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Mhm Lovely to see so many of you here, although of course regret about the circumstances that you're finding yourself in. So when I, when I talk, I very rarely use powerpoint because most of my sessions for you, I really want you thinking about the material rather than just frantically trying to copy down powerpoint slides. Uh Do please jump in when I, when I ask for answers and things like that? This topic in particular capacity is one that there's, there's lots of thinking and talking. Uh the the kind of the concrete information is actually very small. Ok. Try not to, I know people are a bit shy. You don't know everybody else here. Try not to get caught up in worrying about what if it's a wrong answer. Uh The great value of wrong answers is that they give us something to talk about. Right answers are just a right answer and we can move on from that. Ok. So even if you don't feel brave enough to speak up, please do lots and lots of thinking during this session rather than waiting for someone else to give an answer a little way into the session. Um I've broken one of my own rules and there is actually something that, that you can use as a worksheet that has little bit of information and we're going to be discussing different cases and it'll give you a quick outline of the cases and then space for you to make notes about what are the key issues with respect to capacity and making decisions um in, in this particular context and all of the cases that I'm going to give you are real cases. Ok. So capacity, can somebody tell me what we understand in healthcare? By the word capacity? You can type it in the notes or you can shout out or you can put your hand up capacity of uh what I don't understand. Sorry. Uh I didn didn't understand capacity for what as in potential or something we need to do. OK. So that's the first question. Capacity for what? Ok. And it's about whether or not people have capacity to make decisions about their health care. Now, I'm a psychiatrist and so I work quite a lot with people who don't have capacity or whose capacity for making decisions is quite borderline. Generally, we assume that someone has capacity unless we have reason to think otherwise. And that reason is not simply because they've disagreed with us over a care plan. OK? And I do beg your pardon if I pronounce your names wrongly. Um I just saw somebody suggest that it's capacity to do something that technically technically the word you're looking for there, the ability to do something is is competence. So capacity is the ability to make a decision. And competence is the ability to act on that decision. Ok. So somebody needs a hospital appointment for AC T scan, you assume that they have capacity to attend and their competence is when they actually attend. Ok. Fine shades of meaning. Yeah. So capacity is actually enshrined in English law. Lots of countries have laws about capacity and some countries there are also cultural issues that affect how and why you would assess capacity. Ok. So this obviously is being taught from the point of view of English law. But I think the discussions around how we think about capacity are are still very useful even if you're in a country where where you don't have similar laws. OK? So we assume capacity accept where we have reason to believe that there is some kind of impairment of the mind. Ok? So what sorts of impairments of the mind? And I realize that you're guessing but just have a bit of a think what sorts of things might be an impairment to the mind. That means that people may not be able to make good decisions, dementia well done. Natasha, anything else might be a really obvious one but somebody who's unconscious. Yeah, unconsciousness. Thank you very much ril mental health, some mental health conditions. Yeah, we um we become very expert in assessing capacity, trauma, psychosis, yes, delusions. Shout. Yeah, hallucination maybe. Yeah. So any, any kind of psychosis would be an impairment of the mind. People with severe learning disabilities, good. Um people who've had some kind of brain or head injury, people who've had a stroke, um people who are intoxicated, alcohol or drugs. Um and that includes prescription drugs, for example, somebody who's had a general anesthetic is generally assumed to not have capacity for 24 hours after um the the the anesthetic has been stopped. OK. Shock itself. What's the difference between capacity and autonomy? OK. Good question. Capacity is the ability to make a decision. And if you have capacity, then you have autonomy, you can act on your decision. OK? If you don't have capacity and there are concerns about your safety or anybody else's, then that autonomy may be taken from you at least in the short term. So capacity is the legal measure of whether or not you should be permitted autonomy. And that's why we always start with an assumption of capacity. Remember, a patient disagreeing with you does not necessarily mean that there's an impairment of the mind. OK. So all sorts of things could cause an impairment of the mind that might make it more difficult for somebody to demonstrate they have capacity. So that's the first question you have to ask yourself. Am I concerned that this person may have an impairment of the mind? And at that point. If you've answered yes to yourself, then you've got a couple of questions to, to then ask yourself. First thing to think about is, is the impairment, something that is going to improve or alter during the time period when a decision has to be made. Ok. So if somebody is intoxicated and they're refusing treatment for broken bones in their hand because they've been in a fight, um, they might still have capacity to make a decision. They might well be in shock. Somebody with a learning disability may well have a learning disability but still have capacity. So the important thing to remember about capacity is that just because you have an impairment of the mind doesn't necessarily mean, but you don't have capacity, capacity is what we call time and decision specific. So it is only about a patient's capacity to make that particular decision at this particular time. OK. So you're a bit worried about your patient cause cause you wonder if they, they do have an impairment of the mind if it's going to affect their competence. There are four things that a patient has to be able to do to demonstrate their competence, that I beg your pardon their capacity. OK? And I'm not gonna make you guess them, they're on the worksheet that we're gonna give you in a few minutes time. OK? They have to understand the information you're giving them. They have to be able to remember that information long enough to process it. They need to be able to process the information and then they need to be able to communicate their decision. OK. So understand, remember, process and communicate. And as the assessor, it is your responsibility to facilitate the patient to do those things. It is not your responsibility to prove that they do not have capacity the other way around. You do everything to allow a patient to demonstrate their capacity. So for example, understand information, it doesn't specify at what level they need to understand enough to know why it's important. Why are you having this conversation? So somebody who has very poor education, it might be enough to say to them. For example, we want to give you a pacemaker for your heart because sometimes your heart is going into funny rhythms and a pacemaker. That's why you're having turns where you feel dizzy and faint and a pacemaker would stop that happening. Yeah, somebody with better education, you might choose to give them some more technical information. You might choose to say what we do is we attach the box under a flap of skin, we run wires into your heart and give small electrical impulses to mimic the behavior of the heart. So understanding information is very much at a level that's going to be appropriate for the patient. And so somebody with a learning disability who can still understand why these tablets are gonna help them with their nasty chest infection would have capacity to make that decision. Ok. And they remember the information long enough to process it. Now, some types of dementia, the patient will be able to recall information for a short period of time, some types of brain injuries, some types of learning disabilities. So you give them information, check their understanding. Yeah. Have they held on to that information long enough to understand it and then processing the information. Now, if somebody is very focused on one thing or they're in shock or they have a severe depression, they may be able to understand the information and remember it. But they're so caught up in some other thing that they can't move away from that and start to process the information. Think about what does this mean to me. OK. And then they have to be able to communicate your, their decision. OK. So somebody who is deaf, it's your responsibility to give information in a format that they can understand. And that might for somebody who's profoundly deaf that might mean written information or it might mean using a translator who speaks a deaf sign language that your patient understands. Ok. They have to remember the information long enough for them to think about what it's going to mean for them. And that includes the risks as well as potential benefits. They have to then be able to process that information and then your de patient has to be able to tell you what they've decided and they can do that by nodding or shaking their head by writing their answer down by using a translator. OK. So it's your job to give them every chance to demonstrate capacity? Ok. So perhaps we could ask our facilitator, could you send through that word document now? Ok. You should see appearing in the chat now, um a link to a word document that you can download and I've given you um a brief outline of the cases that we're going to talk about today on there as well as a summary of what we've talked about so far. Ok. Now, capacity, as we've talked about it so far is about adults, which in the UK means people over the age e uh 18 or over. Ok. So yeah, anybody over the age of 18 years, you make the assumption of capacity, things get a little bit trickier when you're talking about young adults, which in Britain are the age group, 16 years old and 17 years old. So that little gap between really being a child and really being an adult, they can give consent to treatment. They are, you assume that they have capacity to consent? Are they have much less capacity, much less protection in that respect for refusing treatment. And Children under the age of 16, you've got a slightly separate test called Gilli competence. This is all in your written notes. Um And you have a set of guidelines called the Fraser guidelines. So if we just go back to our requirements for capacity being a child could be considered to be an impairment of the mind if compared to an adult. Ok. But remember there's no specification about what level of understanding a child would need. And so for some things, what young Children may well have capacity to consent. Parents or a legally recognized guardian obviously have um the authority to consent or refuse on behalf of the child, Children do not have capacity to refuse treatment. Can anybody come up with a reason why we would say Children can give consent but not refusal, tricky one. Why might a child refuse treatment? Why might a child, brother used to have an injection? The shot. Uh Yes, the because the child doesn't know what he or she is a problem. Well, they are like uh scared for them. Yeah, fear and chil Children, you're absolutely right. Fear. They don't understand the process. They may not understand how unwell they are painful and so they may well refuse for reasons that are actually nothing to do with, with a reasoned judgment. Ok. Remember it's up to you to do your best to help Children understand what's happening to them. But ultimately, Children are more likely to make decisions based on fear or anxiety or uncertainty about the unknown than adults. Notice that phrase more likely, right? Adults also sometimes made poor decisions because of fear, lack of understanding and so on. Ok. So let's think about a case there you are in the emergency department. And a lady is brought in by ambulance because she was out in her garden doing some gardening and her next door neighbor saw her for and that she had, she got up but she was struggling a bit to get up. So next door neighbor called an ambulance. Ambulance comes in. Little old lady very, very unhappy with the situation. She wants to go home right now. She says she didn't agree to come. They made her come, she didn't want to and she wants to go home now, just looking at her just what I call the end of the Beram. So when you just look at a patient, you can see that she's fallen, she's probably fallen onto her outstretched hand and it looks like there's a little bit of bone deformity there. You think she's probably fractured her wrist? Very common uh problem in people who fall. They have to put out a hand to try and catch her yourself and it takes the impact but it fractures the bone. Ok? What's the very first thing you're going to do? The triage nurse comes and says, look, she won't tell me anything. She's just absolutely determined to go home doctor, go and sort it out. What are you gonna do? Mhm Situation. I have to tell you. Yeah, I have to tell you that I have never ever taught this case. And it's a useful one in, in lots of situations for teaching and have somebody actually come up with the right answer within the first few. But we assure her that we are here to help her not to harm her reassurance. What haven't you done yet? Talk to her? Well done Heba apologies. If that's not the correct pronunciation. Talk to her. Why does she want to go home? What's so urgent cause she's in pain? Yeah, she's broken her wrist. Even if you don't break the skin, it hurts. She's in pain. Why does she want to go home so urgently that she won't even stay for a basic assessment? Mar she does doesn't trust there's no trust the communication. Mhm. Yeah. So people have all sorts of reasons for needing to get home. Maybe she's the carer for her husband with dementia and she's worried about leaving him alone in the house. Lots of elderly people in the UK and this is a failing of our society. It's not something I'm proud of. Their main companion is a pet and surprisingly often you'll find that the elderly single people are desperate to get home because they're worried about their dog or their cat and who's gonna feed it. OK. So by talking to the patient finding out why they need to leave, remember, she's probably got a little bit of shock going on there as well. Yeah, you're young and fit. I had to fall myself fairly recently and it left me pretty shaken up, you know. So find out what the problem is because it may be that she's just a bit upset, a little bit distressed and she's not able to process what could be done to deal with that. You know, what a, what about my dog? My dog shut up indoors. Have you got a neighbor who can get in the house? Do you leave a spare key with someone so that someone can pop in and check the dog's? Ok. Take it for a quick walk feed. It. Demented husband. Do you have any carers? Do you have any friends who know about your husband and your family who could go in? Ok, because you all have to stay and get sorted out, but she's not going to, to comply with you. She's not gonna cooperate unless she feels that this is more important. Yeah. And that's the problem that she's worried about is easily fixed. Ok. So we're not gonna do the ins and outs of what the treatment is. Ok? Because that's a whole different set of electrics. Um, you talk to, huh? You explain that you really need to do an, an x-ray and send her to, to, um, fracture clinic to get her a sx lap put on and, you know, and, um, that then you'll make sure she gets home safely and she is still absolutely adamant that she wants to go home. Ok. She tells you that her daughter lives in Australia. Her daughter always telephones her at some time in a couple of hours time and if she's not there, the daughter will worry about her. So she wants to go home and she'll come back tomorrow. Ok. Are you going to flat again? No, he said no. Was that you? I said yes, we make sure that, uh, her daughter will be fine and make sure that we let her communicate where she is right now from the hospital that she's see. Yeah, you could, you could offer that, couldn't you? This little old lady is not having it. She wants to go home. So Heba, again, if she's got capacity, you're absolutely right. If she has got capacity, one of the things enshrined in the Capacity Act and when you look at it, it's about the Act itself is about that thick. Ok? It's big stuff. It specifically says that you are allowed to make unwise decisions. Ok. So fractured wrist, you've explained to her in terms appropriate to her and her comprehension that it can be left till tomorrow that you'll give her a bit of analgesia to tide her over the cli but that the longer it's left, the bigger the risk that she'll actually have some loss of function, uh You won't be able to get it sorted out. Ok. So as long as she understands that she's got capacity and you have to let her go home. Ok? She's making an unwise decision by our standards, but there's no risk to her life. Ok, if she'd fallen on her face and you thought she might have facial fractures and that there might be a bit of a bleed going on. Remember, you may not see symptoms of a bleed for quite a long time, especially in an elderly person because the brain has shrunk. So there's quite a lot of spare space in the skull on an elderly patient. So if you think it's lifethreatening, then you're in slightly different territory. And somebody suggested talking to the emergency contact, talking to the daughter. So if you now think your little old lady's got a head injury, you are now talking potentially fatal. Yeah. No, just loss of function. And so under those circumstances, you have to think about whether or not you're going to overrule her capacity to go home. And in Britain, we have something, we, we have a very complicated legal system because we have 2000 years worth of laws. Um And um so we have something called common law, which would mean that you could act as the, the, the phrase it used is in the patient's best interests. Ok? Do if there's time you need to look a, you know, you have to really think about overruling a patient who has capacity so that you can save their life. Ok. So it's very common people with a fall, they're a bit shaken up, they're kind of on that capacity. Borderline. All right. They're often elderly, they're often frail, they're often a carer for someone or a carer for a pet. And also we have a bit of a culture amongst our elderly population in the UK of, I don't want to be a trouble doctor. It's like you would be far less trouble if you stayed and got sorted out. Ok. Let's think about case number two. It's a 22 year old male. He is drunk. He's drifting in and out of sleep because he's so drunk when he is awake, he's slurring. He, he's poorly coordinated. Um He's got in a fight, he's been pushed down a flight of stone steps. I'm just looking at him because he's refusing examination at the moment. He's not cooperating when he's, when he's in an unconscious state, you manage to do a few bits and pieces and it's pretty obvious to you that he has a flail chest and he's probably got a hemothorax. So flail chest for the more junior amongst you is where you have fractures on both sides of the sternum. And so instead of the rib cage moving in a unified way, when you breathe in the middle section, actually get sucked down by the change in pressure in the lungs instead of being part of inflation of the lungs, um suffice to know this guy is going to die if you don't do something, even if you do something, he's gonna spend a long time in the intensive care unit. Ok. Won't worry about treatment. Chest pain for hemothorax. Obviously, flail chest he is going to need surgery. He's going to need careful pain management because he's drunk pain management plus alcohol, bad combination. So what are you gonna do about this guy? So his impairment of the mind, it's temporary because he's drunk, he's sober up. Uh, is he going to sober up in time to make a decision? And the answer is no. So he's got no capacity. Well done. Alade you get on and treat him, ok? Save his life first. Deal with the questions later. It's an emergency. He's going to die. And mostly as doctors, we try to keep our patients alive, just bear that in mind. So he has no capacity. So what is your legal justification for treating him uh emergency condition? So we treat them. Yeah, it's an emergency condition. Uh The patient will not be able to make a capacitance decision uh in the time frame where things will rapidly deteriorate into fatality. And so you treat him in patient's best interests under common law. Ok? It's that straightforward. The little nickle here while you're in the theater, you've changed your job. Now, you're now in the theater assisting the surgeon and you notice that as well as his chest problems. It's got a very nasty ingrown toenail that looks like it's got a little bit infected. What are you gonna do about your toning. Leave it alone. IBA. Well done. Why? Cause it's not a life-threatening situation because it's not lifethreatening. Ok. So that's not an emergency. He will have capacity to make that decision in a suitable time frame. Yeah. So if you operate on it and he decides to, he can actually prosecute you for assault because you could have waited. It was not necessary to do it. Right. Right. At that time. Ok. So let's think about now, another elderly relative, I think I've put female, but it could be male, elderly, elderly, frail, you're working in the out of hours. GP. And she's brought in by family who realize that she's not very well. And you see from her notes that she's had pneumonia about a year ago, otherwise she's pretty fit and well for age when she had pneumonia last year, she was treated in hospital for a few days. She did have some delirium. Ok. Family tell you that she doesn't speak much English. Um, last time she was ill, the hospital said they didn't have that. She didn't have capacity. So don't bother to speak to her about it. Just tell them, um, what he's doing. Are you going to accept that? And the communication part is one of the four parts, the communication part is not right. So capacity is impaired. Wow. So she doesn't speak English or she doesn't speak the language that you speak. What are you going to do? About that. We try to communicate, we try to under make the person, the patient understands the situation or translate. So, so firstly, you've only got the family's word, but she doesn't speak any English. Right. I'm a nasty, suspicious type. I never believe a word. Families tell me may be true. May not be. I don't make a judgment about it. Would you use family as a translator? No, no. Ok. Why not? Lots of people say no, you're absolutely right. Why won't you use family as a translator? Because the family might not translate or might take, have their own agenda for you can't be sure they translate. The number of times I've sat with patients and a family member as they've had a conversation with a family member about a question I've just asked and they talk for about 2.5 minutes and then the family member turns around and says she says, no, she like she may well have said no, but she said a bit more than that. And you're not telling me that. So wherever you can use a professional translator, OK. You don't know. Somebody said there could be conflicts within the family. You don't, you don't know and that's not your business. What's going on within the family. The patient is the patient is yours. The family is not. Ok. So wherever possible and most hospitals in the West will have access to professional medical translator services. You may have to do it by phone, which is not ideal, but at least you'll know that what's being given to you in the translation is what the patient says and thinks. Ok, next best option. Um, what is, if you're in a pretty multicultural place is to see if you can find a member of the hospital staff or a member of the team who speaks that language. It's not as good as a professional translator for exactly the same reason that because they're employed by the same organization of you as you, that there's a little bit of a conflict of interest there, potentially. Yeah. So you always do what's best for the patient and what's best for the patient, whatever the family says is for the patient to be supported, to make their own decisions. And the other thing to bear in mind is that just because someone's not had capacity in the past doesn't mean she doesn't have capacity to have. Yeah. And so you're gonna try and firstly, you're gonna see how much English she really does speak or whatever language you're working in. Um, and organize a translator again. If it's an emergency, you're just gonna get on and do something in the patient's best interest for. Now. She's looking, you know, end of the be gram, she's looking a bit poorly. She's looking a bit bit clammy, a bit pale, a bit tired, you can do basic observations because if you want to take the BP and a patient holds their arm out. You can take that as, as consent. Yeah, it's employed consent. But a patient cooperates with simple elements of a physical examination. Yeah. So, so you can do those basic s you can have a quick listen to her chest. That'll tell you whether or not you can kind of hear. She's got a bit of a wet cough and it's a bit bubbly. Um, so you're pretty certain that she's gonna have a pneumonia, ok? Just because previously, her pneumonia needed hospital treatment and she became delirious does not mean it's going to, to be the same problem this time. Is it ok to ensure the patient's privacy? Yes. And again, I've had patients brought by family, not just adult members of the family, they brought all the kids as well and it's like, you know what, throw them all out except a daughter, you know, one have one person in the room with you, ok? And try to involve the patient in that decision about who it is. Ok? So something that, that really only has five principles is now starting to look really quite complicated in the real world. Ok? It's all about talking and communicating with your patient. Ok. We're gonna push on cause we're near the end. Um I'll skip through, I think I gave you a detained patient just because somebody is detained under the mental Health Act does not mean that they may not have capacity to make decisions about physical health. All it means is that they do not have capacity to make decisions about mental health. So if somebody comes in and obviously has appendicitis, they can really be very psychotic. And again, if they understand the information they can retain process and tell you, yeah, please don't go ahead with the surgery, so they may have capacity because it is decision and time specific. Ok. Children again get quite complicated and I know you've got another lecture after this, but I am going to use up every possible minute. Um Something quite common. It's a particular problem in the United States. But to a lesser extent, we have it in the UK as well. And that is Children of people who are very vehemently anti vaccine who haven't had their Children vaccinated, including against COVID. And what we're seeing is we're seeing some quite young Children, often kind of early teens, mid teens coming to their doctor and saying, yeah, but you know, my best friend got COVID and she was really, really ill. I want to be vaccinated, but you can't tell my parents because they're anti vaccination. Um OK, what are you gonna do? The patient understands the situ situation, then they might have the autonomy, the capacity, they know they, they know they, they've clearly indicated to you that they understand why vaccination is quite important, especially in an epidemic because they've seen how serious it is. What are you gonna do about this? I'm 13. Don't tell my parents, the patient is aware of the situation that the vaccination does. Well, there are cases in which vaccine people who are vaccinated have got COVID. Yeah. So we might, might have to tell the risk that there is no guarantee whether after vaccination, whether you will be perfect or prevented or not. Yeah. And this is where the phrase Gilli competence comes in Victoria Gilli was a mother. I think back in the eighties who found out that the local GP had given her 15 year old daughter contraception without informing her because she was vehemently anti sex before marriage. And um it went right through to the High court. And the answer is this is where the thing that Children have capacity to consent. If the child demonstrates capacity about a decision that child can consent. The important thing about Children is that you should recommend to them that they do talk to their parents about it, but it is not your job to do the talking. Ok. So exactly the same. Do they understand the information? Remember there isn't a standard for understanding set. So age appropriate understanding. Oh, why in this case, vaccination might be a good plan? Ok. It's not an emergency. You're not acting under common law, you're acting within the Capacity Act and specifically with respect to the gimmick competence section, they can process it. They understand that it reduces the risk it doesn't eliminate the risk. So you go ahead and do it, ok? And you don't tell the parents, you encourage the child to talk to the parents is a big problem in America because the anti vaccine lobby in America is very vociferous and very powerful in the UK. It, it's a lesser problem but is still a real issue and is something that does happen. Ok? So the fraser guidelines are specifically about contraceptives for Children. Remember, legally in Britain, anyone under the age of 16 is a child. So if a 15 year old comes to the GP asking for contraception and contraception is free in the UK, um she doesn't want her parents told, but she's got a boyfriend. It's been the same chat she tells you, you know, so we've been best friends for over a year now and we haven't had sex yet, but we're kind of thinking that, that we're ready and I think we're probably gonna have sex quite soon now. But you can't tell my parents because they're Roman Catholic and they're absolutely determined that you have to wait until marriage to abscess. So the Fraser guidelines again, take you back to competence uh capacity. I beg your pardon? And the story that she's telling you sounds very capacitive. She's expecting to have sex quite soon. Um She doesn't want to be pregnant but she can't talk to her mum about it. Ok? So you are going to, again, you're gonna encourage her to talk to her parents, but you're going to give her the contraception. What exactly you give her again? That's a whole different question. Uh, I have a question. Yeah. Uh, when you said that, uh, these two couples who are like teenagers, not, and they are saying that they are aware of the, of the risk, like unprotected cyst. Yeah. Yeah. Sex will be to STD S or pregnancies. But, yeah, like you said, if the story is, uh, like, uh, like they're selling it in a manner properly that they are aware of it. Yeah, just to double check. Can I, like, ask the girl to just have an ultrasound or whether she knows she is already pregnant and she's just having a bit to get the drugs. Yeah. And that, that would certainly be a sensible thing to do. I, an unwritten rule of thumb in all medicine is that every woman of childbearing age is pregnant until you're certain otherwise. Ok. So, so, yeah, you might suggest to her, you know, have you had sex already? Can you just a quick wee sample for me? Yeah. Don't make a big deal of it. She's already embarrassed enough, but she's sensible enough as well if she tells you. So, this is a bit off pieced. But while we're talking about young people and sex, if she says that the reason she doesn't want to get pregnant is because every time her 34 year old uncle babysits her little sister. He sexually assaults her. What are you gonna do? Then it's a legal case and we need to protect. Yeah. Yeah. Absolutely. Young. It is statutory rape to have sex with someone under the age of 16 in the UK. But teenagers are going to experiment if she is talking about essentially a school friend that, you know, they've been going out for ages and, and they're around about the same age. The chances are that this is not an abusive relationship as soon as you start to hear about a sexual partner, whether it's boys or girls, both directions who is much older, who has some kind of authority or power over this person. Um, I wouldn't tell the family, I wouldn't tell her parents because this is going to be massively massively distressing for the family. This is going to destroy the family, this information and if it doesn't, it should have. And that, so you're actually, um, in Britain, what we have is every GP practice where I work as a psychiatrist, we have a safeguarding lead. And if it came to my notice that perhaps one of my patients was abusing somebody sexually, I would take it up with safeguarding and they will act instantly. Ok. So, so we do have a system in the UK where if we suspect that a young person is vulnerable, not just sexually vulnerable. Yeah. You know, some parents are just really not very good parents and so safeguarding lead and if you don't know who the safeguarding lead lead is, um, you need to find out urgently or if the safeguarding lead is, I don't know off sick. Yeah, you can just ring social services and, and it's not the best route through because the paperwork won't be quite right. But just ringing social services. Ok, boyfriend, same age ct pressure. Absolutely. I'm sure us girls have all come across cases and probably some of the boys as well. But people say if you really love me, yeah, you would, if you loved me, it would make our relationship so much more special. And so that would be something you'd want to look at. If it's age appropriate, I would still give her the contraception. I mean, I'll give her the contraception in any case. I do not want my 15 year old pregnant. Ok. Um, but I might, I, so I might suggest that she comes back with her boyfriend. Um, if no police or safeguarding is available, then, then you probably would want to talk to the mum. The problem. We are literally in our last few seconds. The problem with that. A patient of mine a few years back now as a child, mom and dad split up, dad was had her weekends and at weekends his friends paid to come and have sex with her from the age of seven. Mother knew and facilitated it because if she didn't, she was worried that her ex-husband wouldn't give her any money. So who to tell in that case, if there's no police, no safeguarding. Uh In any case, I would talk to your immediate senior and, and talk through together, what, what's best to do in that case? Ok. And if you end up working in um, Britain or anywhere in Europe, uh your organization will also have an expert lawyer and you can just talk to the lawyer. Ok. It's been, we are now overrun. I'm not gonna keep you. Thank you so much for coming. My next session will be the second part of PTSD. Um I still have one session with no topics allocated. Do please send messages? Um If there's a particular topic you would like covered have as good a rest of the day as you can. Thank you very much doctor for this. No problem. Hope you have a lovely evening. Can I have to just fill out the feedback and join the next lecture? Should start in a minute or two. Thank you very much at night. Thank you for your help today. Bye. You too. Bye bye.