The scene

A GP was contacted by the manager of a local care home because a resident’s daughter objected to her mother receiving the COVID-19 vaccine. The daughter, who had a lasting power of attorney (LPA) for health and welfare decisions, claimed the vaccine was untested and posed an unnecessary risk, but other family members disagreed.

According to her medical records the patient had recently been diagnosed with early-stage vascular dementia and had a 10 year history of type 2 diabetes. She had been compliant about taking medication for this and had always been willing to receive an annual flu vaccination.

The GP called the MDU for advice.

MDU advice

The MDU adviser agreed this was a sensitive situation but that the GP’s overriding objective should be to determine what course of action would be of overall benefit to the patient.

The first thing the GP needed to do was make their own assessment of the patient’s capacity to decide whether to be vaccinated, bearing in mind that capacity is time and decision specific and capacity might fluctuate in a patient with early-stage dementia.

Even if the patient’s condition meant that she was unable to understand the relevant information or make an informed decision, as set out in the two-part test in the Mental Capacity Act, it was important to consider practical ways to help her make a decision – doing the capacity assessment at a time of day when she was most alert, for example - and giving the patient every opportunity to be heard.

The assessment and discussion should be clearly documented, including the information given to the patient, what questions were asked, her response and the outcome.

If the patient was assessed as lacking capacity, the next stage was to determine whether vaccination was of overall benefit. Although the daughter had an LPA, she could not simply veto treatment that was felt to be clinically necessary and which aligned with her mother’s needs, preferences, values and priorities.

In order to reach a decision, the GP needed to take into account all relevant circumstances, including evidence of the patient’s past and present wishes, such as the fact the patient had previously consented to having flu vaccines, as well as the views of her daughter and others interested in her welfare.

As the issue had become so contentious, the GP should call a best interests meeting, involving relatives and care-home staff to discuss the options, risks and benefits and see if an agreement could be reached. If this was not possible, the GP would have to seek legal advice about making an application to the court of protection.

Outcome

Unfortunately, a consensus could not be reached during the best interests meeting so the GP was obliged to ask the CCG to apply to the court of protection for a decision. After hearing evidence from all parties, the court decided it was in the patient’s best interests to have the vaccination and this went ahead without further objection from her daughter.

Assessing capacity for COVID vaccine

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