A 72-year-old woman with dementia is brought into the surgery with symptoms suggestive of a UTI. She has had many infections in the past but this time says she does not want any treatment. When you examine her you find she is slightly tender in the lower abdomen and she is febrile and confused.
She does not recognise you or know which day of the week it is. Her carer states that her dementia has been gradually worsening over the past few months. A urine dipstick is positive for leucocytes and nitrites. You feel that she needs a course of oral antibiotics to treat her UTI but the patient does not want to take any more tablets. What should you do?
A GP's response: Dr Raj Thakkar is a GP partner in Buckinghamshire
It is clear that antibiotics would be beneficial for this patient and it is reasonable to assume that the UTI is the cause of her confusion and the confusion is acute in this scenario.
In the first instance, it would seem appropriate to explore her concerns with respect to taking antibiotics; despite her confusion, you may be able to address her fears and gently persuade her to take treatment. If she refuses, it is worth addressing her capacity with respect to the risks of not having treatment, particularly noting the morbidity and mortality associated with acute confusion.
If you are sure she has capacity, you may have little choice but to respect her decision, although it would be useful to know if her agenda was born out of depression or the wish to die. This being the case, you may be able to employ the use of psychiatric services, although they cannot treat a primary physical illness under a Mental Health Act section. Alternatively, you may elect to review her later in the day.
If she lacks capacity and there is no advance directive or power of attorney, you may decide to treat her using a 'best interests' approach. From a practical point of view, it is unlikely that even if you did treat using this approach, she would actually swallow the antibiotics. Alternatives to consider may be antibiotic syrups, IM administration or hospitalisation for IV antibiotics.
Once treated, a number of discussions and considerations will need to take place regarding risk assessment, dementia review, crisis-management plans and care package review.
A medico-legal view: Dr Jayne Molodynski is a medico-legal adviser for the Medical Protection Society
Making decisions about patients who lack capacity is governed by the Mental Capacity Act 2005. Patients are presumed to have capacity and can only be regarded as lacking capacity once it is clear that despite receiving all appropriate assistance, such as arranging for them to attend with carers or providing them with written information, they remain unable to understand, retain, use or weigh up the information needed to make the decision, or communicate their wishes.
If a patient who lacks capacity has registered a lasting power of attorney (LPA), which means they have nominated someone they trust to make decisions on their behalf if they lose capacity, their views should be sought, and they may be able to make decisions on the patient's behalf, as long as the LPA is relevant and applicable in the circumstances.
In the absence of an LPA, decisions on behalf of an incompetent patient must be made in their best interests. To help assess best interests, you should consider the patient's previously expressed preferences and views, and the views of those close to the patient and of the healthcare team and carers.
Prior to making any decisions, thought should be given to whether the patient is likely to regain capacity and what option would be the least restrictive to the patient's future choices.
You may also have to decide what information to share with others. The GMC, in its publication Confidentiality, advises that: 'You should establish with the patient what information they want you to share, who with, and in what circumstances. This will be particularly important if the patient has fluctuating or diminished capacity or is likely to lose capacity, even temporarily. Early discussions of this nature can help to avoid disclosures that patients would object to.'
If a patient lacks capacity the GMC considers that it is reasonable to assume that they would want those closest to them to be kept informed of their general condition and prognosis, unless they have indicated otherwise.
A patient's opinion: Antony Chuter is an expert patient
The carer says that the patient's dementia is gradually worsening, but a diagnosis of dementia does not automatically mean that the patient does not have the mental capacity to make a decision. UTIs are common for the patient and I would expect that any doctor would consider treating the infection.
What needs to be established is the patient's ability to make decisions and if she has the mental capacity to make a decision for herself. As a layman I don't know how a doctor could treat her if she refused to take the medication.
If the infection is causing the patient's confusion and she is judged not to have the mental capacity to make a decision for herself, I would expect the doctor to consider treatment.