Case 23 Endless wandering

Dr Stefan Jacobs is a 92-year-old retired GP. He was admitted to the hospital five days ago having been found by his daughter, visiting from South Africa, to be struggling to manage his own affairs at home. On admission, Dr Jacobs had been unkempt and malnourished. His house had been in quite a state with evidence of vermin infestation. Over a thousand unopened copies of the British Medical Journal had been stacked up along one side of the staircase – some of them over 20 years old.

Dr Jacobs’s daughter had described him as always having been ‘a law unto himself’. People seemed to regard him as a something of a character, although his behaviour had become more unusual and insular over the last 10–15 years since the death of his wife. He has no close friends and no hobbies, having always been fully absorbed in his work. Contact with family has become rare.

Dr Cheung, a consultant gastroenterologist, is popping into his office one Saturday morning to collect some job applications to review at home over the weekend. He meets Dr Jacobs who has wandered off the ward in the lift lobby. Dr Cheung sees Dr Jacobs walking into the lift and notices that his hospital gown (the only thing he is wearing) is undone at the back and that he is carrying all his belongings in a carrier bag along with four copies of the BNF (all labelled as belonging to Mulberry ward). Dr Cheung thinks this is odd and asks the patient (who he has not met before) if he is OK and whether he would like any help. Dr Jacobs replies that he is fine and that he is heading to the tea rooms for a sandwich.

Dr Cheung is worried about Dr Jacobs and persuades him to take a seat in the lift lobby whilst he calls a nurse from Mulberry ward. The nurse arrives and thanks Dr Cheung. She says that this is the sixth occasion on which Dr Jacobs has left the ward since last night and that there aren’t enough staff to cope – not least because the ward has two very sick patients. Dr Jacobs had been a nuisance all night – pulling at another patient’s catheter bag on one occasion and hiding all the ward files (protocols, procedures, nursing off duty) under his bed. Security had been to the ward several times but had had to return to ED. Half an hour ago, Dr Jacobs had attempted to strike the domestic with his walking stick when he had come to collect his breakfast tray.

What should Dr Cheung do?

Dr Cheung has every sympathy for the staff nurse, whom he has known for the best part of a decade, and he offers to prescribe a sedative for Dr Jacobs. Dr Jacobs has no wish to take any medicines and Dr Cheung therefore administers 2 mg of lorazepam intramuscularly whilst two staff members hold him down in a chair. Dr Cheung then leaves the ward and proceeds to his office to collect the job applications. Twenty minutes later, Dr Jacobs is much more placid and allows staff to help him to his bed where he sleeps on and off for the remainder of the day.

Expert opinion

There are two elements to this case which deserve discussion: the safety of the intervention made by Dr Cheung and the ethical and legal aspects of restraint.

It seems that Dr Cheung has acted with the best of intentions. He has found an elderly man who appears to have limited mental capacity attempting to leave the ward in odd circumstances. Dr Cheung was worried about his safety and therefore contacted the ward team to collect the patient. At that point, on hearing of the difficulties faced by the ward team the previous night, Dr Cheung elected to assist them by sedating the patient.

However, it is by no means clear that Dr Cheung weighed up all the relevant factors in relation to the risks and benefits of this course of action. Aside from the prescription there was no documentation at all. Several questions arise:

• Was Dr Jacobs considered to lack capacity?
  
• What were the perceived dangers to Dr Jacobs and others?
  
• Was there any less restrictive way of managing the situation?
  
• Was the choice of drug appropriate?
  
• Was any effort made to consider relevant comorbidities?
  
• Was any effort made to assess for precipitants of delirium?
  
• Was any effort made to ascertain renal function?
  
• Were appropriate arrangements made for the monitoring of a sedated patient?
  
• Was the ward team covering that weekend made aware of Dr Cheung’s helpful intervention?

From a legal and ethical perspective, it is Dr Cheung’s responsibility to ensure that intervention is required and justified, and that the least restrictive course of action is followed. This does not appear to be the case with Dr Jacobs who will be at heightened risk of falls, dehydration, renal failure, respiratory compromise and VTE following the intervention. Furthermore, he will be highly likely to display further challenging behaviour when the lorazepam wears off give that the aetiology has not been addressed.

Legal comment

Under the Mental Capacity Act (MCA) 2005 it is the role of the ‘clinical decision-maker’ (the consultant in charge of the patient’s care) to make the best interests assessment. It was not appropriate for Dr Cheung to have intervened in this manner.

The more appropriate course of action for Dr Cheung would have been to contact the consultant in charge of the patient’s care to notify him of his concerns and permit the treating consultant to act.

The administration of the sedative may have been appropriate if it was the least restrictive method to ensure the safety of the patient and to avoid harm to staff.

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