Consent in emergency medicine

The scene

An elderly couple were brought into A&E after a road traffic accident. The husband was unconscious and taken straight to theatre for urgent abdominal surgery. The wife remained in A&E for treatment for a broken humerus, her only injury. Although alert and able to communicate freely, she was agitated and seemed mildly confused, primarily about the cause of the accident. She was, however, adamant she would not consent to an operation on her fractured humerus until she knew how her husband’s operation had gone. The A&E consultant was worried she might not be competent to make a decision, given her recent physical and emotional trauma. He rang the MDU 24-hour advisory helpline for advice on assessing capacity.

MDU advice

The immediate question in this case might be “Does this patient have the necessary capacity to refuse this treatment at this time?”. However, where the treatment could be delayed without causing serious compromise to the patient’s care, it might be appropriate to defer the decision and reassess an apparently incapacitated patient after a period of time.

Since this did not appear to be an emergency, the consultant considered he had time to liaise with orthopaedic colleagues before going back to see the wife. The adviser explained that it would be advisable to make a note of his discussion with the wife, setting out what he told her about the pros and cons of operating there and then versus delaying the operation. The adviser recommended that the consultant then formally record his assessment of the wife’s capacity, step by step.

Should the assessment prove inconclusive, and a short delay would not be life threatening or lead to a serious deterioration in the patient’s health, the adviser recommended seeking a second opinion either from an A&E colleague, or if that was not possible, from a psychiatrist.

The adviser explained that if the wife was found to have the capacity to make this decision, then her refusal should be respected. If she was found to lack capacity, consideration should be given to whether her incapacity was temporary, perhaps as a result of stress, fatigue or emotional upset. If the incapacity was considered to be temporary, the adviser suggested it might be prudent to schedule a re-assessment within a short time, for example after 12 hours or the following day, providing the delay would not lead to serious harm.

These are fictional cases compiled from actual cases in the MDU’s files.

This page was correct at publication on 01/08/2012. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.