Case 20 Irrational but not incompetent
Peter Walton is a 57-year-old sales representative who develops unsteadiness when walking and a persistent frontal headache on Friday morning. His wife is worried about him but he refuses to see a GP as he has had a lifelong antipathy to medical and dental interventions – in fact he has never registered at a practice. He heads off to work but is involved in a minor road traffic accident when he fails to notice a vehicle pulling out to pass him in a queue of cars. An ambulance is called and although they confirm that no one has significant injury, they do note that Mr Walton’s blood pressure is 266/153 and they persuade him to go to the local emergency department.
Dr Goldberg is the staff grade on duty and he finds Mr Walton to be very dismissive and apparently irritated by having been brought to hospital. Over the next 90 minutes, Mr Walton’s blood pressure remains very high and Dr Goldberg is concerned that this level of hypertension is causing the headache, unsteadiness and may well have contributed to the accident. Mr Walton agrees to have some blood tests, a chest X-ray and ECG but is very clear he will not be staying in hospital and wishes to go.
The ECG shows left ventricular hypertrophy with strain and there is cardiomegaly on the chest X-ray. Mr Walton has a potassium of 3.2 mmol/l and a creatinine of 165 mmol/l. Dr Goldberg tells Mr Walton that he believes that his recent symptoms are all a result of severe hypertension and that left untreated the risk of serious complications like stroke or death are high. This is dismissed by the patient who says ‘your blood pressure would be high if you’d just had an accident and had been forced to come in to hospital against your will – there’s nothing wrong with me that a bit of rest won’t cure’. By now, Mrs Walton has arrived and she tries to persuade her husband to stay while Dr Goldberg does more investigations and starts some treatment, but he is very brusque with her and demands to be taken home.
What should Dr Goldberg do at this point?
5 mg amlodipine is prescribed, but Mr Walton refuses it and so Dr Goldberg calls the medical consultant on take for advice on how to proceed. Dr Mason arrives and agrees with the clinical findings and the likely diagnosis of hypertensive emergency. He too explains the risks to Mr Walton of not staring immediate treatment, and he wonders if Mr Walton’s judgement is clouded by hypertensive encephalopathy.
How would you assess Mr Walton’s competence to make a decision about his care?
Dr Mason considers that Mr Walton appears to be able to retain the information given to him and he appears to be able to reiterate the consequences of no treatment, including the risk of death. He however denies that this is as serious as the medical team are making out and he asserts he will take his own discharge against medical advice. Reluctantly Dr Mason accepts this and documents the conversation he has had in the notes. He provides Mr Walton with an appointment to return to clinic the next day and urges him to register with a GP as soon as possible. He also provides Mr Walton with a supply of amlodipine tablets and instructions on how to take them if he should change his mind. Mrs Walton is very upset but defers to her husband’s decision and they leave the department.
Do you agree with Dr Mason’s course of action?
Two days later Mr Walton is readmitted as an emergency in status epilepticus. His blood pressure is initially unrecordably high. He is given intravenous diazepam and phenytoin and a CT scan of his head is performed which shows a large posterior fossa intracerebral haemorrhage. Despite obtaining control of the blood pressure gradually over the next six hours, he does not regain consciousness and dies later that day.
Mr Walton’s son, who is a psychiatric nurse, had been at his father’s bedside for the last few hours of his life and he is very angry with the medical team. He asserts that they failed to insist he received treatment two days earlier that would have saved his life. He also says he believes his father’s decision was entirely out of character and was symptomatic of impaired cognition due to the severity of the hypertension and he should have been detained and treated under ‘common law’.
Expert opinion
This case was very difficult. Mr Walton had evidence that his hypertension was causing neurological impairment (headache, unsteadiness, lack of awareness when driving, irritability) and yet he was able to answer the rather basic questions which were used in the assessment of competence. Mrs Walton was frightened of her husband and did not feel she could push him further to comply. The son later expressed the opinion that this was out of character for his father and evidence that he was not thinking normally.
Dr Mason discusses the case with the Trust Medical Director and with his defence union, and in due course a complaint is made by the son against both Dr Mason and Dr Goldberg to the General Medical Council.
Legal comment
Mental capacity is decision specific and time specific. Can the person make this decision as this time? The five principles of the Mental Capacity Act (MCA) 2005 are:
- Presume capacity unless there is evidence otherwise.
- Do all you can to maximize a person’s capacity.
- Unwise or eccentric decisions don’t of themselves prove lack of capacity.
- If you are making a decision for or about someone who lacking capacity; always act in the best interests of the person.
- In making a best interest decision, seek the least restrictive option that will meet the person’s needs.
Assessing capacity is a two-stage process. Does the person have an impairment of mind or brain, or is there some sort of disturbance affecting the way their mind or brain works, either on a temporary on permanent basis? If so, does that impairment or disturbance mean that the person is unable to make the decision in question at the time that it needs to be made?
A person has capacity to make a particular decision only if they can carry out all four of these following steps:
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