Refusing treatment



Background

As accurate a history regarding the toxins ingested, amount and timings will assist in managing these difficult cases.

Treat the "medical" effects of the overdose in an ABC fashion (Toxicology section). Further advice may be available TOXBASE (Check resuscitation room PC for login details) or by phone at The National Poisons Information Service (01 8379966 or 01 8092568). The BNF will soon be available on line.

Involve the senior ED Duty doctor early in the case.

If it is uncertain whether the toxic threshold for aspirin or paracetamol will be breached, consider taking a blood sample before the standard four-hour period is up and attempt to extrapolate the serum level.

When it is decided that the ingestion poses a significant risk, every attempt must be made to try and persuade the patient to stay. Any individual who develops a rapport with the patient should be allowed time to apply his or her powers of persuasion.

Enforced sedation and active treatment is potentially dangerous. It should only take place with the support of senior ED, Psychiatry and if necessary Anaesthetic staff.


Treatment Refusal, the role of Common Law and the Mental Health Act in the ED

1. Medically unwell patient refusing medical/surgical treatment or wanting to leave ED

  • Assess capacity to refuse
  • Assess mental state including risk
  • Try to persuade to stay/give information to improve capacity
  • Relieve any emotional distress
  • Decide whether or not to detain under the Common Law for treatment (ie urgent risk concern in a patient who lacks capacity to decide for themselves and treatment is deemed to be in their ‘best interests’). The Mental Health Act is not appropriate here.
  • Seek senior medical advice
  • Seek Psychiatric opinion if mental health concern : call the Liaison Psychiatry or On-Call Doctor

2. Medically well but Mentally unwell patient refusing Psychiatric assessment or wanting to leave the ED

  • Assess capacity to refuse treatment (see below)
  • Assess mental state including risk
  • Try to persuade to stay/give information to improve capacity
  • Relieve any emotional distress
  • Decide whether or not to detain under the Common Law (ie urgent risk concern in a patient who lacks capacity to decide for themselves and treatment is deemed to be in their ‘best interests’)
  • Seek senior medical advice
  • Seek Psychiatric opinion : call the Liaison Psychiatry or On-Call Doctor
  • Decide whether to apply for involuntary detention for treatment of mental disorder under the Mental Health Act, 2001 (see www.mhcirl.ie for details). Such an application will need to be followed by transfer to an Approved Centre (ie a registered acute mental health inpatient unit)

Consent

In patient requiring, yet refusing, urgent medical treatment, the issues are:

  1. The capacity to give consent
  2. The necessity for urgent medical intervention to save life
  3. The use of Common Law
  4. The place of the Mental Health Act 2001 (information)

General Principles

A patient has the right, under common law, to give or withhold consent to medical (physical) examination or treatment.

This is the basic principles of health care. Patients are entitled to receive sufficient information in a way that they can understand about the proposed treatments, the possible alternatives, any substantial risk that may be special in kind or magnitude to the patient so that they can make a balanced judgment.

A mentally competent patient has an absolute right to refuse to consent to medical treatment for any reason, rational or irrational or for no reason at all, even when the decision may lead to his or her own death. In general, medical treatment can be undertaken in an emergency, even if, through lack of capacity, no consent has been competently given, provided the treatment is necessary and does no more than is reasonably required in the best interest to the patient. However, treatment must not be given if the patient has previously refused treatment and this refusal was given when the patient was competent, is clearly applicable to the person’s circumstances and is known to the doctor attempting to treat at this time.

For example, Jehovah Witness’ make it quite clear that they do not wish to receive blood transfusions under any circumstances. Although this decision may appear unusual to some, it is clearly within the culture and belief of Jehovah Witness’ and must be respected.


Competency or capacity to give consent

An adult has CAPACITY to make a decision (including a decision to refuse treatment) if he/she can:

  • understand and believe the information relevant to the decision.
  • retain that information long enough to be able to make a decision.
  • use or weigh that information part of the process of making the decision.
  • communicate his/her decision (whether by talking or by other means).

In order to be mentally competent to make a decision they must comprehend, retain, believe the information which is material to the decision required especially as to the ikely consequences of having or not having treatment:- they then must use the information, to weigh the information as part of a process for arriving at a decision.

What is of utmost importance is that the doctor develops a clear rationale for reaching an opinion that there may be a temporary impairment or otherwise of the patient’s ability to comprehend, and that this is noted, including enquiries that have been made to family members and attending friends. Also whether or not a second opinion is taken from the Consultant on-call so that it could be argued that no reasonably competent doctor would not have rationally made that same decision, with sufficient information available.

It may be important to start the process of a Mental Health Act (2001) assessment at the same time as intensive resuscitation is going on.

Patient a threat to themselves or staff?

Level of threat Type of observation needed

Definite threat?

Arm's length (inform security, CNM3, senior doc)

Potential threat?

Eyesight (inform security & CNM2)

Just agitated?

Intermittent (inform CNM2)

Calm and cooperative?

General

Protocol for use in ED for patients presenting with Challenging Behaviour known to be under the Mental Health Act Treatment Refusal & Mental Health in the Emergency Department (ED)

A. Medically unwell patient refusing necessary Medical treatment or wants to leave ED:

  • Assess Capacity to refuse (see below).
  • Assess mental state including risk.
  • Try to persuade to stay/give information to improve capacity.
  • Relieve any emotional distress.
  • Decide whether/not to detain under Duty of Care and Best Interests (Mental Health Act not appropriate here).
  • Seek Senior Medical advice (if in doubt about capacity or if the consequences of treatment refusal are serious).
  • Seek Psychiatric opinion if mental health concern.

B. Medically well patient refusing necessary Psychiatric assessment or wants to leave ED:

  • Assess Capacity to refuse (see below).
  • Assess mental state including risk.
  • Try to persuade to stay/give information to improve capacity.
  • Relieve any emotional distress.
  • Decide whether or not to detain under Duty of Care and Best Interests.
  • Seek Senior Medical advice (if in doubt about capacity or if the consequences of treatment refusal are serious).
  • Seek Psychiatric opinion : phone the Liaison Psychiatry or On-Call Doctor.
  • Decide whether to apply for and transfer for involuntary treatment of mental disorder in a Psychiatric Unit (under the Mental Health Act, 2001; see www.mhcirl.ie for forms and information)

Patients who has left the ED prior to completing necessary assessment/treatment:

  • Search the area.
  • Inform Security.
  • Contact Next of Kin.
  • Consider contacting the Gardai if urgent risk.
  • Complete an incident form.
  • Inform the relevant clinical team.
  • Document it.

The role of Security Staff

  • Only as a last resort, Security Personnel have a role in the restraint of such patients.
  • In such situations, Security staff needs to be told: ‘This patient lacks capacity to make a decision about leaving hospital/refusing treatment. We have a duty of care here and we request your assistance to prevent this patient from leaving as it is in their best interests at the present time’.

Refusing Traetment


Content by Dr Íomhar O' Sullivan. Published 15/03/2004. Reviewed by Dr ÍOS 09/12/2006, 10/11/2007. Next review 11/10/2008