Anthony David and colleagues' article (1) rose to find clarity and
debates on this interesting dilemma of the balancing act for a clinician
which attract our attention due to its relevance to our work.
Ms Wooltornton's death in 2007 attracted press coverage (2-3) and led
presentation of her case in our local peer discussion group attended by
both psychiatric consultants and junior psychiatric trainees. It led to a
heated debate with seniors opting for the use of Mental Capacity Act,
Mental Health Act or respecting the patient's wishes. This discussion
instead of reassurance led to our feelings even more apprehensive about
decision making, being in practice the first port of call for the second
opinion regarding capacity during the out of hours A&E work.
The sticking feature was that there was no consensus on the approach among
clinicians. This situation is common, especially when the patient is under
the influence of alcohol and the situation is well dealt by our colleagues
in the accident and emergency department.
We would also like to draw the attention to the 16-18 year olds who at
time pose a greater challenge, and was rather surprised not to see a
mention of them in David et al's article. Mental capacity act is
applicable to young people over 16 years of age (4). This is specially so
when it comes to declining interventions and in emergencies. Although all
people aged 16 and over are presumed in law to have the capacity to
consent to treatment unless there is evidence to the contrary. A child
aged 16-18 cannot refuse treatment if it has been agreed by a person with
parental responsibility or the Court, and it is in their best interests
this is according to the children's act 1989 amended in 2004, which
provides a legislative spine for the wider strategy for improving
children's lives. This covers the universal services which every child
accesses, and more targeted services for those with additional needs (5).
At times these matters end up with the courts which can over ride the
child or the parent. Therefore they do not have the same status as adults
and needs a more measured approach. The clinicians' agreement with the
person with parental responsibility could have an impact on the
therapeutic relationship and future engagement with the professionals.
We think that the best way to deal the situation is to discuss the issue
with both the A&E and the Psychiatric consultants on call and always to
err on the side of caution and to take legal advice in these grey areas.
When in doubt, it is better to treat the patient and act in their best
interst.
References:
1. David AS, Hotopf M, Moran P, Owen G, Szmukler G, Richardson G.
Mentally disordered or lacking capacity? Lessons for management of serious
deliberate self harm. BMJ 2010;341:c4489
Rapid Response:
The balancing act?
Anthony David and colleagues' article (1) rose to find clarity and
debates on this interesting dilemma of the balancing act for a clinician
which attract our attention due to its relevance to our work.
Ms Wooltornton's death in 2007 attracted press coverage (2-3) and led
presentation of her case in our local peer discussion group attended by
both psychiatric consultants and junior psychiatric trainees. It led to a
heated debate with seniors opting for the use of Mental Capacity Act,
Mental Health Act or respecting the patient's wishes. This discussion
instead of reassurance led to our feelings even more apprehensive about
decision making, being in practice the first port of call for the second
opinion regarding capacity during the out of hours A&E work.
The sticking feature was that there was no consensus on the approach among
clinicians. This situation is common, especially when the patient is under
the influence of alcohol and the situation is well dealt by our colleagues
in the accident and emergency department.
We would also like to draw the attention to the 16-18 year olds who at
time pose a greater challenge, and was rather surprised not to see a
mention of them in David et al's article. Mental capacity act is
applicable to young people over 16 years of age (4). This is specially so
when it comes to declining interventions and in emergencies. Although all
people aged 16 and over are presumed in law to have the capacity to
consent to treatment unless there is evidence to the contrary. A child
aged 16-18 cannot refuse treatment if it has been agreed by a person with
parental responsibility or the Court, and it is in their best interests
this is according to the children's act 1989 amended in 2004, which
provides a legislative spine for the wider strategy for improving
children's lives. This covers the universal services which every child
accesses, and more targeted services for those with additional needs (5).
At times these matters end up with the courts which can over ride the
child or the parent. Therefore they do not have the same status as adults
and needs a more measured approach. The clinicians' agreement with the
person with parental responsibility could have an impact on the
therapeutic relationship and future engagement with the professionals.
We think that the best way to deal the situation is to discuss the issue
with both the A&E and the Psychiatric consultants on call and always to
err on the side of caution and to take legal advice in these grey areas.
When in doubt, it is better to treat the patient and act in their best
interst.
References:
1. David AS, Hotopf M, Moran P, Owen G, Szmukler G, Richardson G.
Mentally disordered or lacking capacity? Lessons for management of serious
deliberate self harm. BMJ 2010;341:c4489
2. http://www.dailymail.co.uk/news/article-1078439/Woman-swallowed-
anti-freeze-dies-refusing-treatment--doctors-feared-assault-claim-saved-
her.html
3. http://news.bbc.co.uk/1/hi/england/norfolk/8284728.stm
4. Department of Constitutional Affairs. Mental Capacity Act 2005
code of practice.
www.opsi.gov.uk/acts/acts2005/related/ukpgacop_20050009_en.pdf
5. www.everychildmatters.gov.uk/strategy/guidance/
Authors:
1. Dr Hifzi Huzair, CT3 in Psychiatry
2. Dr Bartlomiej Matras , CT3 in Psychiatry
3. Dr. Imran Mushtaq, Locum Consultant Child & Adolescent
Psychiatrist Hertfordshire Partnerships NHS Trust St Peter's House, 2
Bricket Road,St Albans, Hertfordshire AL1 3JW
Competing interests: No competing interests