Ahmed suffers from advanced stage dementia and has been found to lack the capacity to make a decision on his care and treatment; he currently requires full-time support and supervision. The care and treatment could be provided in a specialist dementia psychiatric unit, which would be highly restrictive.
The least restrictive option would be to receive care in his own home; however, this may not in the Ahmed’s best interests owing to concerns for his welfare and safety when his carer’s are not with him.
The less restrictive option could be a nursing home, which allows him more freedom and a less restrictive regime than a psychiatric unit, but has more supervision than he would receive at home.
Robert has been involved in a road traffic accident as a pedestrian and has an internal bleed. He is unconscious at the point he arrives at the accident and emergency department, although his wife is with him. When she is informed he has lost some blood and requires a blood transfusion, she protests and states that it goes against Robert’s firmly held beliefs as a Jehovah’s Witness as blood represents life and only God can give life. She states he would rather die if this is God’s wish. It would save Robert's life to receive blood, however this would cause him significant emotional and psychological distress as it goes against his religious beliefs; taking Robert’s religious beliefs into consideration, it would not be in his best interests to receive a blood transfusion. However, alternative forms of medical support could be explored.
Ingrid is in the early stages of dementia and is currently receiving support in her own home from professional care workers. She has recently been meeting up with her 38-year-old grandson every week in a local restaurant and has been paying for lunch each time. Her support worker is concerned that the grandson is exploiting Ingrid for money and free lunches and considers whether the situation needs to be formally investigated. Ingrid, however, is able to recognise the concerns that the support worker has and explains that her grandson is the only relative she has contact with and is happy to spend her disposable money on him as it maintains their contact and makes her feel like she still has a purpose and identity as a grandmother.
Although this decision may appear unwise, and does cause some alarm, where the individual has capacity, their right to make unwise decisions should be protected.
Niko used to be a security guard working nightshifts at nightclubs and bars; after suffering a severe stroke however, he now requires full time care and supervision in a care home. Niko requires invasive surgery to fix a shunt in his brain to help alleviate pressure and reduce the likelihood of future strokes. Initially the decision maker (DM) spoke to Niko about this decision around midday after a meeting at the care home; the DM suspected Niko lacked the capacity to make this decision as he presented as lethargic, withdrawn and disengaged. However, the care home staff informed the DM that he is much more alert in the evenings as this was his routine for most of his working career. Upon returning out of hours, the DM was able to communicate more easily with Niko who was then able to make an informed decision.
Meeting with the individual at a time when they are more alert (including out of ‘office hours’), or by using aids that help them understand or communicate, is taking practicable steps to help the person make a decision.
Mrs. Collins is 82 and has had a stroke. This has weakened the left-hand side of her body. She is living in a house that has been the family home for years. Her son wants her to sell her house and live with him.
Mrs. Collins likes the idea, but her daughter does not. She thinks her mother will lose independence and her condition will get worse. She talks to her mother's consultant to get information that will help stop the sale. But he says that although Mrs. Collins is anxious about the physical effects the stroke has had on her body, it has not caused any mental impairment or affected her brain, so she still has capacity to make her own decision about selling her house.
‘You must assess a patient's capacity to make a particular decision at the time it needs to be made. You must not assume that because a patient lacks capacity to make a decision on a particular occasion, they lack capacity to make any decisions at all, or will not be able to make similar decisions in the future.' (GMC Guidance - Consent, paragraph 71)
Points to consider -
Case study examples taken from practice and linked to information in the toolkit to give practical examples of different aspects of the Act.