give `very careful and detailed consideration to the patient's capacity to decide' 4Re
Tadult: refusal of treatment)41992)). The more serious the decision, the greater
the capacity needed to make it.
Authoritative guidance on how patients should be approached was made
available by the Court of Appeal in the case ofRe MB medical treatment)41997).
Medical teams should start from the presumption that patients have the capacity to
reach their own decisions. Patients are entitled to make irrational or foolish
choices. Scope for overriding their wishes arises only when there is evidence of
impaired mental functioning. Pain, shock, medication, fatigue and drugs may
induce temporary loss of competence. So may fear, if it destroys the ability to make
decisions.
Where there are genuine reasons to doubt a patient's capacity, the safe course is
to determine a treatment plan which is in the patient's best interests, and to invite
the court to declare it lawful. Procedural safeguards to protect the patient in such a
case were put in place byRe MBand must be strictly complied with.
10.3.2 Maternal-fetal conflict
Where a pregnant woman wants her baby to be born alive and healthy, its safe
birth will normally be in her best interests. But where the wishes of a competent
mother rule out a safe birth then, according toRe MB,they must nevertheless be
complied with because they override her own best interests and those of the fetus.
The issues raised in such a situation are more fully discussed in Chapter 7 on
consent.
10.3.3 Denying treatment to patients
When critically ill patients are referred for intensive treatment but fail to respond,
the decision to cease treatment must be considered. Whenever possible, patients
should participate in the decision process. Their wish to continue treatment
should not easily be countermanded but the final decision lies with the health care
team. In relation to cardiopulmonary resuscitation policy, the Royal College of
Nursing has jointly with the British Medical Association and the Resuscitation
Council 4UK) produced guidance on the applicable legal and ethical standards
[15]. Patients at foreseeable risk of cardiopulmonary arrest can expect to be fully
consulted on plans to attempt resuscitation or to withhold it. If patients oppose the
making of a `Do Not Attempt Resuscitation Order', no order should be issued.
Discussions and decisions are to be fully documented, signed and dated, in
patients' records. The views of all on both the medical and nursing team should be
obtained.
10.3.4 Case study
Carla, aged 30, has been admitted to hospital following a car accident. She has
suffered an open fracture of the left femur, laceration of the left femoral artery and
aclosed fracture of the right femur. She is conscious, and despite repeatedly being
The Critically Ill Patient 203