 What two additional provisions were introduced by the Mental Capacity Act to protect vulnerable people and what are the implications for doctors?

Answers

1 The Mental Capacity Act states a presumption of capacity unless proved otherwise. When people refuse examination or clinical diagnostic investigations, how should a doctor question the assumption of capacity?

Short answer

The Mental Capacity Act 2005 requires the doctor to conduct a two stage functional assessment of capacity regarding consent to the examination …

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