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Okay, so that should be us going live now. So good evening, everybody. Welcome to today's webinar on capacity. So we've got a doctor embarrassing to me who works at the hospital, and Lizzie Evans, who works at Kingston talking you through self discharging patients. So over to you, Lizzie. Sorry, Lizzie. I think your muted is that better. Can you hear me a lot better. Thank you dot Hi. Hi, everyone. Thank you for joining us. Um, welcome to our webinar on capacity and self discharge. Just a couple of housekeeping notes before we begin. Um, make sure you send all of your questions in on the Facebook lives so that we can answer them all. At the end. The session is going to be recorded, and we'll send out all the Lincoln materials to providing your registered, so make sure you're registered in mind the beat dot com forward slash webinar dash registration. We'll put that in the chart as well. We've also got two members of the n D. You here to support us today? We've got Doctor Ross and Lausanne. Um, and they'll be giving us a couple of slides at the end and helping us answer the questions. Remember that you need to get your MD foundation membership sorted before you start your shadowing. Unless you filled in the foundation application form, your student membership will cease in the summer. So it's essential that you have your indemnity cover. So we'll send out some links now to help you with that. Um, so with no further ado your hand over to Doctor ob and we will start our best talk on capacity. Thank you very much. Let me thank you for that. Um uh, there's a specific point where we're going to get back together again, but if you want till then, you can turn your camera off and, uh, just watching the background. Okay? So hello again, guys. My name is, uh, I'm one of the f word working around feeling hospital. Um, I've done my F one F two in Brighton East Point. Hastings. Uh, mainly done a lot of work in in surgery, but a little bit in, uh, Edie and stuff as well. Uh, since, uh, f two today, and we'll be talking to you guys about capacity and self discharging. Uh, we're not going to get into too much the mental health aspect of self discharging. Um, and, uh And then, Doctor, what's gonna pop in and say everything I've said is incorrect and correctly, which is going to be a treat. Um, but let's let's do a quick chat about the capacity stuff. First, I want to start off by actually asking you guys why you guys think the capacity is important is, uh why would you think capacity is important? And when I asked myself that, I then started, imagine imagine, in a scenario where you know, you wake up in prison, I want you guys trying to imagine this as well. At the same time, you wake up in the prison and everyday mask people come in and you know, they talk over you in a foreign language. They start performing procedures, prodding you, poking you. None of them tell you what's going on, why you're there. And when you try and leave the stuff guide you back to your bed, they sedate you where they stop you from leaving. Um, I mean, imagine the powerlessness. You must feel the the anguish, the terror of sleeping in an unfamiliar place, having people do things to you and you not tell you what they're doing and what's going on? Of course, obviously exaggerating. But I hope you can understand the parallels between this scenario and what multiple elderly patients go through the hospital when they admitted. Thankfully, we're trained to communicate with our patients and get their consent before procedures. But if we didn't, it's easy to see what kind of a nightmare scenario could occur in hospital, especially as stresses are put on to an already overloaded system. And that's why you need to know about capacity because it's not just, oh, we want to do what's best for the patient. So let's do this. You're making life altering decisions on someone else's life. Imagine waking up one day missing a leg and not knowing why again, over dramatization over dramatization. But the fundamental is important. Fundamentals are important. Consent is the bridge that allows the public to trust us to treat them and consent intrinsically requires capacity. So that's why today we need to talk about capacity. There you go. That's our link. So, uh, for our content today we're going to be talking about how we assess it. What happens when a patient like's capacity and what happens when they have capacity. So the NHS UK website defines capacity is the ability to use understand information to make a decision and communicate any decision made pretty on the nose for how we actually assess it. If we look at another source, the M D u States capacity is the the ability to make a decision or taking action that impacts on a person's life? It indicates that person is able to make a decision about their own care and treatment. The GMC of released guidance on decision making and consent that goes into capacity. Uh, and actually I think I I refer to that later on as well, because it's really useful. It's really accessible information. Actually, there's a couple of points I wanted to make about capacity. Uh, number one. It could be lost temporarily or permanently. Uh, an example of temporary loss of capacity is when you may have an infection or because you've decreased GCS because of hyperkalemia secondary to blood loss in a in a trauma scenario, uh, and then you know, if they if you fix the underlying issue capacity, the GPS will go up and capacity should return. Secondly, a situation and time dependent. So if a patient fails in the capacity assessment for a specific procedure, let's say a surgery. It doesn't mean they now like capacity to decide if they want to go downstairs for a smoke or what they want for dinner. So, uh, they may still be able to make those simpler choices. Uh, so you need to assess reach decision individually. Um, and each decision needs its own assessment of capacity. Now, you assume now the last thing is assuming capacity. You assume that anyone you see has capacity, and then you have to assess them to see if that's the case or not. You can't start off by assuming they don't have capacity. It may feel like a shortcut when a patient has dementia in their past medical history. But as we know, dementia is a spectrum. It's a progressive disease. It doesn't mean that they immediately lose all capacity at the moment, have any memory issues. So you assume they have capacity, and then you work to see if they don't have it afterwards. Now, how to assess capacity so you should be able to remember these 44 tenants of capacity. But before we actually get to the official way of assessing capacity, there are some situations when this full assessment isn't required. So implied consent and verbal consent is something that I use daily is like when you when you examine someone, uh, you do need to explain what we're going to do. We don't have to, like, sit down, ask them to wake up the pros and cons of getting their abdomen examined. Uh, if you say I need to examine your tummy in a in an E d setting and they pull up their shirt, it kind of indicates that they're that they're giving their consent. Now, you may remember, for medical school the capacity is broken down into these four sections. Uh, patient needs number one. Understand the information relevant to the situation. They don't need to know the exact biochemistry. So it's up to you guys to give them the information, give the information to them in a way they can understand and also give the information that's relevant to them as well. That includes using an interpreter or writing it down, or however they want to communicate if they can't communicate. Uh, in the same language that you can like sign language as well. It's sometimes you have to go down that route. Number two, uh, retained. They need to be able to retain that information. So patients are on well, may have a lot of difficulty with the steps, so that's probably the one that that you can kind of jump to when you're assessing capacity to be able to quickly say they don't have it, we'll go into that in a second. Number three uh, they have to be able to consider the pros and cons of the decision. You can give them the pros and cons, but they have to be the one to consider them. And keep in mind that the outcome of their consideration maybe different to how what sort of outcome you would have had if you can, uh, consider that information so they're allowed to basically make choices that don't match yours as long as they have capacity for it, and they need to be able to communicate that information back to you. Now that may be nonverbal. I've heard of versions of things that look like a board, like they have the most common words they use on the sides. And then they have, like, a list of, um, uh, letters in the middle. And they use this indicator to be able to say, Well, they want to see when they can actually verbalize because they have, like, a, uh, something in their throat or what have you So but as long as they can somehow get that information to you, that's good enough. They don't have to verbally say, um, Lizzie, are you there? Yeah, I am on second. Lizzie. How do you feel about doing a little scenario for us? I would love to. Okay. Do you want to take it away? I'll be the patient. You go ahead and be the doctor. Okay? Sure. So hello there. My name's Lizzie. I'm one of the doctors on the ward. What's your name? My name is AP. Nice to meet you. Nice to meet. You know, I've been asked why one of the nurses to come have a chat with you about some of your medication. She mentioned that you've been having some concerns about it. Is that okay? Yeah, that's fine, Doctor. Perfect. So I understand. I think the medication you were concerned about is something called a statin at all. The statin you're taking that for? Yeah, I think I think one of the doctors really bring down my cholesterol. Yeah, exactly. And do you know why That's important? Not really. Would you like me to tell you? Go ahead, please. So high cholesterol has been linked with problems such as blood clots, which can go into different places such as the heart of the brain, so you can put your higher risk of things like stroke and heart attacks. And that's why we put you on a statin to try and bring down your cholesterol. So taking this basically means I don't get a stroke, right? Not quite. It reduces the chances of you having a stroke or a heart attack that doesn't completely remove the chance. So what would the chances be? Well, I'm glad you asked that. I've actually got a leaflet here which can tell you all the information about it. So I do have a read. Thank you very much for this. I can see that. You know, it doesn't. It's not that much initially, but it adds up over time, huh? Yeah, Exactly. Alright. Well, see, Doctor The thing is, these pills, they give me dizziness and, you know, they gave me terrible wind. I really can't bear the side effects. It really does make my life a heck of a lot harder. Oh, I'm sorry to hear that, but I can see that you have read your leaflet and you understand the benefits of taking the statin that have considered them against the negatives of having such side effects such as the terrible, terrible wind. And I think I'm right in saying that you don't want to take the medication. Correct. So why don't you finish reading that leaflet and I'll have a chat with our pharmacist and we can kind of come back and reconvene. And you really don't want to take the statin? Perhaps we can find you an alternative or talk about different methods. Thank you very much. That's very helpful. Thank you, Doctor. I wish we were Thank you, Lizzie. You can disappear again. I wish we were doing this in real life that you could take about. That was beautiful. Thank you so much. Okay, So that was a scenario where a patient had capacity. But let's say the patient has dementia. That's why we have the blue butterflies. There is. The patient has dementia. The nurses informed do that, You know, they don't know where they are. They don't remember much of anything, but they need a specific procedure. In that case, as a as a as a general tip, what I've done is, um, after the initial introduction, uh, just getting getting them comfortable. I asked them why. Uh, why they don't want the procedure. Because you have to also remember that your reasons for not wanting a procedure might not be the same as theirs. So they'll say why they don't want a procedure. Then what I'll do is I'll list a few reasons why they should have the procedure. I e they don't die or what have you? Um, and I tell them about the risks that they don't have a procedure like if they die, Um, and then I then list their reasons for why they don't want it back to them. Okay, so I've given the pros of having the procedure and the cons that they've given me the ones they think are important to me. I've given it back to them, and then I asked if they can state any of those reasons why they should or should not have the procedure. They just need to name me one of each a lot of the time. With dementia patients, you should be giving them time to be able to communicate with you. But a lot of the time they actually stumble on that very simple step of be able to recount anything back to you. And that means that obviously they don't have the ability of retaining that information. I can put that example down on the notes, and that'll be that'll be my I can then go through the rest of steps as well. But that's one way of saying boom. I'm happy to say that they don't have to pass it to make that decision at that point in time. Another important example is when there's an emergency and the patient's unconscious. Obviously, they can't do a lot of the assessment so they won't have capacity. You have to make a decision. Uh, you have to decide if decisions can wait until they regain capacity or if you have to start treating it normally in the E. D. We just start treating you start fixing the problem when they lack capacity, you're given to guidances from the GMC number one. You have to choose the option that's in the patient's best interest. And generally this is life prolonging, as doctors are not allowed to, uh, make decisions that are, uh, inherently many to show in the patient's life. Um, but you shouldn't be doing this in a bubble of making any decisions without consulting. They're close friends or family. They don't get the last word. But you you should be consulting with them to kind of understand what the patient's wishes would have been if they were able to make that decision there, Um, and then Number two is You go for the procedure. That's least restrictive. So you don't you don't go to the to the end point where it's where it's maybe they you lock off a limb or what have you go for something that that is the least researcher for them. So if they do come back to consciousness, they do get capacity again. They can make a full decision themselves. Um, if they have capacity, then you need to attempt to work with them to meet their needs give them options they can choose the one that's most in line with their views help facilitate their decision making. So you ask them what their worries are, and then you give them options and give them the pros and cons because they have capacity, they can weigh it up themselves. They can decide what they want to do. You want to try, and the goal of that is you want to try and keep them as safe as possible without putting in a restriction they don't want. Okay. And generally, if they have a capacity as a junior, if your patient is refusing, let your seniors know that they refused because they may want to put themselves in surgery. Um, if a patient was indicate to me, they didn't want to, um, have a surgery done, even though the war ground with the bosses. They said they did. Then I shouldn't just let that sit there. Um, and if they if I can't explain well enough, why they need it or if they continue to say they don't want it, the bosses need to be informed so that they don't realize that the patients really, uh, presented their consent just before they try and put the patient to sleep, because that really slows everything down. So let your bosses know early if patients are refusing, um, have capacity. Make sure you document I'll keep saying this. Make sure you document clearly your your assessment of their capacity. Um, that's the end of the capacity stuff. Just a bit of further reading. So there's two websites. Um, hopefully in the in the recording. It's high. Def. Enough that you can actually take these down Number one. It's the GMC. So I got this link from from the mind the BLEEP website when I searched, uh, when I search self discharge and they gave they had this link there. It's really accessible. It's really easy to read. Um, it does cover a broad base of stuff, So there's a lot there. Um, and I think the M D U website was really good. Um uh, condensing that down. But we have the do you guys, uh, ourselves. Anyway, we're lucky to have them. So, uh, they'll be having a chat with us later on. And I think lazy. That's my cue. Are corporate decision. I'll be 20 to 30 seconds if it's okay, I'll be right back. Lovely. Thank you for that one. So just whilst we're switching on to the next slides, um, if you could just copy this QRS code and have a go at getting some feedback, Um, if you could be as detailed as possible just so we can make the next sessions as kind of fit in for you as we can. So good and bad feedback. Remember, we've also got two people from the M D u here. We've got Doctor Ross and we've got Lausanne. Um, so any questions for them as well? Do you let us know? I'm just looking at the Facebook live. I can't see any questions at all. There's got to be some questions, so make sure you write them down as we go. I'll make a note of them and we'll address them at the end. It's because I'm covering it so extensively, Lizzie. It's all okay. Excellent. But if there's any some questions challenging. Thank you, Lizzie. Thank you. Okay. I think I'm ready to go for the next one. I do believe we are now doing the self discharge. We're not. Yeah. Okay. Give me 30 seconds just to remind everybody that if you fill in the feedback, then you also get a certificate of attendance, which is really good for your portfolio to make sure that you do that even better. You said that where the voice come from. Okay, thank you very much for that. Okay, so I'm ready for the second one. All right, So I hope you guys had a break. Have a little sip of your drinks. Let's get into the second round. So could I just interject for a second? Please do. So I just run a quick poll on on Facebook. So the question was, which of these is not a component of capacity, And I think you're doing pretty well because almost everybody has got the right answer. So 93% got the right answer. So keep up the good work. All right, there we go. I've only put 7% of people to sleep. That's good. Let's get some more energy in our voices as well. Let's do this. And this one is where the meat potatoes at the of the talk comes in. So this is about self discharge. Uh, you know what? Funny enough me and Lizzie when we met yesterday. Just make sure we were happy with, uh, with the presentation. We talked about how when we were younger, we were so worried and so worked up when the patient said they were going to self discharge. But as time has gone on and you've got more comfortable in the hospital environment, you understand that it's just it's part of the process of a patient, you know, they they can take their care into their own hands. You don't need to be so concerned about it. And really big thing is to keep in mind you're taking care of unwell patients, right? Really sick patients that can't choose to leave the hospital because they're not conscious or what have you. So keep in mind your priorities in terms of you're taking care of unwell patients, right? They take, uh, well, patients. You're trying to keep them safe. Uh, the prefix. What I want to say is, take your cue from your seniors. Um, in surgery, Uh, your patients are generally two unwell to get up and and walk out of the ward if they actually have a surgical pathology. Um, and with surgical problems, they end up eventually getting worse. So just make sure that you safety net people and tell them. Hey, you know what? Your, uh I've assessed you. You're safe. The boss has seen you. He says you're safe to go. So it's finally facilitate your discharge. I'm not endorsing it, but I'll help you. I'll help you keep you safe. But keep in mind when it does get worse because we think it will get worse. You come straight back over here and, uh, we'll take care of you. And that's the best way to keep yourself safe. It's by keeping your patient's safe. Um and, you know, But if your bosses are like a good thing is if your bosses are really helpful and they help you with your time management, they say, Hey, you've got three other patients. They're really unwell. I need you to take care of them. Don't worry about the self discharge in patients moment. The nurses will talk to them. In the meantime, take care of the patients right now. Take your cue from your boss is okay. They have more experience with this than you might do when you start. Uh, so the the contents of this talk is how the introduction. There are two main steps, Um, when a patient self discharge and then they're going to be three different kinds of outcomes based on those two steps, and we'll go through a little list of what you can do, and there's a lot more stuff on the mind. The BLEEP website. I've used that as a little bit of a template, but they should hopefully give you like a 20 minute whistlestop tour that gives you some more information on it. So step number one finding out about the patient so you get called by the nurse. She's frazzled. She's at the end of the rope, saying this patient threatened to self discharge. What you want to do is when you get a chance, get down there, read their file. What's their diagnosis? What was the plan for the last couple of days? Um, specifically like, were they meant to be for an operation two days ago and then cancel the end of the day after they got started? Then yesterday they were meant to be for that same operation. Start for the whole day, and they got canceled once again. They got pushed today, and now they're just at the end of that together. Now anyone would want to be would would be upset at that. You know, um, check to see what their what? Their And if there's been any comments on their behavior in the last couple of days, we might indicate why they're so jittery. But why they want to leave hospital. Ask the nurses what's been going on because generally the nurses there, there with the patient all the time as a doctor, you're not there with them as much so the nurses have a better read than you do. If you turn up and you know about the patient, it gives the patient a feeling of importance as well. And that's actually quite positive because it starts a positive report. The report already positive because you're a doctor, and that's generally thought of as being like a helper and a healer. And what have you and you're not there like a nurse's. So you're not you're not that that authority figure that the nurse kind of has to be now and again, um, other things to consider. Is there anyone been anyone? Has anyone been there to visit. Um, if they have, they have made them a bit, Uh, they made them agitated. Or is it because they haven't been to visit there? Agitated? Um, if there's a psych possible psych issue, then consider asking the psych team to assist. You definitely need to get the psych team involved if there's any sort of, uh, sectioning that's gone on before the patients under a section, Um, and generally in hospital, they have a mental health liaison team. They're normally out of hours, they'd be nurse lead. And to be honest, most of these threats of of self discharging are going to happen on the floor. Or they're gonna happen, Um, in the in the evening, because there's stuff going on in the day. Patients feel like they want to sit around. But in the evening, when there's not as much going on, they get a bit more desperate. They might wanna they feel like they might wanna leave and take their health on their own hands. Um, and then the last thing about nurses, So check to see how the what the nurse think the patient feels towards that nurse, the website says. Tha consider taking the nurse along because they're friendly face. Um, I'd say the other flip point of that is the nurses or probably the person that's been talking to the patient and kind of reflecting the patient for the last couple of hours, they might be seen as an authority figure. They might be someone that the patients, but it heads with. So keep in mind, maybe having the nurses might aggravate the patient rather than get them more on your side way that up. Decide whether or not you want to take that. Keep that patient there. But if you're worried that patient is dangerous or agitated or could or could could be a physical threat to you, then you want to have someone there or you want to make sure you're not locked up. You have some sort of escape escape pathway. They're keep yourself safe. So that was Step one right. Find out about the patient step to meet the patient. Simple right, So you want to figure out why they want to self discharge, and that's when you start talking to them. Are they trying to get a little high? Are they missing their alcohol? Uh, Maybe they're confused or scared in a new environment. They're demented. They won't probably won't know that there's actually stuff we can do for those things for well, for the for the alcohol and and for for other, uh, other substance abuse, there's programs that they could be on. I'm not sure it's very low, cal specific in terms of whether or not they can start those programs in hospital. Um, but alcohol definitely. Most hospitals will have you can. You can give them chlordiazepoxide and other stuff to just keep them calm. In the meantime, um, you want to ask them what they want to do when they leave, like the dangerous one is. Do they want to go home to kill themselves? Because that's like a mental health risk, and that's we're not going to touch mental health stuff too much right now. We're not touching that mental health act, Um, but we're just going to keep pointing that because that is a big part of this as well. Awesome about their home situation. If any pets they want to be taken care of at home and they're they're worried about them or any kids. Um, and then Maybe you can try and decide with them some sort of arrangement where a neighbor or family member pops in or what have you. Um, at this point, when you're having that chat, that's when you can check for a capacity. Um, and if there's any perceived mental health issues that goes down the Mental Health Act, which doesn't use capacity intrinsically. But you can use your capacity assessment as part of your decision for whether or not, uh, for for for the mental health, um, so you can't say, Well, they don't have capacity. Um uh, for the mental health at capacity, it doesn't really matter too much, but you can use their capacity state when you're describing how they are as part of mental health assessment. Um, patient lax capacity. So the three outcomes, right? Let's say the patient lax capacity number one, escalate the escalated to your seniors. Uh, these conversations probably need to be had by Senior. They're complicated. Uh, you're telling the patients something they don't want to here, which is that they're stuck in hospital or or they can't leave your your, which generally we don't normally do. Normally we're agreeing with patients. They're facilitating their decisions. They'll have more experience with it. They'll be able to nuance it in the right way. Um, go for the least restrictive option. The website, Uh, website, uh, kind of leave offers, uh, considering using GP ambulatory care of the health, Other healthcare professionals. The only thing I temper with that is when I was an f one, I was all about Oh, hey, let's we have an ambulatory care. You can come back and then and then O G two doses was fine. Come back in the morning and come back in the evening like you're making a complex plan in a pathway that is not there. And you're not even going to be the doctor that has to enact that plan. You're making the on call team have to enact this really complicated plan. So when you're thinking of using the GP ambulatory care, what have you run them by a senior? A lot of this is going to be running it by a senior. Um, you're probably gonna be the first one they sent a have that talk and you probably do the capacity assessment, But, um, you'll probably be getting input from seniors afterwards by the telephone. And what have you? Um, step number three. Talk to them. If you need to stop them from leaving, try talking to them to calm them down if they're not responsive. But they're feeling a bit competitive as well. Call security. It's amazing how the hives jackets have a way of just calming patients down. Um, security is, uh they're limited in what they can do if there aren't the proper forms in place, like dolls or what have you? Um, which is, but, um, just be They are definitely now just be there. And that does help in some scenarios. Your hospital guidelines may have other teams that you need to contact as well. And if you're keeping them in against their will, or if you're doing any sort of action that's going to be depriving them of their freedom, Uh, then you need to fill out something called the dolls, which is a deprivation of liberty safeguards. Uh, is it, uh, is in a couple of my doctor bodies. They had experience where they had to fill out the 17 page behemoth. Um, I haven't personally, I I've been lucky to be in places where the nurses have been filling filling that out for us. Um, but, uh, disease advice for that was just, uh, make sure that you just you be brief, but you document specifically. Why don't Why? I think they don't have capacity. Uh, number four. Document. Document everything. Document the capacity assessment document What they did document what you did list the people involved in the decision making, uh, just, uh, share the burden of this decision around. And number five as an F one. You cannot detain patients under the Mental Health Act. Nurses can put in a section 54, which is something that they can put in to hold the patient for for quite a few hours until they get formally assessed. Um, or you can ask a senior to come in and they can put in a five too. But as an F one can't do any of those. All right, um, now, what happened to the patient Has capacity number one document document. How you think they have capacity include examples of the discussion. Uh, rule number one is Get everything run by a senior before you just go ahead with whatever plan you consider your Reg can consider when the, uh when the consultants should be informed. I know when the website says consider letting the consultant know. I tell you, if you tell them if you call the consultant at midnight or two, AM saying, by the way, one of your guy's trying to, uh, self discharge, they're gonna have a very interesting demeanor in the morning with you. Um, consider if period of leave would work. So the website once again offers Hey, have you thought about period of leave and honestly, in some elderly patients? Sure, that could help. The only problem is that there's a couple of different other different factors. Period of leaves aren't very common. Uh, generally, it's a very senior person that that, uh, that confirms that they can have that, and it's for for it's for special occasions. It's rare, Um, because if patients are generally unwell enough to warrant a bed and hospital there, probably too unwell and it's unsafe for them to be at home. Um, so it's nothing. You really shouldn't be making decisions that they're okay. Tha to be hoped to be at home for any real period of time, and it does make the logistics of the world a little bit more difficult in terms of medications and what have you. So so you can kind of offer that option up to a boss and then have them make that decision for you. Um, Number four getting to sign the paperwork, saying that they know the risks of self discharge, including death, and they're happy to take those risks into their own hands. That's just some, uh, some legal framework thing to do in the state that they're allowed to come back at any time, But they'll probably have to come back in by a and most A. And you do have this rule where, uh, if the patient comes back within a day or two classes, a failed discharge and it goes straight back to that same department, but they will, they'll just always be a wait for them in A and B, so they you're not going to keep their bed for them. Just let me know that they make the transition as safe as possible. So if they're on antibiotics, consider switching to the oral antibiotics as a as an alternative, give them, give them a discharge summary send that discharge summary to the GP, so it's still continuity of care, and you can ask them that discharge summary. If the GP can do a review in a couple of days to make sure that patients okay, um, explain the medications that they want to be taking home. That might take a couple of hours to prepare. And if the patients say, you know, I don't want to wait for those, uh, give them the option. Hey, come back in a couple of hours. Maybe we'll be ready then or come back tomorrow. Maybe it'll be ready then lost scenario. Let's say the patient absconded pre assessment. So when I was initially writing this in the trust that I trained in, uh, in the e d. If a patient left with the cannula, you just straight up have to inform you have a duty of care to inform the police. Having said that when I was researching actually writing these slides, I saw some other trust that had guidance that said you didn't in low risk cases. You didn't have to do that. So the thinking behind why you want to inform the police when you have a when a patient leaves the cannula is, um they can use it to shoot up. You've given them access to a place they can shoot up. They can put all sorts of stuff directly into their veins. But they probably couldn't where they maybe couldn't have done if you didn't give them such good access. And you also can assess the Canada site itself and they can track infections right into the bloodstream. And that's obviously a big problem. Um, but the the guidance that I saw said, sometimes maybe district nurses can get involved or or we'll have, you know, you can just call the patient asked me to come back so you can move the cannula. So what I'd say with that is I read your local guidance. They don't have it run by the bosses. Uh, you can just be a quick thing about Hey boss, the the patient just ran out of here and they had a cannula, and you need to call the police and they'll be able to help you make that decision. And it's generally base that I'll come into the police in a second, but but it's it's got a couple of factors to it. Um, I'd say as a general for their safety, that kind of has to be removed. Number two, you want to track where the patient is CC TV. There's lots of in the hospital. Go to security and they'll be able to track it. Track them by a CC TV, too, when they left the actual premises. Um, let security and the site managers know when the patients have absconded and the site manager can actually start a little bit of a of a site wide search for the patient. Let them know what the patient looks like and try and hunt them down. And then let the red, you know to just so you've given them a heads up and then you can start doing the rest of the work while the Reg is to take care of other unwell patients while you try and hunt down this patient, uh, number three. If seniors decide that police need to be involved, call them and give them the relevant information they need to make a decision themselves as to whether or not we need to find, uh, restrain that person. So generally they'll be called that the patient is in a real and present danger. And the whole team believes they need to come back. And it can't wait until the morning for a GP to be contacted or for social worker to be contacted to try and get them to facilitate the return. Okay, Um uh, police have their own specific way. Uh, like legislation to allow them to bring people to hospital. One of them is when they bring them to a safe place. I believe in the mental health. Gosh, I think it's like a three digit number 16 to 1. I'm unsure. They thank you, Mr Ross. That's why we have him here. Thank you, but yeah. So they have their own laws that allows them to to decide when they're allowed to take it personally. Wouldn't want policeman just randomly picking people up and taking them places without some sort of legislation of place. So give them the information they need to make their decision about how they can help your patient number four. Like I said, I assume capacity. You have to assume they have capacity, but you can check the notes. You can check with the nurses to see If that has information to say whether or not they do or don't have capacity A m T e s t score of zero probably they won't be able to retain much information. Um, have advanced dementia. And they say non patients nonverbal or what have you? Maybe they're going to have some difficulty in in, uh, in in their capacity assessment. We'll have you so you can use that information even though they're not there. Um, and that can at least, uh and always also, you can check the notes for, like, a mobile phone number and try and contact them and have a, uh, an informal capacity assessment over the phone. It's better than nothing. Um, I'm not sure how much it would help in terms of getting them back in the hospital. They don't want to be there, but at least you have something you can actually investigate. Document. Because if they're sounding great on the phone, then maybe that kind of stops you in your tracks in terms of how much you can do in terms of further reading, there's a website from mindedly I think that was the best one that I had for for this one. It points out a couple other resources. Well, that we can use. Um and that is once again the feedback you are, Which means we're at the end of the second, uh, presentation. I think I went through that bit more quickly and normal. Hey, let's see how you doing? Hello. I'm good. Thank you for that. Lovely. Another lovely talk. I was very succinct. Thank you. Very good explanation of what to do with patients. Self discharge and in different capacities. So thank you for that. Um, so we've got to excellent questions already on the chat. I'm sure there's many more pendant. Um And I believe Doctor Ross from our sponsor, the M D u. Is going to give us a couple of slides. Kind of give us a bit more information. Is that right? Hello? I'm sorry. Hello? Um, let me just share that screen. Um, and thank you for that incredibly enthusiastic talk. I'm not sure I would be able to match that level of energy I should have taken. Should have taken energy drink before I started this. Right? Let me. Can you see my slides? Not yet. So you haven't shared okay? There we are. Let's do it now. There. So you should be seeing, um, uh, side seeing patients taking their own discharge. Now, ABS has gone through some really important information. And in reality, I think he's covered all the vast majority of anything I would want to say. All I was intending to do here was to give you a summary from our point of view, how we deal with it just to give a bit of background. Um, I was a consultant surgeon. I was a consultant neurosurgeon. So I dealt with a lot of patients in whom capacity was an issue. I was consulted, Neurosurgeon in England, in, in older Hey, and in the Waltons Center and then also in Scotland. So I was dealt with all the different jurisdictions, at least, uh, within, uh apart from Northern Ireland. Um, and that's the point that I didn't bring up what I was talking about. There was very much the English and Welch approach. Now, the good news is, if you're going to good Scotland, whilst the jurisdiction is different and the law is due different, the effect of the law is really very similar. So what about has been saying in that talk. A lot of it is transferable to you working in in Scotland. And if you have to work in in Northern Ireland, although there isn't capacity legislation fully in place yet in Northern Ireland again, the common law effects as judge made law is very, very similar to what has been discussing a couple of things. I would, I would point out, that I had mentioned I wanted just to to emphasize, and I'm going to take a different tact from above because I was a consultant. I think the F ones are are enormously important in in how a team works, Okay? And I think it was a consultant who's ignoring F one and not listen to what everyone is saying to them. That's a consultant who may end up with some trouble. So I would never as a consultant as a consultant, your surgeon be annoyed. An F one called me maybe slightly grumpy at four in the morning, but I would I would appreciate that they've done that for a good reason, and ultimately they have the responsibility of care for these patients. So please do remember that if you're not getting anywhere you can't get through to your registrar. The senior nurses aren't being helpful. Um, the consult is part of the team. They are on call, too, and they will have a wealth experience that you can tap into. Um, they might wonder why you recall them first, and they may want to chase up with the middle grades why they ended up answering the phone at four in the morning. But it's better to share your worries and your woes and concerns about patients and find out the next day that you you've made a made a difficult situation worse with what you've done. That's what I would say. I would take another thing that I've said well, but nurses, I think that is right. Sometimes if you've got a patient who's been butting heads with the nurse you're having that nurse with you is not helpful. That being said, some senior nurses can be a font of knowledge and information, which can, which would be unwise to ignore so often they can be incredibly helpful. And even when I was doing consultant ward rounds, I would not not infrequently ask, Ask the charge Nurse, what do you think because they are professionals, they do have experience and the other experiences different. It's still worthwhile. And if one's and in fact all juniors and and consultants to can learn from nurses that were all part of the same team. One other point I wanted to bring up about something that I've said right at the start about implied consent he would give exactly example of, uh, I think lifting up your shirt to let somebody examine your belly. And, of course, that's that implied consent is something that the GMC recognize it's It's in the consent guidance from the GMC. But there are some caveats to that. You need specific consent for certain types of examinations, and you should be aware of cultural sensitivities to, um, some. Some women may not be comfortable even with a male doctor being close to them, for instance, doing ophthalmoscopy or examining their knee, not areas that you would imagine. Normally it would be sent to the areas or or or potentially intimate areas, but culturally, that can be something that people are concerned about. So I have a pair that in mind, and similarly, if you have to go to a proper, Um sensitive, very examination be. That's a rectal examination or internal examination or gentle examination. Then those situations in which you want to really have talk to the patient said, Is it okay if I do this and get clear Yes or no? And actually, in gynecological examinations, you would normally write down the fact that you you've got consent from the patient before doing the examination. So as is right for the vast majority of things. But do you think about those specific situations where, um, you might run into problems? So I've drifted off slightly to pick up some of the things that I was talking about in the capacity part, just coming on to this patient's taking their own discharge. Or, as the slide was just before I started patients talking their own discharge, which is obviously not the point, but taking their own discharge. Um, it is something that we see. Um, so let's have a look at the the next slide, and I think that this and labs and I haven't talked about this in advance. So we're obviously saying from the same him sheet or we're both wrong completely, and I think it's the farmer rather than the latter. The first question is what I've said. Does the patient have capacity to make the decision that has to be made at this point right now? Um, as he said, Um, capacity is time and decision specific. So, um, for my patients, they may not have capacity to have to discuss how I would take out a particular brain tumor, but they would have capacity to be able to decide what they wanted to wear that day. That's that. That's a sort of, uh, silly example, but that defines that there's a difference between certain types of capacity. Um, and ultimately it's about autonomy. That first story that Abbes talked about when you had a patient who was, um, seeing people talking over her didn't know what was going on. They were speaking of foreign language is which is what a lot of medicine can sound like. Two patients. You are denuding that patient of their autonomy as a person, and patients who have capacity are entitled to exercise their autonomy. You know, any way that they see fit as regards their own care, they're allowed to make decisions, and they're allowed to make decisions that appear to be bizarre decisions, decisions you would never make. And I think that's often One of the hardest things for juniors to do is to accept that sometimes people will make bad decisions. And there's so much case law out. They're backing that up that, you know, just have a look at the consent guidance from the GMC Sorry, the the consent kinds GMC. It lists some of the relevant case law, which is quite shocking, shocking to read, but is it makes the point that if they have autonomy, if they have capacity, should say they are autonomous and they can do what they like. And that's hard to think for doctors. The next thing is these patients without capacity. We've kind of talked about that. And when you're dealing with a patient who lax capacity and I have talked about what that might mean, So in terms of the test, that's a two stage test. Is there an impairment or disturbance and the function of the person's mind or brain? So that's where you start off. Um, you don't start off by assuming that they're lacking capacity and stuff. Question first and then you go onto the next part of it, which is, Is the impairment or disturbing such that the personal? It lacks capacity to make a particular decision? So that's understanding what they are being asked to talk about as to think about to retain that information, Tawake up the information and their decision making and communicate that information back to you. The law in Scotland is difficult difference. You say it's the adults been capacity act. The effect is almost identical. The Adults and Capacity act about five years before the Mental capacity Act that talks about the same sort of things. Um, so, uh, you know, if a patient is unable to do any of those things, they lack capacity by definition. And in that circumstance, um, the treating doctor is entitled to make best interest decision with one caveat, which is that you may have a patient who has a proxy decision maker in place. Okay, absolutely mention this, um, and it is a bit of details in the in the in the mental capacity act, and there are similar, um, uh, provisions in Scotland as well. So in England, you might have somebody who's got lasting power of attorney who who is a health and welfare attorney and who's allowed to make decisions for that patient. So in that circumstance, you aren't the decision maker. They are okay as long as they're lasting power of attorney is for that particular decision or that that healthcare issue, um, there is another thing there is if there has been advanced decision made by a patient as well, not going to go down that line. But there are these patients who have made written, advanced decisions to refuse certain treatments, uh, in the event of deterioration. So in that circumstance, it's not just their best interests, best interests, you know. You can always give a whole talk about best interests itself would be really boring, but you could, and important and best interest. It's not just their medical best interests. It's a broad scope of best interest. So other things there's, there's their home life, their their family, their social, the social, if all these things to factor in the best interests. And as I have said, if you're making the best decision you have to, and this is part of one of the founding principles of mental capacity is do the least restrictive thing. So give me an example of that. If you are imagining somebody had it was a lost capacity because of hyponatremia, secondary to bowel obstruction, they were being resuscitated. The CT scan that showed that they had a large bowel, a large bowel, uh, tumor, um, resulting in obstruction the when the patient lax capacity there's nobody else to make decisions for them. The sensible thing to do is to do the safest operation right then and there to save their life, to return to a position where they might be able to make decisions. Um, it wouldn't necessarily be the right time to go into the most aggressive cancer reception that could be done. You could do something in a staged way to save their life, to retain, to get them back position where they can make decisions and then afterwards offer them the option of having a second surgery as an example where they go and do whatever a total me directly excision or whatever it is that that the bottom surgeons are doing these days. So that's an example of, uh, the least restrictive approach, and I also mentioned the risk to sell for others because of acute mental disorder. I think he's right not to get into mental Health Act territory. I think the Mental health act is complicated. You should not be having to do that as a junior doctor. You should be involving the mental health team. That's what they're there for. And if somebody has an acute mental health disorder, as in, they are actively showing signs of psychosis. They are manic and a risk to themselves, or they are severely depressed and expressing suicidal ideation. There's just examples. You absolutely should be referring that patient on to the mental health team to get their expert input because they're going to be needed to apply the Mental health act anyway, at least most aspects of the Mental Health Act. There's another group of patients, which is, of course, that when this comes right back, the first thing I said about you being part of a team, sometimes you're not going to be sure of a patient's capacity, and it's difficult. Sometimes it will be. I get called from a D and E s in the middle of the night, not that infrequently by doctors and the registrar's and consultants that time who are not sure about capacity because it can be quite hard to assess. So don't think for a second that you as an F one will be right on it. Um, easily able to make the assessment of capacity that any problems you may not be, And that's okay, because you're part of a team and these things are difficult. So, you know, on top of that, sometimes the risks that are involved can be incredibly serious. And as a junior, you may not be able to fully, um, comprehend what all the risks are, particularly when you're doing specialty surgery or specialty medicine. Um, when you your experience is relatively limited. So expressing those risks to a patient can be very difficult if you're. And that's the situation that you need to ask somebody else to give you a hand. Uh, sometimes the conditions are so complicated that the next step isn't clear. And again, as I have said, you shouldn't be making complicated plans that you yourself are not going to follow through. Gosh, I'm sorry for that, that, uh, talking so quickly they're all right. Let's have a look at this one here. Nice short slide discussions. So that was to prompt me to remind you again, as as I had said, to make sure that you wrote down in the medical records the discussion you had not necessarily verboten, but the important parts of it that made you reach the decision that you did about the patient's capacity. Also record with whom you discussed your assessment of the patient. Just don't just write discussed with Reg discussed with CT one. Write their name down so they can be contacted by the decision making. Should there be an issue around it. Make sure again that you've considered the relevant classic legislation. There will be guidelines in your trust. All of your trust will have that. If you're in Wales, your health board Scotland your health board, not around the hospital trust they will all have, um, guidance on this. Look at the guidance. Its there for a reason. Because you're complicated pieces of legislation, you can't expect to understand everything, but you can be expected to go looking for the information. So and if you're not sure, ask somebody, please, better to ask and get the answer right and feel a little bit embarrassed. He didn't get it. All right, First time, then make a mess of it. Say something else there, make a mess of it and, uh, and live to regret that or worse, the patient Not live for you to regret that. Be careful that you clearly recorded why you think somebody lax capacity. And as I've said, if somebody has capacity and leaves against advice, safety net incredibly important doctors fall down with this all the time. Make sure you've told the patient what to look out for. If things are getting worse, make sure if there was something you've got consent that you tell your family member. If this happens, come back to the hospital. You're not going to share a lot of information. Obviously, you're not share any information without consent. But you can do that with family or something that I would do not infrequently. Ideally, make sure you've communicated about the departure. The untight unexpected departure with their GP. I think GPS often get a little bit annoyed for us to go and see somebody specifically, so don't try and hive off their follow up to a busy GP, but at least communicate with the GPS. So when they call a GP practice, you know, two days later saying they're they're they're paying as much worse. The GP knows that they took their own, uh, their own discharge. I think that's all I really wanted to to say. In addition, um, I hope I haven't spoiled things for abs there. And I hope that makes sense. There are a lot of guidance out there. Um, do look at your defense organization. Make sure you're a member of one. And do you remember the GMC guidance? It's a great It's a gold mine of information, um, to be used, uh, liberally and referred to literally. Thanks. Thanks so much for that talk. Uh, doctor Ross, that was it was really good that you saved my bacon there by, uh, by, uh, by protecting the nurses when I when I said maybe don't consider. Don't bring them. I'm sure that the nurses over the weekend would tell me exactly what they thought of me, Uh, over online. Thank you so much. Nothing. Thank you, Doctor Ross, for that. That was really helpful. Absolutely. Like the part where you went into detail about the implied consent. Um, certainly some reminders there, which I haven't thought of for a while. So thank you for that. Just before we go into a couple of questions that have come through. And if you can make sure you're doing your feedback Firstly, it helps us improve the service so we can make the lectures coming more suitable for you and change things as we need to. So the most more detail you can give us the better. Um, Secondly, if there's any more questions, do you write them at the bottom? Um, this is a safe place. There's no silly questions to do. Write them down. You've got, you know, junior doctors here. You've got a consultant neurosurgeons nd you here to support you. So any help we can give you were here. Just a point for the feedback again. You get a certificate yourself if you can put the feedback in. So it's another tick portfolio going forward and also gets it for his portfolio as well. So, um, he's given up his time to help us today, so that really, um, be grateful if you could do that. Another reminder. Just make sure you got your indemnity cover before you start your shadowing in the next couple of months, and there's links in the chat at the bottom about any kind of I think there's an email from the san who can help you and how you can go forward. So on to the questions. Are you ready, Doctor ob. We've got to excellent questions. I think the first one I think we've already kind of covered from Doctor Ross is, um, talk just then. But have you got any tips for documenting your capacity assessment or for a patient who is self discharged? So maybe from Doctor, um, from a kind of junior point of view, if you have any kind of structure you like to follow when you're documenting Well, why don't I give the shot? The answer 1st, 1st Doctor Ross can jump in and actually say all those No, no, don't do that. But yeah, So basically, I think the in any conversation that you have, there's going to be some things that stick in your head that say that will indicate this person does. It does not have capacity. Those quotes, you can put them in, Um and that will be really good. And the other thing is if you actually break down the four parts of the capacity assessment, understanding, retaining, considering what have you and then actually have little quote saying They said this therefore not didn't do this. They said that therefore they can't retain or we'll have you. Um, if you make it obvious for people, then they can follow your reasoning for why you think they didn't have capacity. Yeah, No, I agree. I think that's fine. I think one of the most important things is that people, uh, particular juniors in their in their early jobs are covering a lot of people and may struggle to keep good records. And what will save your bacon should things go wrong are the records that you have kept? So I think the lab said, it's it's fine. I don't have any problem with that makes you time to sign that identified people with whom you've been speaking and share the decision making, and this goes all the way through your career. You are not there alone, and you're not expected to make doing things by yourself without any input. So share this is making and write down with whom you shared it lovely Thank you. Um, another question, I guess. Again, for both of you, if you've got any anecdotal experience, have you had any challenging capacity assessment before? And what were your top tips? Please? Gosh, I have had one that was very challenging. And honestly, I'm not sure if if legally, everything I did was with culture. There was there was problems with the nurses, said, I'm not sure I'm happy with how we've assessed this. And the consultants were saying No, no, no. His assessments. Okay, follow through the plan. Basically, this patient, that was they had, uh, osteomyelitis of the base of the skull. Um, and then with that, the infection that caused them to, uh, they needed they lost the ability to swallow. And this would be happening for a long time. So they had a n g tube inserted, and they kept saying, Yes, I will take the MG, and every night they would then take it out again. And it was a horrible experience to put it back in. It was mentally jarring. Um, and we had to start, uh, you know, talking about Do they have the capacity to refuse? Um, the, uh Do they have the capacity to request us to remove the N G tube, and it was really difficult to do that. And the problem was they would have capacity to put it in. But then when we try to assess capacity for us to remove it, they would fail the capacity there, which which made it really complicated. Um, and the nurses, because they were stuck by the patient's bedside, they were kind of having they they didn't know where they allowed to be, depriving them of their ability of removing the end, you know, because we were talking about, like, mittens and stuff from them. Um, and honestly, it was, I think, because we all went on the same page for that capacity probably did affect the patient's, uh, care somewhat. Thankfully, we were able to get the patients family involved as well and and discuss it with them and say, Look, we're really struggling here. Um, I don't think we were smart enough to to contact a medical legal team, which we really should have done, but we were like Doctor Oz said, like you get really busy and you kind of tunnel vision on something, Um, and that was my difficult experience, and honestly, I did. All I learned from from it was that it's just a difficult experience and you need seniors because they'll they'll you. They have more power. You feel than you do when When you have a senior pop in and they say something, you kind of give that some credit and it makes life easier for you. I think that's a really good example, because what you're describing is the situation of potentially fluctuating capacity. Capacity is coming and going. That's really common. Um, the sun goes down, patients lose capacity. Um, we used to see that all the time. It's a very common problem in the dark and things. So it's about maximizing the capacity of patient has documenting it, sharing a written information with them as possible. Ultimately, as the problem that you had, it would be the same problem the consultants would have. And if the consultant called me or you call me and saying, Well, you need to escalate your consultant, you may need to get a second person involved somebody who's not directly involved with the case. To get a second opinion on treatment, you may need to make sure the family are on site and ultimately, if the patient accepting treatment at one point or most of the time but refusing at others but predominantly accepting it and the family are all inside. And there's an underlying organic disorder. You know, for instance, and meningitis, as I suspect, is going on there or whatever. Um, I think in that circumstance you might very well just go ahead and treat. Um, and you'd probably be reasonable able to defend yourself in that situation, but I think it's always, um, situation dependent mine. I think it's probably vicarious nowadays. And so I think the last the typical one I get called about is the person who has come into the emergency department with an overdose and and doesn't want to be there. They turned up in any any Any said, I've taken 40 paracetamol, but I don't want to be treated, Um, which is a typical sort of thing I get called about. Um and then, of course, you know, you're coming down to just as I said. Do they understand what the Why they're, you know, um what? The risks are not taking treatment. Do they understand? Are they sober? Um, do they? Are they acutely depressed? Is there a psychiatric illness which has brought them to the brink and made the decision to impair their capacity? Or or are they put themselves at risk because of underlying mental health disorder? These are not easy things to sort out, and they're not easy for F y one way. If I to f y four c t two consultant. It involves the whole team, and ultimately you're going to involve other people. You're going to be calling the crisis and say, I'm not sure what we're doing here were short of time. We need some input. This is why I need some input. Can you help us? That's what they're on call for. Call them and get to make a decision. You may not like it. That's what they're there for. So your job is wise to recognize the problem not necessary to sort it, Um, there will be ones that you can sort of one of your consultants are struggling with. And that's ultimately what the courts are for. And sometimes the courts mentally not overdose per settlement because the courts would take some time to sort things out, but there will be situations. You might even involve the courts and treatment. So that was a very long winded way of saying what I said. Right to start, which is you're not alone. Don't try and do alone. Get some help. Perfect. Lovely. Thank you very much. And I guess a question I've got just following on from you mentioned the Mittens album and going kind of trying to do the path of least resistance. I mean, obviously, there are guidelines depending on what trust you're on. But do you have a kind of escalation path? But if things are getting out of hand, you have a patient who doesn't have capacity and, you know, simple techniques like trying to talk them around etcetera are helping, I think, as an F one. That was the thing I was really worried about about being out on call on my own, having to deal with difficult situations. Have you got any advice for F once, he might be in a similar situation. Uh, well, in terms of like, how How you would decide to deprive their liberty sort of thing. Yeah, well, I do have a kind of a step wise ladder that you do with you know, how you would try and deescalate a situation like that. Okay, So, um, I feel like from my experience when you get to the point where talking and having people around to talk isn't working at that point. Unless there's an obvious risk to sell for others, I either combative and you need to give something to sedate them. Then, no, I would I take my lead from my bosses. I didn't bring up the idea of of, Let's use mittens. A senior nurse did because, um, like I didn't think of it. And I've seen it in some patients, but I didn't think that we would use it in this case, Um, in stuff like, uh, pharmacologically sedating patients, Uh, like there's so much risk in terms of, you know, difficulty in breathing and like the medical risk to that, that, um for someone to make that decision, they need to have experience with that, which probably won't have as an F one. And they need to be able to take that, like take responsibility for that decision, which probably is an F one you shouldn't be doing. That's that's my cop out of an answer, which is probably actually what you should be doing as an f one. What do you think? That Doctor Oz. Gosh. Now, um, I think it varies. We we did use mittens, um, in neurosurgical patients. But those were patients who were definitively lacked capacity to make decisions. And we're harming themselves by trying to pull it, for instance, monitor integrated monitors or drains or whatever. Um, it wasn't comin out with that. This is what I did, I forgot to say Was above mentioned the dolls. Um, the definition of liberty safeguards as something that you might be involved in. Um, you know, dolls is a very complicated legal process. It's not a straight forward process. And I think that, yes, various doctors may be able to fill in parts of the form, but there are legal requirements for who is able to complete adults, and as an F one, you certainly are not going to be that person who's going to be able to do it. It requires a Section 12 approved doctor requires various people who need to be involved in it. So, um, just bring in the dolls into into place by yourself is going to be impossible to do. Um, it may be possible with the broader team. That's a copout complete of ladies question, which is what the thing to do, as lazy would probably know is anaesthetist. Often the underlying problems with acute confusion is to do with organic issues is to do with the patient is in the dark. The patients have medications. The patient may be infected to me in a high temperature that may be hypoxic. All those things may impact upon their ability to make decisions. So it's correcting these simple things that you can do as an F one, which will make it much easier for the seniors to go and correct the more complicated things afterwards that needed to be addressed. Listen, I don't know if that address that question at all, but that's how I would always want. I want to know. The A, B, CS A B, CS DS were approached first before we start to bring out the big guns to try and deal with more complicated matters. Yeah, absolutely. I think the also things I've seen in the past it's familiarizing kind of environment to the patient was not more comfortable, So I saw a very good example of an F two out of ours were acutely agitated patient, um, and it's pre coated. So the family members were brought into the daughter, was brought in and immediately de escalated. I think trying to think outside the box as well, how you can Is there a nurse that they know from multiple shifts that they get on with the way that you can change the environment. They're more comfortable, make it more like being at home, getting a cup of tea, etcetera. But as I've said, if they get into appointment at risk to themselves, other people, then it's a different story We need to get seen is involved usually brings it back to what I've said in that. First, that first story he presented about the patient not understanding what's going on. That's exactly what happened. Some of these confused patients they moved around from bay to award or beta room. The lights are on, lights are off. They don't know where they are. Um, they don't. They're different nurses coming in an eight hour shifts. They don't know who people are, and they're confused. So it's getting into a well ward. It's getting people around that you know things around that. They know, um, and the same reassuring face is going in and being kind to them rather than shouting at them for being an annoying person who's used the buzzer for the third time in 15 minutes? Yeah, absolutely lovely. Well, thank you for that. I think I can't see any further questions that have come through. So I think that concludes the webinar this evening. So just to finish off, it's Please do the feedback. Make sure you get indemnity cover and always escalate to a senior. If there's any doubts, would be my take home tips from that. Would you agree? Totally perfect. Neurologist only asked me to add before we No, not really. Just thank you very much, everybody. I know that I learned a lot, so I can imagine the hundreds of people who are watching did as well. So thank you very much. Um, and Lizzie. Thank you, Doctor Ross and our partners at the MG you, for all of your support, we really do appreciate it. And everyone who's watching make sure that you fill out the feedback form so we can make the events better for you. Um, and like the Facebook page to be notified about our event next week, which I believe is on referrals and requesting scans. So obviously something that everybody would like to hear about. And I think you get to see ob as well next week. Is that right? Yeah. I'll be there in the background. Great. So no, no more for me. And thank you very much. Loss as well. Great. Thanks, everyone. Thanks for coming, Doctor Oz. Bye bye now.