Questions over mental capacity

A patient rejects life-extending cancer therapy but his family says he is not competent to decide.

The dilemma
A middle-aged patient of mine was diagnosed with a bronchial carcinoma. The oncologist had recommended maximal therapy with chemotherapy and radiotherapy, but my patient refused all treatment. He did not want to suffer the side-effects, despite the consultant's reassurance that he stood a good chance of extending his life significantly.

After this consultation, his wife and daughter came to see me. They insisted that it was my responsibility to convince him of the error of his ways. I explained I had to respect my patient's wishes, but they said he was deeply depressed and not able to make a rational decision, and demanded that I sign a statement saying he was mentally incompetent. I did not believe him to be incompetent. What should I do?

A GP's view
Dr Louise Warburton, a GP in Ironbridge, Shropshire

Being depressed does not necessarily mean that a patient is incompetent to make decisions about his treatment.

In this situation, I would make a visit to the patient's home (with his permission) and, in a private, non-threatening environment, speak to the patient and perform a mental health assessment.

It would be necessary to discover if the patient had any thoughts of suicide or ending his life. I would need to find out whether he had any irrational beliefs about his illness and the way that his life will end as a result of the cancer.

I would also contact the patient's oncologist, because sometimes brain metastases can alter a patient's behaviour and personality and it may be necessary to have a CT scan of his brain performed.

If I had any doubts about the state of his mental health, I would ask for an assessment by a psychiatrist.

If the psychiatrist deemed the patient so depressed that he was endangering his own life by refusing cancer treatment, a mental health social worker and his GP would have to take the decision whether to admit the man, if necessary under a section, to treat his depression.

I would also have sympathy with the patient's wife and daughter, because they probably felt they were acting in his best interests when they asked you to sign a declaration that he was mentally incompetent.

It would be necessary to explain carefully to them how you are going to proceed in the circumstances, so that they understand your motives.

A medico-legal opinion
Dr Bryony Hooper, medico-legal advisor at the Medical Protection Society

Under UK law an adult is assumed to have capacity unless shown to lack it. This position has been reinforced by the Mental Capacity Act 2005, the relevant section of which came into force in October 2007. If there is doubt about the patient's competence, you will need to make an assessment of his capacity, relating specifically to the decision in question.

The assessment should involve both the patient and the family or carers. Consider whether the patient is able to understand the information relating to the decision, and weigh up the facts in order to reach a decision that they can communicate to you.

In this case, the patient's family believe he is severely depressed following his diagnosis of lung cancer, and that this is preventing him from making a rational decision. This is something you need to explore with the patient.

If he is depressed, he may need treatment for it. Consider whether any depression may affect his ability to understand the potential benefits of treatment, or prevent him retaining the information in order to reach a decision.

Because his decision has significant implications, you should consider asking a psychiatrist to assess his capacity.

Sectioning the patient under the Mental Health Act 1983 for assessment or treatment of a mental disorder is unlikely to be of any relevance here, as if applicable it would only allow treatment of the mental disorder and not treatment for cancer.

If, in your view, the patient is competent, it is his choice whether he has chemotherapy and radiotherapy. If you consider that he lacks capacity, it is up to you and those caring for him to act in his best interests.

A patient's view
Elizabeth Brain, member of the RCGP Patient Partnership Group

Provided that you know he has made an informed decision, you are right to respect the wishes of your patient.

It is not your responsibility to convince him of the error of his ways. However, you should ensure you have provided him with all the relevant information showing the benefits of treatment, and reinforced the consultant's reassurance of a significant life extension.

Given the patient's apparently flippant reason for rejecting treatment, the next stage might be to explore whether there is an underlying reason for this, other than his family's perception of depression. For example, the patient might have had a relative who struggled for years with a similar condition and outcome.

The family's concerns should be listened to and understood. Searching for some synergy between the views of the patient and his family might lead to a clear way forward that is in the interests of all parties.

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