told that she will die unless treated with blood products, she refuses transfusion on
the ground that it is against her religious beliefs.
The health care team should presume that Carla is able to make her decision,
unless there is clear evidence to the contrary. Her refusal of a transfusion should be
carefully recorded. Although her beliefs are unconventional, she is entitled to base
her refusal on them. It is possible that the trauma of the accident and pain which
she suffers impair her capacity to consider treatment, but this conclusion should
only be drawn if she appears unable to absorb or process the information she is
given. A transfusion should not be administered in this case without a court
declaration that it is lawful. Such a declaration is not likely to be forthcoming.
Aggressive resuscitation, and, if necessary, intensive care should be offered, if the
resources for this are available. Patients like Carla have survived in similar cir-
cumstances but this may not make their choices easier to accept.
10.4 Adults unable to make their own decisions
10.4.1 General principles
Adults who lack the legal capacity to make treatment decisions cannot give a valid
consent to medical interventions, nor can anyone else do so on their behalf 4Re F
mental patient: sterilisation)41989)). It is, however, lawful to treat them provided
that treatment is in accordance with the appropriate professional standard and is
in the best interests of the patient concerned 4Re A41999)). Nurses have a key role
to play in the process of determining what is in a patient's best interests. As a
matter of good practice, the patient's family should be consulted, but the final say
rests with the health care team. The courts can be asked to issue declarations
indicating whether or not a proposed intervention is lawful. Once a referral has
been made it falls to the court to assess where the patient's best interests lie 4Re SL
adult patient) medical treatment42000)).
The law in this area is under review. Recommendations for law reform by the
Law Commission [16] and the Lord Chancellor's Department [17] have been
incorporated into the reportMaking Decisions[18], presented to Parliament by the
Lord Chancellor in October 1999. Several of the proposals in the report are in line
with the provisions of the 1997 Convention on Human Rights and Biomedicine
which supplements the European Convention on Human Rights. However,Making
Decisionsdoes not insist on quite the same level of protective representation for
patients. Its specific recommendations will be referred to at relevant points in the
text which follows, even though no timetable has yet been drawn up for
implementing them.
10.4.2 Advance directives
Patients increasingly prepare for the onset of their own mental incapacity by
producing a set of instructions as to the treatment they would seek, or seek to
avoid at that point. Known as `advance statements', such instructions may take a
variety of forms, ranging from signed, witnessed documents to a spoken wish.
204 Nursing Law and Ethics