Saturday 1 June 2013

Grey Areas

”67 year old male, ? overdose, acting aggressively”

Despite the offer of police assistance we declined and said we'd be happy to investigate first and then request police only if necessary. I felt that with 3 of us on hand we should be able to manage by ourselves! As I've written about previously, it saddens me to attend suicidal elderly patients. They are given anti-depressants and sedatives like smarties. It almost feels like they are given them just to shut them up. Rather than address the cause, let's just make them sleep more, eh?!

We pulled up outside and were met by the patients daughter. She told us that he didn't know we were coming and that he wouldn't be remotely pleased to see us! Regardless of health problems I really wish people wouldn't do this! It makes our job infinitely harder and sets us off on an uphill battle from the get go! I understand why people do it, the emotional tug of loved ones is hard to ignore, it just makes them much harder to treat when we do arrive.

Sure enough, we were greeted with a steam of expletives. Reading between the lines, I think the essence of what he was saying was "Go Away". I am, of course, paraphrasing! He was indeed confused and overly aggressive, nothing like the way he appeared in all his photos. Apparently, he had taken an overdose of pretty much everything he had. We weren't sure exactly how much and of what, but he did need medical help, that was for sure. His family had rung the GP, but the minute they said 'overdose', the GP rightly called us.

At this juncture, where a patient is refusing treatment, but is, in our opinion, in need of help and may lack the capacity to refuse, we would assess him under the Mental Capacity Act (2005) to determine whether he has the capacity to refuse. It involves a form and some questions. The upshot is, the patient needs to be able to explain a rational and reasoned decision and withhold information given to him. If he fails, in our opinion, them we have the right to treat him against his will. It is a crude tool that is often mis-used but in a patients own home, is all we have available to us, short of the GP arranging a mental health assessment and a sectioning. That, doesn't happen quickly, by any stretch of the imagination!

Now, all I've just said, we did. We assessed his capacity, for what he had done. Every question we asked him he replied something like:

"Fuck off, get out of my house, you're not taking me to prison."

I didn't take it personally, clearly something was going on. There was a twist however. Under normal circumstances I wouldn't have thought twice about taking him to hospital for treatment. The issue was that he was a palliative care patient with weeks to live.

Is it morally right to force someone to have treatment in hospital when they want to die at home? There was a DNR in place and this mental deterioration was likely due to the cancer. Surely his previous wishes of non-treatment should be adhered to?! That said, we weren't here for his cancer or even his mental deterioration, we were here for the overdose and that was something that could be treated without conflicting with the wishes of the DNR. Yet again, we were stuck in a grey area, a mine field of mental health uncertainty! I certainly wasn't comfortable with putting him through the distress of being physically forced into going to hospital. And the likelihood was, if we had to take him, then it would be the police who would have to physically drag him out screaming. It isn't how I'd want my friends and family to remember me. 

We decided to call the GP back. Luckily, after eventually bypassing the GP reception security and interrogation I was put through to the locum doctor. She didn't know the patient and it would have been very easy for her to pass the buck and be of little help. Instead, she was excellent. She agreed hospital was not the right place and offered to come out and assess him. Due to his aggression and refusal of treatment, even at home, we requested police. This wasn't necessarily a police job, it was health related, and even though mental health is a huge part of police work, this still wasn't really their remit, but we felt their presence was necessary for the safety of us and the GP. Within half an hour, everyone was there, and with the assistance of the police, he got assessed by the GP. 

She decided that based on what he had possibly taken, he could stay at home. She offered to come back later and check on him and if further treatment was required she would call us back or arrange a home assessment. We thanked her, thanked the police, and we all left.

THIS is how healthcare in the NHS should work. THIS is how mental health should be treated and THIS is how the police should be used with regards to mental health. An outcome that is in the best interests of the patient. An outcome which is as least restrictive as possible and utilising the police when they are needed and not because the words 'mental health' appear. The NHS can work, inter-professional working can work and work very well. There is no need for us to stretch each others resources when it isn't appropriate. The patient got the best and most appropriate treatment, taking into account his physical and mental well being. Perhaps if other areas of the NHS can see things like this as a model for GP led treatment then things will start to improve. 


  1. Yeah! This is a great post. Good on the locum doctor and a great job all round by public servants. Woohoo! I love what's left of the NHS.

  2. What a positive outome for the patient involved in the end, truley person centered care. Just found your blog through twitter, really enjoying reading it. :)

  3. Absolutely spot on post again. The problem though is when you get wishy-washy/weak managers who don't think about a patient's best interests (either mentally or physically) and demand that they be taken in to be treated. All they are thinking about is the repurcussions to them if the patient dies. Mind you this isn't helped by patients' families who cannot accept that their loved one didn't want to be around any more and look for someone to blame i.e. Health profession.
    Time and again, our weak management insist on officers remaining with such Mental Health patients even when the Crisis Team/GP/Hospital tell our control room that the patient is not in need of hospital/MH treatment, just because they say that they feel suicidal. The bosses, despite the guidance of better qualified bodies, are frightened to death that the patient will top themselves and there will then be an investigation into what they could have done to prevent it.

  4. Wow, that sounds all very stressful, complicated, and heart-wrenching for the daughter. But well done to you for sorting it out and bloody hell what an amazing locum!

    Shame about how things are going for the patient though.


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