Patient refusing treatment Flashcards
You are the IMT 1 on-call covering the busy acute medical unit. One of the nurses has asked you to come and see a patient who is refusing to take her antibiotics. The patient was admitted earlier with a urine infection and is known to have mild cognitive impairment. They appear increasingly agitated about the medication.
How would you approach the situation?
Issues raised
* This scenario raises the issue of patient autonomy, capacity and patient safety
Seek info
* Review the patient’s notes for admission details, prescribed antibiotics, and cognitive history.
* Speak to the nurse about the patient’s behaviour, the urgency of the antibiotics, and any potential alternatives.
* Speak to the patient if safe to do so, ideally in a quiet space, to avoid overstimulation, with the nurse present.
* Try and understand why they don’t want to take the antibiotics and if they undestand why the antiobiotics were prescribed
Patient safety
The scenario mentions that the patient has cognitive impairment and has also been admitted with a urine infection. They would be at high risk for developing delirium on top of their known cognitive impairment and this may be affecting their decision-making.
Immediate measures
* assess the **patient’s capacity **with regard to taking the medication, as this will influence my next course of action.
* Other measures that could be taken to help with taking medication include involving a family member or friend to help **reassure or explain further **to the patient the reasons for the medications. This may also help the patient to calm down and they may also be able to provide further information regarding advanced decision-making or any lasting power of attorney.
What do you understand by mental capacity?
Definition:
Mental capacity is the ability to make one’s own decisions, specific to the decision and time of assessment.
Key Principles:
* Presume all adults have capacity unless proven otherwise.
* Age, diagnosis, communication limits, beliefs, or unwise decisions do not imply lack of capacity.
* Capacity may fluctuate and must be reassessed for each decision.
Capacity Criteria:
* understand information relevant to the decision in question
* retain that information
* use the information to make their decision
* communicate a decision
Support:
Provide reasonable help and time for patients to demonstrate capacity.
How would you make decisions for a patient who lacks capacity?
Act in the Patient’s Best Interests:
* Prioritize the patient’s welfare and well-being.
Check for Advance Directives:
* RESPECT forms, DNACPR
Consult Next of Kin:
* Seek family input on patient preferences and values.
Lasting Power of Attorney (LPA) for Health & Welfare:
* If present, the LPA has legal authority for decisions.
* If No LPA Present: Healthcare professionals make the decision in the patient’s best interests.
Follow Hospital-Specific Policies:
* E.g., Consent Form 4 for best interest decisions.
What is an Independent Mental Capacity Advocate (IMCA)?
Definition:
An IMCA is a legal safeguard introduced by the Mental Capacity Act 2005 for individuals a) lacking the capacity to make specific important decisions and b) who don’t have family or friends with whom to consult. Usually involved for decisions about serious medical treatments.
Role:
* Support and represent individuals who lack capacity.
* Ensure the person’s rights and preferences are considered in decision-making.
When Involved:
* Decisions about serious medical treatment.
* Decisions about long-term accommodation changes.
In this scenario, you assess the patient’s capacity and decide that they do not have the capacity to make decisions about their medication. What next steps would you take?
Managing Medication Decisions for Patients Lacking Capacity
Capacity Assessment Outcome:
* Patient lacks capacity to decide on medication.
Best Interests:
* Administering medication is in the patient’s best interest to manage infection and prevent harm.
* Discuss decision with the medical and nursing team.
Attempt Non-Coercive Administration:
* Allow patient to calm down.
* Seek assistance from family or friends to help administer the medication cooperatively.
If Non-Coercive Measures Fail:
* Consider covert administration or IV cannula if essential for care. Complete a Deprivation of Liberty Safeguards (DOLS) form if restricting patient freedom becomes necessary.
* Emergency DOLS can be completed by the on-call team and reviewed by the local authority within 7 days.
Escalation and Documentation:
* If unsure, consult senior colleagues before administering treatment that limits freedom. Document all assessments, decisions, and actions thoroughly in the patient’s notes.
