Isabella – scenario for training

Mental Capacity Act workbook

Commissioned by, and hosted here on the MCA Directory on behalf of, the members of the NHS Eastern Region Safeguarding Adult Forum facilitated by Eleanor Sherwen & Sarah Robinson.

View here online or order a DVD or workbook

Learning outcomes

For participants to recognise that

Isabella’s story

Isabella is 24 years old (known as Issie), she is a mature student studying for a B.Sc. in Psychology at university. She lives and studies away from home. Issie has cerebral palsy (ataxic), epilepsy and increasing issues with her swallowing, which has resulted in recent episodes of aspiration pneumonia. She is now on thickened fluids. She uses a wheelchair and relies on the carers for a lot of her personal care needs. She lives in specially adapted accommodation at the university and has a team of personal assistants who support her 24 hours per day. Her only relative is her mother who lives abroad and has alcohol problems. She has all but given up on Isabella.

Late on Saturday evening under the care of a temporary support worker, Isabella collapsed and was admitted to hospital. She is currently unconscious as a result of her choking and an epileptic seizure.

Current decision making issues for the professionals involved

Issie has had treatment at this hospital before so there is some medical information on file. However, the Junior Doctor now needs to establish further background information to assist her in planning the next few hours of her care. Issie’s health situation is not yet stable. She is unconscious and therefore she lacks capacity. There appears to be an incomplete picture as to what actually happened before admission. The Junior Doctor, Dr Simmons, is discussing Issie’s situation with her personal assistant, to establish relevant information to what would be in her best interests, including whether she has made any advance decisions to refuse medical treatment.

The ethical decision

The dilemma for the professionals is about making immediate decisions about Issie’s care, assessing what plans to put in place if her health deteriorates; balanced with a lack of knowledge about the person, in a late evening/ night time situation. She lacks capacity because of her current health status. The situation raises questions about when treatments of a life-saving nature might become futile, who should be consulted, when might it be appropriate to withdraw medical treatments?

Cases from the courts

From the court of appeal in 2014 a woman with complex medical issues, whilst she had capacity, the courts were concerned with need to make consultations with family

In a case before the Court of Appeal, [2014] EWCA C iv 33, considered that the NHS Trust involved had not consulted the family members (her husband) in relation to a DNACPR placed on her file. It was found that an NHS Trust had a legal duty to tell a patient, with mental capacity, that a Do Not Attempt Cardiac Pulmonary Resuscitation (DNACPR) order had been placed on her medical records.

Transcript of case

Commentary on case

From a High Court in 2015 a young man with cerebral palsy, epilepsy, spinal deformities and other associated health conditions. The family were not consulted over the dnacpr. This was a violation under the human rights act.

In a legal case Winspear v City Hospitals Sunderland NHS Foundation Trust [2015] EWHC 3250 (QB); [2015] WLR (D) 468. It was found that the core principle of prior consultation before a DNACPR decision was placed on a case file applied whether the patient had or lacked capacity. The judgment, handed down on (Friday 13 November 2015), found that the decision to impose a Do Not Attempt Cardio-Pulmonary Resuscitation ‘DNACPR’ order on a 28-year-old man with cerebral palsy, without the knowledge of his family, was a violation of his Article 8 rights, under the Human Rights Act.

Transcript of case

Commentary on case