Confused patient Flashcards
You are the SHO covering the Care of the Elderly and Stroke wards overnight. You are contacted by one of the nurses asking you to come and see Mr Jones who is trying to leave the ward. He is a 92 year old man, admitted following a fall. He subsequently developed hospital acquired pneumonia and is on IV antibiotics. The patient has also been refusing food and is receiving IV fluids. On arrival to the ward you find Mr Jones in an argument with the nursing staff. He is trying to leave the ward and shouting that he doesn’t want to be kept in prison. He is trying to get through a door that a nurse is holding shut. He has a background of dementia, heart failure and COPD.
How would you approach this situation?
This scenario raises the issues of patient capacity and patient safety and descalation
I would first try to deescalate the situation. I would introduce myself, explain who I am, and try to get Mr Jones to come with me to his bedside, or a quiet room. If he agrees, I would ask one of the nurses to come with us. If he remains agitated, I would contact a family member to come in as it may help him see a familiar face.
I would then seek information, trying to establish what is wrong and why the patient is upset. Listening calmly to the pt may be enough to calm him down and would give me an opportunity to explain what is happening. I would calmly explain why he is in the hospital and receiving antibiotics for an infection.
Next steps would to be to assess the patient’s capacity. Capacity in patients with no cognitive impairment is assumed, as the first step of capacity assessment. If there is a history of cognitive impairment, capacity needs to be assessed. Does he understand what is happening and what the risks are to leaving the ward, especially at night?
I need to make sure that the patient is safe and that I am working in his best interests. Where possible, I would aim to get a collateral history from his family to gauge his baseline.
What could be causing this patient’s confusion and are there any simple measures you can do to help it?
There are multiple factors that could be causing this:
* The patient has a BG of dementia, so this could be his cognitive baseline
* It could also be caused by delirium due to a number of factors. With his BG of dementia and old age, he is more susceptible to delirium.
- It is possible that the delirium is caused by his concurrent infection. I would check bedside observations and most recent blood tests to rule out sepsis. If signs of his infection worsening, I would discuss changing his ABx with microbiology.
- Other common causes of delirium in elderly include dehydration, pain, constipation, metabolic & electrolyte disturbances.
The stress of being admitted in hospital could also be a factor and there are a number of things we can do to help make the pt more comfortable.
* Ensure he has his visual and hearing aids.
* Having pictures or clothes that the pt recognises
* Giving them a side room may help
* Same staff day in day out
PINCH ME - useful for delirium causes
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment
What do you understand by capacity
Mental capacity is the ability to make decisions by yourself.
The 2005 Mental Capacity Act states that every adult has the right to make his or her own decisions and to be assumed to have capacity until proven otherwise. All individuals should be encouraged and empowered to make their own decisions. Individuals have the right to make decisions that may seem unwise to others
How would you assess this patient’s capacity?
Capacity is assessed using the following criteria in the 2005 Mental Capacity Act.
The patient should be expected to:
- Understand the information relevant to the decision
- Retain the information
- Weigh up the information in the decision making process
- Communicate the decision
You determine that the patient does not have capacity. The patient is still trying to leave the ward. What could you do next?
If the patient does not have capacity and is still trying to leave, I need to put measures in place to protect him. I have dutyr of care to the patient and need to work in his best interest. In this instance that means stopping the pt from leaving the ward as leaving would likely put him at harm.
I would follow the Deprivation of Liberty Safeguards (DOLS), a legal process that must be followed where it is necessary to deprive someone who lacks capacity of their liberty to consent to their care and treatment.
As an on-call doctor, I can sign an emergency DOLS which is valid for seven days. The paperwork must be signed and sent to the Trust Safeguarding Team who will then review and authorise the standard DOLS
DOLS should be as short as possible, but can be up to 12 months.
How do we safeguard patients who are deprived of their liberty?
The first safeguard is the assessment process for a standard DOLs authorisation, which involves at least two independent assessors.
Family, friends and paid carers who know the person well should be consulted as part of the assessment process. They may have suggestions about how the person can be supported without having to deprive them of their liberty.
People who have noone to represent them should have an Independent Mental Capacity Advocate (IMCA) during the assessment process
