Treatment In The Emergency Department

Question 1

Why are emergency situations are different?

Answer 1

• Less time to think with higher consequences
• Life-threatening situations
• Heighten what is at stake

Question 2

What is required for consent to be valid?

Answer 2

1. Capacity
2. Information
3. Voluntariness (freedom coercion)

Question 3

Why might gaining valid consent be difficult in an emergency situation?

Answer 3

• Conciousness
• No/little communication
• Lack capacity
• May not hear or understand info
• Might not be making rational decisions e.g. severe pain (voluntariness issue)

Question 4

What should you consider when gaining consent in an emergency situation?

Answer 4

Level of info needed/possible (low-high risk interventions)

How/whether to facilitate capacity (e.g. pain relief, environment, timing, support)

Question 5

If patient lacks capacity, proxy consent may be possible (Mental Capacity Act - MCA) in the form of:

Answer 5

1. Lasting power of attorney (LPA) - appointed by patient in advance
2. Court-appointed deputy - appointed when patient lacks capacity

Question 6

What is the problem in emergency situations regarding consent?

Answer 6

Autonomy is an important ethical concept in Medicine and part of respecting autonomy and the person is the requirement of consent - situations arise in which patients cannot consent

Question 7

Could respect for patient autonomy respect that you do not treatment any patient who cannot consent?

Answer 7

No

Question 8

How do you treat patients without consent?

Answer 8

1. Doctrine of necessity (common law) i.e. urgency (life-threatening and reduced time for capacity assessment)
2. If patient lacks capacity, treatment must be in best interest (MCA checklist)
3. Patient can be detained under MHA whether or not they have capacity but only under very specific conditions

Question 9

When are you allowed to treat a patient without consent in an emergency situation?

Answer 9

Providing the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition - treatment must be least restrictive of patients future choices (GMC consent guidance)

Question 10

In order for a patient to have capacity, they must be able to do all of the following:

Answer 10

1. Understand info necessary to make decision
2. Retain info long enough to make decision
3. Weigh the info
4. Communicate decision

Question 11

What assumption should be made regarding capacity?

Answer 11

Person should be assumed to have capacity generally - onus is on showing that patient lacks capacity

Question 12

What should you consider when deciding what was in someone’s best interest?

Answer 12

1. Not motivated by desire to bring about death
2. Person’s past + present wishes/feelings (particularly any relevant written statement made when they had capacity)
3. Beliefs + values that would be likely to influence decision if they had capacity
4. The other factors the patient would likely consider if they could
   Not merely on:
5. Age/appearance
6. A condition or aspect of behaviour which may lead others to make unjustified assumptions about what might be in his best interests

Question 13

What is restraint as defined by the Mental Capacity Act (MCA)?

Answer 13

When someone:

1. Uses or threatens to use, force to secure the doing of an act which patient resists
2. Restricts patients liberty of movement whether or not patient resists

Question 14

When can a doctor restrain a patient under the Mental Capacity Act (MCA)?

Answer 14

1. Doctor believes its necessary in order to prevent harm
2. Act is proportionate response to:
   - Likelihood of patient suffering harm
   - Seriousness of that harm

Question 15

When it comes to children, whose consent should be sought first?

Answer 15

1. The competent (Gillick) child

2. Parents under Children Act 1989

Question 16

Who does parental responsibility of a child lie with?

Answer 16

1. Mother
2. Father if married mother at time of child’s birth or;
   - If registered on birth certificate
   - By Parental Responsibility Agreement with mother
   - By various kinds of court order

Question 17

What must you do if a patient’s capacity is compromised in an emergency situation?

Answer 17

1. Try to assess/facilitate capacity
2. Respect competent refusal
3. Respect advance refusal
4. Consider proxy consent

Question 18

What other issues are important in the emergency department?

Answer 18

1. Disclosure of information to family, police or social services
2. Organ donation (donation after circulatory death)
3. Resource allocation