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I can fall and and so lecture in next Fy Survivor bad scene. And I hope you enjoyed the previous sessions and if you have them in the previous one, so hopefully you enjoy how I so um this issue is how expansions. Um and how does that work? This will be in this session. So I will have talk to him to introduce himself. Hi, good evening guys. My name is Hans. I am a CT one core surgical trainee at the moment and today's session is on how to deal with complex patients and it is the final session of the foundation year Survival Guide. It's part of the National Surgical Teaching Society Program and today's session is going to have a particular focus on the elderly and frail um rather than just complex patients in general. Um Before we continue, could I just check, would you guys be OK to drop in the comments? What year of medical student you are or if you're a foundation doctor? Um Just so I know where I'm pitching this level at really cool, fine on you. That's fine. Anybody in third year of med school, fourth year of med school that's fine. Ok, we've got a couple of final years. Ok. Age cool. So just a little bit about myself guys. Um Like I said, I'm a core surgical trainee. Um I went to med bars, did academic foundation training in West Yorkshire Logan for a couple of years and now I'm in core training in West Yorkshire. Uh And what do we aim to cover today? So the topics I'm hoping to cover in this are delirium. Um Specifically what types of delirium, there are signs and symptoms, how to manage it. Some of the complexities, um things like restraint, um that I want to go to the Mental Capacity Act, discuss what it is, what it does. Same thing with the deprivations of liberty safeguard, er, just touching upon what a lasting power of attorney is, is it's not something that I really comfort at medical school. Er, and then finally just touching one DNS E pr. Um Now again, the focus of this is when you're a potentially a surgical F I one or a surgical junior, a large proportion of your patients will be the elderly for specialities like orthopedics and you will come across a lot of these things on the wards, especially when they're ill um post procedure. Um So I think it's good to cover and be aware of some of the aspects and just a disclaimer because this is such a wide topic. Um This is just a snapshot of things like the Mental Capacity Act. Um There's a lot of things in this presentation that I couldn't fit in. So it's really important that you refer to your local guidance, first National Guidance. There is a Code of Practice for the Mental Capacity Act, which you should be familiar with before you start working with it. Um So I'm hoping to just give a brief overview really and any issues whilst you're actually on your job. In the first instance, you need to refer to your local guidance as well as discussing it with the senior. So just coming on to delirium, um what is delirium? Delirium is commonly defined as an acute confusional state. There are different types of delirium and the three main ones we think about are hypoactive, hyperactive and mixed. Hypoactive is fairly in the name. So the symptoms are to do with hypo. So lethargy, motor retardation, um sleepiness disorder, sleep wake cycles, um um abnormal attention, not paying much attention and hyperactive is the opposite. So, abrupt change from baseline, um hyper aroused, uh having hallucinations and delusions, um motor restlessness and agitation and then you can also have delirium where there's a mix of them. Now, the one to be more careful with them because it's less obvious is the hypoactive delirium can be mixed with different things and it's very easy to miss. Ok. So what are the risk factors for delirium? So, the common ones that ni describes are being at the age of 65 and above having known cognitive impairment or dementia, having a current hip fractures. We recognized as a risk factor as well as having current severe illness. When we think about causes what actually causes a delirium. Pretty much any medical problem can cause a delirium. However, we normally ize them to the most common ones and we have acronyms that people use. Uh the one that I use commonly is pinch me, but there are other ones like delirium. Now, the letters can change. There are multiple things that you can put in there. Commonly I go with pain for pee. Um, and specifically as well, I look for suprapubic tenderness, potentially urinary retention. It can be pain from pretty much anything. Um, infection commonly in the elderly. Chest and urine nutrition. Are they eating and drinking enough? Are they dehydrated? See, for constipation and you will get commonly in the elderly, especially they're having surgical procedures. They're having a lot of opiate analgesia. They can get bumped up really easily. Uh, and that can cause the delirium just by itself hydration. Again, you can need to change out with things like hypoxia, hypotension and hypoglycemia. And that's one relevant in, uh, diabetic patients who are on things like insulins. Uh, then we come on to medications. Now, medications in themselves can cause delirium, excesses of medication can cause delirium as well as withdrawing from certain medications as well. And e we can go for electrolytes So things like hyponatremia commonly can cause things like confusion, hypocalcemia as well is well known for that as well. And finally, in the elderly population, a simple change in environment can cause delirium. And I've seen it tens of times in some of my elderly patients on the wards, um simply being moved from one bed to another on the ward has caused the delirium, moving wards in the middle of the night has caused delirium and it can be quite debilitating, especially if they were recovering quite well, doing well with physiotherapists and then they moved was and that's, it's a massive change for them. So it's always good to look out for that as well. Now, how do we screen for delirium? Nice guidance says we use something called the four A T score. Now, what is the four A T score? Um I apologize for the quality of the image in this. It was much clearer when I made the presentation. Um But if you can read it, I'll try and read bits out of it. The first thing that they will look out for is alertness. So is you look out for, is the patient markedly drowsy? Are they agitated, hyperactive? And they ask you to observe the patient and then you score it based on that. So if they're normal, you know, fully alert, but they're not agitated throughout the assessment, that's the zero. If they've got mild sleepiness for less than 10 seconds after waking and that's normal, that's again zero. But anything else other than that is clearly abnormal, so markedly drowsy or hyperactive or agitated that this use four points automatically. The second thing that they want you to do is is they call it A MC four. And that's looking at four things that's age, date of birth, the current place that the patient is and the year. And so you ask the patient if they know those four things and based on how many they get correct, you then score that. So one mistake its you 1.2 or more mistakes. It two. The third thing they want you to look out for is attention. So as a patient, can you tell me the months of the year backwards, starting from December and depending on how far back they get, you score them. So if they get seven months or more correctly, then there's zero if they start a score less than seven months or they refuse to start as one and if they just can't do it, um it's unt testable and that's two and the fourth and final one is any acute change or fluctuating course. So any significant change or fluctuation in their alertness of cognition, mental function within the last two weeks, but still evident in the last 24 hours and having that just gets you four points automatically. And what does this score mean? Once you've totaled all those four things up down in the bottom left, it explains um how you stratify them. So, if any score of four and above is a possible delirium plus or minus a impairment, a score between one and three is a possible cognitive impairment and zero means the delirium or cognitive impairment is unlikely. So, based upon that you can risk stratify and then go down the path of investigating them further for delirium. What is involved in the assessment of a patient that you think has delirium? So first of all, you need to have a look at the, the notes and generally when you're the F I one on call, we call about these patients by the nurses, you'll be bleeped. You want to get more information from the nurse themselves because they might be familiar with the patient over the last couple of shifts. They might be familiar with them earlier in the day, have a better idea of their background. Um So you want to find out the age what they initially came in with any treatment they had? They're a surgical patient, what surgery they've had and how long ago were there any complications with it? Their escalation status is always useful to know, especially if they're acutely unwell and delirious. Um It's good to know that early medical background and comorbidities. Um Do they have any known conditions? Um Do they already have a, a diagnosis of dementia or cognitive impairment? And it's good to know their baseline So what is their normal function? What's their normal cognition and how do they normally communicate? Because these make a big difference when you're assessing somebody with delirium to know what their baseline is and how far off of that they are. It's useful to look at something called the CgA or a comprehensive Geriatric assessment, which often for patients who have, when they come into the hospital and most of these things will be within that. Um, it's also good to see if they've had a four A T or even an AM TS score done on admission because then you can compare it to the one that you do and see how far off that they are. When you're looking at the notes, it's also good to have a good scheme of the, um, recent results like blood tests. You know, if it POSTOP, uh, the POSTOP bloods, were there any abnormalities, was something missed? Um, have a quick look at the drug chart. Um, were there any new medications introduced? Are they using a significant, uh, prn usage, for example, opiates and then things like observations. Has their new scot changed on the fluid or food charts? Has intake increased or decreased on the stool chart? When was the last time they opened their bowels? These are all things that will help you decide what's going on. Um, the next thing you need to decide is, is this confusion new and the way you do that is by taking a full history from the patient. If they are properly delirious, you might not get much from them. And in that case, a very useful thing to do is get a collateral history that might just mean giving the next of kin or your family member a quick phone call. Somebody that knows the patient well and getting a background of what they're normally like. What is their cognition normally? Like have they had delirium in the past? Are they functioning normally? How do they normally communicate? Do they require any specific age to communicate with? Are you confusing or deli for this? Them just not being able to understand you because they don't have the hearing aid. And one that I found particularly in the elderly population is regarding alcohol. A lot of elderly patients, one wants to admit that they drink excessive alcohol when they're initially admitted to hospital. They may say that they don't. But then for example, you might speak to the next of kin and they might say actually, yeah, they drink, you know, half a bottle of brandy a day and have have them for a while and that's gone unnoticed and they've been in hospital for a few days now and actually they're withdrawing. Um So that's also useful to get from a next of kin, if possible. Then based upon your history and the history that you get up mainly on the history from the patient, you then calculate it for A T score and you can rest stratify the patient. Um How do you assess a patient in terms of physical examination? I know this has been covered in previous sessions. So I'm not going to go too deep into the A T assessment, particular things to look out for when you are examining a patient with potential delirium. So on the neurological examination, look for any focal neurological deficit, things like stroke or an acute bleed can cause delirium. Look at the GCS um a careful assessment for pain. So again, is there any palpable bladder? Is that tender? Um is it a uti um if you think they're constipated, consider apr examination and using things that can off and nutrition and then based upon your history and everything that you've seen so far, the examination, you decide on basic investigations that you think you need that can include things like bloods, cultures, standard TS um imaging chest, x-ray, abdo xrays and CT head. If you think there might be something intracranial going on. Now, the bloods that you normally get for someone with delirium are commonly referred to as confusion screen bloods and I've included them on here. Generally the ones that are included, but there can be additional things to this, but it will generally include things like a full blood count use and, and CRP to get a sort of an infection screen, see if inflammatory markers are raised LF S because liver problems can cause delirium, um deficiencies and things like B 12 folate, uh calcium electrolytes, all of those things as well. Um In the use of these, looking at the kidney function, is it an A K? Are they dehydrated and things like vitamin D as well? Now, use the F I one, you need to do as much as you possibly can. So do as much of an assessment as you can do all the basic investigations. And then from there, if you're still stuck, then you, then you get uh then you escalate and seek advice or if you're worried, you escalate. Anyway. Now how do you manage delirium? So generally the way you manage delirium is by treating what you think is the underlying cause. Now, it could be more than one and it may not be initially very clear and you only really get an idea is after you once, when, after you start treating it to see, does the patient improve? The main thing that knife recommends here is that you make sure there's effective communication, reorientation with the patient. So making sure that in an appropriate environment, um potentially getting a family, a family member involved, getting them in to sit with the patient that can often help them get re orientated and become less confused. Um ensure that they all the other things are optimized, things like the fluid intake, the food intake analgesia have they got enough laxatives. Uh So that's how it's generally managed. Um Now, what do you do when you have a distressed patient um or patients that are a risk to themselves or others? So nice recommends in the first instance, you need to use verbal and non verbal techniques to deescalate. So that might just be reassuring the patient, getting a member of staff that they're familiar with to come and sit with the patient and talking them around that way. Now, if you've exhausted all of the, you know, those ver non verbal techniques to deescalate, you may want to consider um short term sedatives such as Haloperidol, which is what nice recommends in the first line. Um But I will say with haloperidol and sedatives in general, with the elderly, you should be quite cautious in terms of the doses that you're using to go with the lowest possible at first and you titrate it cautiously, they can have a lot of side effects, particularly sedatives in the elderly, massive falls risk. Um So you need to carefully consider after the sedative what what's happening with the patient as well, particularly with Haloperidol. It's contraindicated in things like Parkinson's disease and Lewy body dementia and it has a lot of cardiac and neurological side effects. Um things a QT prolongation, uh anti uh an param side effects, extra parad side effects, even sorry. Um and things like if they already have hypokalemia or any, you should ideally be looking at um the baseline bloods before and making sure they're not hypokalemic um as well as getting, trying to get an EG maybe as well to make sure they've not got QT prolongation. Now, alternatives include things like LORazepam. Now, if you are considering a short term sedative, um always check your local guidance first because it can vary, trust to trust. Some trust may recommend a different medication at the first line because that's what they've got available. So it's always good to check that first and obviously discuss it with your senior. Um If you're, if you're considering giving someone a sedative, I would be as an F I one consider discussing with your senior first. Anyway. Now let's, let's give you an example scenario. So you are the F I one on call for orthopedics at night, your ward cover. Um, one of the nurse bleeps you about a 75 year old lady by the name of Daisy. Now Daisy is four days POSTOP for a right hemiarthroplasty, uh for an intracapsular neck and femur fracture that she sustained after a fall in her garden. The nurse says that she appears confused. She's yelling out at staff, slightly aggressive and she seems to be asking for her mum. What else do you need to find out? Um If you wouldn't mind, would you be able to drop in the comments? What you think you need to know here? What more information do you want from the nurse or from the patient's notes. Um And we'll take it from there. Good. Excellent question. Is this new for Daisy? Anything else guys? Cool. Um Now what are we thinking differentials wise? Does anyone put a comment with you? What, what do you think is possibly going on here? Good. That's a good question. When did she last open her bowel? So you're already thinking, is it constipation? Uh You think regular analgesia, is it a side effect of medication? Good? And then is this new for Daisy? Are you thinking actually, does she have a known cognitive impairment or dementia? Good? So these are all things, these are all good differentials and they're all things that are possible at this moment in time. You don't know enough, you need to have more information, you need to assess the patient and take it from there. But at the moment, it could be anything really that is causing this delirium or possible delirium. So, um you get a, you get a better handle from the nurse that called you. The nurse tells you that she was on shift yesterday and Daisy was fine and settled and she was completely orientated. She normally has no issues with her cognition and new score at the moment is zero and it has been all day. She took all of the prescribed medication in earlier, earlier in the day without any issues. This how she's currently presenting is a very abrupt change. There was no consent handed over from the day team about her and actually the nurse that called you has noticed that she's got a slight cough now and then while she's doing that, you also, luckily you're an Entresto has electronic notes and so you review the notes remotely before you go to see Daisy. Now you look at her notes and it says up on her mission. A four A T score was zero doesn't normally have any issues with cognition. Lives with her husband in a bungalow with twice a day carers normally mobilizes with a weird simmer frame. She doesn't have any issues with speech, but she is slightly hard of hearing and has hearing aids, medical background wise, hyper hypercholesteremia and hypertensive. Um and there's no other documented history of things like mental health problems. You have a quick scheme of her bloods, um POSTOP day one bloods and there wasn't really anything wrong with them. Have a look at Rob's chart again. No significant change. You look at her stool chart. She's opened the bowels yesterday. A type four stool and the drug chart. There's no significant uses of PRN or any new medications really on there either. So now you go to the ward, um and when you get to the ward, Daisy's alert in her bed, but she's still yelling out for her mother. She doesn't seem to recognize any of the nursing staff. Now you try and take a history from Daisy, but it's quite difficult. She seems to know her name. She knows her date of birth, but she's grabbing at her own clothes while she's talking to you. She's asking where she is because she doesn't know she thinks she's 16 years old and it's currently 1964 and you try and ask her what the months of the year are backwards, but she only makes it to September. Um, you then ring Daisy's next of kin, which is her son, Dave. Um When you speak to Dave on the phone, he confirms what the nurse told you and what the documentation says in terms of Daisy's baseline cognition and he agrees that her current presentation is completely out of, of a normal for her never previously happened as well. What I'd like you guys to try and do now is calculate for a T score for me if you can and when you've calculated it just drop it in in one of the comments. Cool. OK. So maybe you put the answer there. Good. So yeah, um 11 is the correct answer. So we look at alertness. She is um we could say probably hyperactive or agitated here. She's yelling out for her mother doesn't recognize nursing stuff. I think that is clearly abnormal. So you've got four for that in terms of the A four, she's made two or more mistakes. So again, two of that four plus two with the tension she's starts but scores less than seven months. So one point for that. And then there is definitely an acute change in her the last 24 hours. And so it's a yes for that. So in total that comes to 11. Um So good job guys. Um fine. So what does that mean? That's quite clear. Her score is way above four and it's a possible delirium, cognitive impairment. So you risk assessed her and she's at risk of the possible delirium. Now, you examined Daisy on her examination pretty much. The only thing that you can find abnormal is that she's got right, basal crackles. Rest of your examination is all fairly normal. She move all four of her limbs equally. Pupils are equal and reactive. Her blood sugar is fine. Other, other observations are fine. You're not concerned about a hip wound at all. There's no pup or bladder and no other pain that you can elicit anywhere else. What investigations would you like to do if you can just drop in the comments? Um I'm not fussed about which order you do them in just any, any random ones. Good. Fine. So imaging wise, we've had to do a chest x-ray. Anything else you'd like to do? Excellent. Go to repeat bloods, anything else at the bedside? You might want to do? Good PM. So we've, we've, we've already managed to get the BM anyway, whilst you're doing the A T assessment. Good. Um So ABG ABG, I'd really only consider if the patient was hypoxic um, other than that, you can get most of the other parameters that you need off a venous cath. Really? Um, but no, that's fine. That's good. You might want to get a venous cath. See if there's any acute electrolyte abnormalities, um, any, uh, problems with things like raised lactate if you down the lines of sepsis. Um, but that's good. Yeah, you got a good range of them that, um, so things you can possibly do um good blood cultures as well. So at the bedside, things like sending off a urine M CNS. Now, although there's no signs and symptoms of a uti when you're suspecting a new delirium is worth sending one off. Anyway. Um ECG again, I, I would probably only normally do if I thought there was an abnormal pulse or, you know, tachycardia. Um But in this case, one of the nursing staff has kind of done it for you and it's a normal sinus rhythm. You pull off a PG as you're taking the other bloods and everything is within the normal range. The lactate is 0.8. Now you do the bloods and the bloods come back a few hours later. Um On the CBS 1 30 white cell, 17 neutrophils, 15 crp 1 30 renal function looks ok, electrolytes are all, OK. Calcium is fine TSH and pretty much everything else is ok. And again, oh, that's, that's an excellent one as well. I didn't actually write that down but yes, a COVID swab. Um That's excellent if there's a new cough. Yeah, fair enough new, new delirium to go with that. So, from these bloods, it looks like she's got raised inflammatory markers, imaging wise again, quite rightly. A chest x-ray is indicated here if you got a cough, right, basal consolidation on there, um that's fine. And then you could also still consider a CT head if you think actually, I'm not quite sure on the cause here. Um Some things something's not right. Is there something intracranial going on here? So you could still consider a CT head now, differentials wise, what what do we now think that Daisy has again? Just drop it in the comments. Good. Yeah, chest infection. So specifically in this case, it would be called a hospital acquired pneumonia, which is a pneumonia that a patient develops after 48 hours of admission and it's a pneumonia that wasn't present prior to um prior to them coming to the hospital as well. So, yeah, excellent. A lot of you already get that. So yeah, this this looks like it's a hospital acquired pneumonia. Now, in Daisy's case, how do we treat this? Now, hospital acquired pneumonia, generally treated it with antibiotics as per your local trust guidance. Um generally places I've worked is the first line for hospital acquired pneumonia is IV antibiotics, but I think some trusts do still use oral. So in this case, whatever your local guidance says, um So you treat the underlying cause you start her on some antibiotics. Now you have to consider everything else as well for Daisy as nice. Nice guidance on delirium recommend. So hydration encourage her to have a good oral intake, especially if she's got an infection, start a fluid shot. If you need to consider whether she needs fluids. If she's not, if you don't think she's gonna be drinking much. Sure there's effective communication. You try and reorientate Daisy to the ward. Um Do you need to consider her environment? Does she need to go to a side room? Um Do you need to get a member of a family? And do you need some to come in maybe sit with her for a bit, bring some belongings from home to put her around to make her feel more comfortable? Does she need a 1 to 1 to sit with her um to just reassure her? Um and again, making sure she has the right analgesia prescribed prn if needed bowel care, a food diary, making sure she's eating and drinking enough. So that's in Daisy's case, how we probably go about managing it. Now, the questions that come to mind in this are especially if she's got a delirium. Number one, does she consent to the treatment that you've given her? Number two? Does she have the capacity to consent to that treatment? And what if she remains distressed and all verbal and non verbal deescalation haven't failed what do you do then? Especially if she's not consenting to treatment. And that's why we come on to the next bits um about the Mental Capacity Act. What is capacity? And again, um I will stress guys that this is a snapshot. There's a lot of things that I couldn't fit into you because it is a lot of information. I've tried to cover the salient points here, but again, refer to your local guidance. Um I will put links at the end of the Mental Capacity Act Code of Practice, which they recommend that you be familiar with if you are working and dealing with the Mental Capacity Act, as well as some a useful guide from the BM Toolkit, as well as some guidance from um um guidance from about the mental capacity of the healthcare professionals. Um So I'll link that in at the end. Now, what is capacity, capacity generally refers to a person's ability to do something that includes making a decision. So things like consenting to a procedure, things like deciding what to have for lunch. Ok. People can have capacity for these specific things. Now, capacity is both time and task specific. What does that mean? So a patient per person may have the capacity to decide what they're having to eat in the morning. Er they may then lack the capacity to decide what they're having for lunch, different times of the day. And um that's different and again, somebody at breakfast may have the capacity to decide what they want to eat for breakfast. Um On a on a ward, for example, they may have the capacity to decide what they want for breakfast, but they may not have the capacity to consent to a blood test. So again, it's task specific as well. So both capacity assessments need to be time and task specific. Now, what is the Mental Capacity Act in itself? The Mental Capacity Act is a legal framework that helps you decide whether a pa a patient has the mental capacity to make a decision. Now, it's specifically applicable to adults over the age of 16 and over in England and Wales, I believe Scotland has separate legislature and guidance which needs to be looked at separately. The contents of this presentation are related to the Mental Capacity Act in England and Wales. Now, number one, it provides protection and safeguards for the individual whose capacity is in question. And number two, it also provides a defense for you as healthcare professionals. When you're making decisions in the best interests of people who lack capacity, there are criminal offenses associated with all treatment of willful neglect and people who lack capacity. So it's really important that when you're dealing with things like patients who lack capacity, you stick with the advice and guidance of the Mental Capacity Act and you work within the framework and the principles of the Mental Capacity Act, what are the principles Now, I've taken this directly um as a screenshot from the, the government website of legislation. So what are the principles of the Mental Capacity Act? So there are actually five main principles that you need to be aware of. Number one, you have a person must be assumed to have capacity unless it's established that they lack it. So you have to assume it unless you have reason to feel otherwise. And in that case, it's your job, then um it's your job then to decide whether or not um uh to prove that they don't have the capacity. OK. Number two, a person is not to be treated as unable to make a decision unless all practical steps to help him to do so have been taken without success. What does that mean? So we think about a patient like Daisy, we know that she has a hearing impairment and she wears hearing aids. So it, it may affect her communication abilities. So you need to make sure that you take all steps, make sure she's got a hearing aids in, make sure you use any of the verbal visual aids needed to make sure that you can accurately assess the capacity and take all steps necessary. Number three, the third principle, a person is not to be treated as unable to make a decision merely because he makes an unwise decision. So somebody has the right to make an unwise decision that's up to them simply making an unwise decision does not mean somebody lacks capacity. Number four and act done or decision made under the mental capacity Act for our behalf of someone who lacks capacity must be done or made in their best interests. And that is a very important one guys, anything you do, any decisions you make for patients who lack capacity need to be in their best interests and we'll get on to what that means later on. And the fifth principle that they have is that before the act is done or a decision is made, you have to have regard as to whether the purpose for which the decisions needed can be effectively achieved in a way that is less restrictive of the person's rights and freedom. So is there a less restrictive way that the decision that you're making for this person who lacks capacity? Is there a less restrictive way to do it? Is there an alternative? So these are the five principles of the Mental Capacity Act that you need to try and stick to as possible? Um So now how do you decide whether or not a patient lacks capacity? So what they say um about that is number one, a person, you have to decide whether a person lacks capacity in relation to a matter. Now, n the number one thing that they ask here is that they have to have at the material time, they're unable to make a decision for themselves in relation to a matter because of an impairment or disturbance in the functioning of the mind or brain. Ok. So that's number one. So when you're deciding whether someone lacks capacity, the first thing you need to decide is do they have an impairment or disturbance in the functioning of the mind? The brain that can mean a whole wide range of things. So things like delirium, dementia, um other medical problems, um strokes, things like that, you know, a whole wide range of things. Um alcohol, intoxication, drug intoxication, all of these things can possibly fall into that. And it further says that it doesn't matter whether that impairment is temporary or permanent. And it further says that you cannot establish lack of capacity merely based upon things like someone's age, their appearance or a a condition that they have. Ok. The second part of this now is that to determine whether someone's unable to make a decision for themselves. So the first thing, um the first thing you need to decide is whether they have an impairment of the brain or disturbance of the functioning of the minor brain. And number two, you need to decide whether they're unable to make a decision for themselves and you have to go through four things for this. So the first is, can they understand the information relevance to the decision that you give them? Number two, can they retain that information and you, and when it says, retain information, it doesn't mean that they have to be able to retain it long term, months, months down the line, they need to be able to retain that information long enough to make a decision. Ok. Number three, can they use the information that you've given them? And we, that information is part of the process of making the decision. And number four, can they communicate their decision again? That doesn't necessarily have to be verbal or written. It can be a mixture of things, you know, even things like using sign language here. Now, if there's any lack of any, any one of these things, then according to the Mental Capacity Act, they're unable to make that decision. OK. So if they can't understand it by themselves or if they can understand it, but then they can't retain that information long enough to make a decision. That means that for this, for the purposes of the Mental Capacity Act, they're unable to make that decision. So again, if I go back, number one, is there an impairment or disturbance of the functioning of the minor brain? And number two, they are able to make the decision based on those four things. So that will determine then whether the bed and the person to have a lack of capacity for that decision or not. OK. Now what does best interest mean? So the fourth principle of the mental Capacity Act was that any decision, an act done or a decision made under the mental capacity act on behalf of someone who lacks capacity has to be made in their best interests. Now, we can't make any assumptions about what someone's best interests are merely upon their age appearance, what, what medical conditions they have or the behavior you need to try and take all relevant things into account, social issues, psychological issues, um, taking account, er, taking relatives views into account of that as well. And it's important that even even if the patient lacks capacity might be delirious to try and involve the person as much as possible um within that as well. And you also need to think about actually the decision that I'm making for this person who lacks capacity right now. Does it need to be made now or can it be made later when capacity is regained? Is it something that needs to be done acutely or actually, can this, can this decision be made? For example, you know, an invasive investigation that doesn't need to be done acutely, you know, um potentially in a really elderly patient that's very frail, um probably won't um you know, benefit from a surgical intervention for a, a potential cancer that you think they may have um making the decision of whether they want that investigated or not again. Can that wait until, you know, a couple of days down the line or tomorrow morning when they're less, you know, less confused? It's, it's about thinking about that as well. Er, and you as a decision maker. So as, as, as a junior doctor, as the fy one, what should you consider as a decision maker? Again, the individuals past and present feelings? So, if they've previously conveyed what their wishes and feelings are, er, any beliefs, they have religious, cultural moral that you think might influence that decision, er, and any other factors as well and who should you consult? So, anyone that the person has previously named to be consulted, um, within that, that might be documented in the medical notes. Um, any carers, close relatives, friends, anyone else that's interested in the person's welfare, any attorney appointed under a lasting power of attorney. And I will come on to that a bit later in this presentation about what, what a lasting power of attorney is and any deputy appointed by the court of protection to make decisions about the person. So those are two people potentially that you need to, you need to consult when you're making a best interest decision for somebody who lacks capacity. Now, there are exceptions to the best interest principle and this is quite a lot of detail, but I thought I would mention it. So if somebody has previously made a valid advanced decision to refuse a treatment whilst they had capacity, if that decision, the, the advance decision is valid and applicable, it should be respected even if others don't think um, it is in their best interests. Ok. And another reception are there are some decisions that require court approval and that's because the decisions are related to quite serious matters. And each case where that decision is being made needs to be taken to court to decide. And things that the code of me class code of practice have included are things like proposals to withdraw or withhold artificial nutrition in patients in a permanent vegetative state. So it's just good to be aware of that. And there's a longer list within the mental capacity, code of practice. Now, coming back to Daisy, our 75 year old patient who is four days POSTOP, right? Hemi, who's got delirium. Now, in her case, what is the decision that she needs to make that? We think she may not have capacity for? And the decision is, can she consent to taking IV antibiotics? So now we go back to the principles and we have, we have to number one assume that they have capacity unless it's established that they lack it. So we go back to what the Mental Capacity Act says in terms of the two things that you need to look out for. So number one, does Daisy have an impairment or disturbance of the functioning of the mind, the brain? And number two, are they able to make, are they able to make a decision? So does Daisy, number one, understand the information? Can she retain the information, weigh the information relevant to the decision and communicate the decision and that's the decision to consent to taking IV antibiotics. So, in terms of answering the questions, I think it's quite clear. Number one, is there an impairment of disturbance of the brain of mind? Yes. Um You know, she's quite clearly delirious and we think that secondary to a hospital acquired pneumonia. Number two, for, for those four questions. So you try, you try and have a conversation with Daisy about this. Um You try and explain to her that you think she's picked up a pneumonia in hospital and you think that he's treating with antibiotics while you're talking, she doesn't seem interested in the conversation at all. She has her hearing aids in. Um but as you're talking to her and explaining this, she continues to ask for her mum looking around the room, not really paying attention. So it doesn't seem to you that she understands the information. She certainly doesn't retain it. She doesn't weigh the information on balance and she's not communicating anything on a potential decision either. So she answers no from all of these. So now according to the principles of the Mental Capacity Act, Daisy lacks the capacity to consent to taking IV antibiotics as part of a treatment. Now, we need to now decide what is in Daisy's best interests. Again, according to the mental capacity principles, in this case, it's fairly straightforward. Um Is there any less restrictive alternatives to giving antibiotics? Not really, there's not really any treatment for hospital kind pneumonias. She needs antibiotics as part of that treatment. And can this decision wait until later? Now, if you delayed it, giving her antibiotics for pneumonia, she may become more unwell, she may develop sepsis. Um, so, no, not really. It can't really be delayed. So now, antibiotics would therefore be Daisy's best interests. Now, in, in, in real life circumstances, what you'd probably do is you'd explain that to Daisy. Um If you, if possible, she's retaining it or not. Um You then probably after starting antibiotics, you'd telephone call, Daisy's next of kin or relative. Uh Dave in this situation to inform them of the situation, make sure they've not got any concerns. And generally in this situation, I've, I've never had a, a relative say that, oh, no, definitely don't give him antibiotics. They've all said that. Absolutely. That's fine. Please give him antibiotics. Now, how does the Mental Capacity Act protect you as a doctor? It provides legal protection from liability and carry out carrying out certain actions uh in the care of patients who lack capacity to consent, provided a few things. So number one, you've observed the five principles of the Mental Capacity Act. You've carried out an assessment of capacity and reasonably believe that the patient lacks capacity in relation to the matter at hand and you reasonably believe that the action you are taking is in the best interests of the patient. So if you do those things and then you should be covered in terms of the Mental Capacity Act. Now, I would say in the circumstance, the key thing here for you as a junior doctor is to document, document, document, document. So what I mean by that is when you've gone to see somebody such as Daisy, you have to document what you've observed. You have to document your assessment in terms of capacity and you have to clearly document that you believe for for what reasons they'd lack capacity, you have to document that you've taken all reasonable, you know, things into account such as she's got her hearing aids in. Can you, you know, understand that information and time you've done all reasonable things and then any actions that you take, you need to clearly document that this is in their best interests and why you believe that it's in their best interests and anyone you've consulted as well. Ok. Now, if you're in a situation where you're making the best interest decision, especially as a, as an fy, I wanted a junior doctor, I would probably recommend in that circumstance, you should be discussing it with the c before you proceed. So if you're on call, discussing it with the registrar or making sure that they're happy with that plan, what does the mental capacity act say about restraint? So let's go back to Daisy. Daisy was in bed, but now she's managed to climb out of a bed, she's heading down the corridor, limping. Um This is somebody that normally mobilizes with the wheels of a frame at home and she's just had a hip replacement done as well. So it's quite concerning. Um, she's still got bedding over her that's dragging across the floor with it too. So it's quite, it is quite alarming. So the mental capacity act, when it comes to restraint, restraint, they generally defined as the use or even threat of force to do something that the person concerned resists. So that can be a whole wide range of things. Simply using cos eyes, raising the side bed rails, confining someone's movements, closing a door in front of them, removing their aids, um giving them pharmacological therapy, you know, a sedative, these are all things that can fall under the banner of potential restraint. Now, the Mental Capacity Act says that restraint should be a last result, an alternative should be considered prior to using it and particularly regarding the restraint. Um they've set two conditions under the Mental Capacity Act to protect you as a healthcare professional from liability. Number one is that you must reasonably believe that it's necessary to restrain the person who lacks capacity in order to prevent them from coming to harm. That's number one. Number two, any restraint that you use must be reasonable and in proportion to the potential harm. So if you are going to use a restraint on the Me Plasty Act these are the two things that they want you to consider here. Now we come on to um uh when it, when it comes to restraint, again, it's important that you get senior involvement as, as an F I one, I wouldn't be taking any medicine to consider restraint unless it was, you know, very urgent that you did it. Then and there, I would again be escalating to a senior in that circumstance to make sure what you're doing there is is reasonable and correct. OK. What does proportionate mean? So when they say here, any restraint must be reasonable and in proportion to the potential harm, the way they define it in the guidance of the Mental Capacity Act in the code of practice is things like using the least intrusive type of restraints, using the minimum amount of restraint to achieve your objective. And it has to of course, be in the best interests of the patient la in capacity. That's what they refer to as being proportionate. So for example, if Daisy was just merely trying to get out of bed is, you know, potentially five members of staff jumping on her pinning head down to the floor and giving her reception, is that proportionate in that circumstance? Or can you achieve that through alternative, less intrusive means? And this is an example scenario that I've pulled from, I think the code of practice on the mental capacity Act about an individual and appropriate use of restraint that they are given an example of. So in this detail, a gentleman called Derek. Derek is a chap with learning disabilities and he's begun to behave in a challenging way at his care home. The staff at his care home think he might have a medical condition. Um Now the the the wording in this have kept it quite vague in terms of medical condition, I think broadly used for all healthcare professionals. So to think that he might have a medical condition that's causing him distress, they take him to his doctor. I think in probably a GP in the circumstance who thinks that Derek might need to have a hormone imbalance. Again, keeping it quite big, the doctor needs to believes that he needs to take a blood test to confirm this. And when he tries to take the blood test from Derek, Derek tries to fight him off. Now the results of this blood test might be negative. So it might not be necessary. But the doctor in this circumstance decides that a test in Derek's, this test is in Derek's best interests because if they don't uh because failing to treat them for a problem like this whole body balance might make it worse. So the doctor deems in this circumstance uh that doing the blood test is in Derek's best interests and it's in his best interest to restrain him to have that blood test. So the temporary restraints that they've described here in this scenario, they feel is proportionate to the likely harm caused by failing to treat the possible medical condition and by not doing the blood test. So that's just an example of what they've described as a proportionate restraint here. Um So now we come back to the scenario, um Daisy's wandering the ward or she, you know, she's managed to leave the front door of the ward. She's still delirious. She's at risk of causing harm to herself. So what is a reasonable proportionate restraint in the first instance? So you start with the least restrictive measures. So what could you do in the circumstance? Daisy's just got out of bed. You could just try and guide Daisy back to her bed in the first place. Come up to her use, you know, soft tones, perhaps take it by the hand, say Daisy, I think you've, you know, wandered away from your bed. How about we go back to your bed? Um And then, you know, if you manage to guide her back to the bed, maybe raising the side rails in that circumstance to prevent it from climbing up again while she's delirious until until the treatment starts, you could then arrange for, you know, some supervision member of staff to sit with her. You call a family member in that might comfort her as well, bring some familiar objects. So again, start with the least restrictive measures. Now we come to when, when, when can restraint be not, not be used under these principles of the Mental Capacity Act. So for it to be used under the Mental Capacity Act, it must not amount to deprivation of liberty. If it is considered necessary to deprive someone of their liberty in their best interests, it requires separate safeguards. Ok? Not just under the general principles of the Mental Capacity Act, they require specific separate safeguards if there's a deprivation of liberty involved. And that brings us on to our next topic. Deprivation of liberty. Safeguard, commonly referred to as dolls. You often hear that on elderly wards or ward, you know, orthopedic wards where you have elderly patients, people with backgrounds of dementia. Um So what, what is deprivation, what is the deprivations of liberty? Safeguard dolls. Um So these safeguards were added to the Mental Capacity Act, they provide a legal framework to prevent unlawful deprivation of liberty from occurring. Now, it says quite clear there are times when the necessary care or treatment in an individual's best interest can only be provided in circumstances that amount to deprivation of liberty. So it might, it might be necessary in the patient's best interest to give them carer treatment that will deprive them of their liberty. But if you do so, you can only do it, it's only lawful if it's authorized in accordance with those procedures. Ok. Now, this is quite a complex area of law and practice. I would say that when, when anything that you're doing is potentially depriving someone of their liberty. You need to have senior support input and you sure you refer to your local protocol and guidance when it comes to the provision of liberty and the local procedures for applying for adults. So what actually amounts to a deprivation of liberty? Now, there's not actually a very clear answer when it comes to what the mental defines as it. Um and it's actually quite difficult to, to find the difference between using restraint. Um that is restrictive versus a restraint, that is, you know, deprivation of liberty is described in some of the literature with the mental capacity Act as the difference being one of degree or intensity, not really one of nature or substance. And that's from the European Court of Human Rights. So there must be factors in the specific situation for this person which provides the degree or intensity to result in a deprivation of liberty. So that could be the type of care that you're giving, how long the situation lasts, its effects and the way it came about those are all things that can factor into the degree in our intensity. Um And again, I've taken this out of some of the guidance um about examples of the European Court of Human Rights have identified where this is a deprivation of liberty. So for example, where restraint was used, including sedation to admit a person who was resisting to that circumstance, they thought that that was a deprivation of liberty. Another example where professionals exercised complete and effective control over care and movement of a patient for a significant period that again amounted to deprivation of liberty. And they have a number of different examples. Now, what I found quite useful when reading, reading into this topic. And this is actually um something I've taken out of the B M's um mental capacity toolkit. And in this, they've included some guidance that's come from a Supreme Court judgment in 2014 where they introduced an acid test to decide what constitutes the deprivation of liberty. And in that they have these three questions. So number one that you have to ask is, is the person subject to continuous supervision and control. Number two is the person free to leave. And number three, does the person lack the capacity to consent to their care and treatment in those circumstances? And in this Supreme Court judgment, they said that if, if they are under continuous supervision and control and they're not free to leave and they lack the capacity to consent to their care and treatment in those circumstances, then the as a test is met and that the, you are depriving of their liberty. So that's a good acid acid test to use. Asking yourself those three questions. Now, you as a junior doctor, you as an F I one on call. What do you do if you feel that dolls is necessary? So again, like I said, in the first instance, I'd be speaking to your senior and referring to your local guidance and procedures. How do you actually go about applying for adults? And what are the type of dolls? So the managing authority of the hospital has to apply to a supervisory body and that your supervisory body is normally the local authority where the per where the person lives. Now, the way they apply for authorization for dolls, there's two types. Number one, the standard one is you submit an application. The uh the application goes to the local authority and the body, the local authority in this case has 21 days to decide whether or not to grant the authorization. And number two is the urgent authorization and this is the one you'll be using commonly as a junior doctor in hospital with, you know, acutely or more patients that you potentially depriving of their liberty in their best interests. And an urgent one is essentially one that the managing authority that itself. So the hospital in the small circumstances, the hospital themselves issue the urgent authorization themselves and that lasts up to seven days with an option to extend further seven days if the body agrees. And when you submit an auth an application for an urgent authorization, it automatically also, I believe submits an application for a standard authorization too. So number two, the urgent authorization is generally what you'll come into contact with. So now we come back to Daisy. Now you've tried the least restrictive measures, um, verbal and non verbal cues and things like that, but she can't be convinced to return to her bed. She's now becoming aggressive, lash, lashing out her staff members potentially causing harm to herself in the process. She's continuing to try and try and leave the world whilst deli despite best efforts to calm her down, what do we do here? So now you need to consider if restrains and administration of a sedative is now the least restrictive measure and it is in Daisy's best interest to prevent her from coming from harm. So that's again what the mental cast says about using restraints. So is it the new restricted measure and is in her best interest to prevent her from coming to her harm? Uh And you also need to consider now, by doing this is this amounting to deprivation of liberty. So how do we decide that? So I would go back to the acid test and that was described in that Supreme Court judgment. So number one is the person subject to continues to be in control, is the person free to leave and is a patient like the capacity to consent to their care and treatment. Now, in this circumstance, if it was just, you know, just, just giving them a sedative, an oral sedative by, you know that they, they tolerate and accept having orally, probably not. But if you're, if some if Daisy's not trying to leave the ward, she'll likely need the staff members to, you know, potentially hold it down while she administer the sedative, you know, possibly intramuscularly following that will, will Daisy be free to leave? Probably not. Will she require continued supervision and control following that? Quite possibly and quite clearly, Daisy lacks the capacity to consent to their care and treatment at that time. So in that circumstance, I'd probably say, yeah, it probably is an anti to their probation of liberty. So again, you need to discuss with your senior prior to, you know, I I taking any action ideally in that circumstance, you don't want to discuss it with the senior. If they feel it's appropriate, then you could go down that path. And again, if, if you think it is amounting to deprivation of liberty, you need to make sure an urgent Doles application is also submitted and it's also essential that you discuss with family, relatives or if there's any lasting power of attorney, if you have de deprived patients uh liberty without the necessary authorization, it is unlawful. Um The act and the Doles, the documentation on Doles is quite clear on that. And again, I have to reiterate that you need to make sure you document all of this when you're these steps that I'm taking you through what you're considering. Um you know that Daisy's at risk, what's in her best interests, the steps that you're taking. Why you think they might amount to a deprivation of liberty and, you know, you need to document all of that and you need to document then the discussion with the senior and that you're submitting a do S application. Ok. So that's, that's covering some of, you know, the mental capacity act. What a deprivation of liberty safeguard is. What is the lasting power of attorney? Now, I've briefly touched upon this a few times now. So lasting power of attorney, er, it allows an individual who's 18 years or above to give authority to somebody else, that person, somebody else becomes the attorney in this circumstance and they allow them to make decisions on their behalf. If at some time in the future, they lack capacity to make decisions themselves, essentially to make decisions on their behalf. Now, the individual who's the term is the attorney, um, the individual who grants them, the lasting power of attorney decides how much power their attorney has over the decisions. So they can specify that, you know, my, my lasting power of attorney, this, this attorney can only make decisions regarding XYZ or this medical condition or this decision or this, this treatment of this care. Ok. Um, they can have a person who can have more than one lasting power of attorney. They can have multiple and they can also appoint um those multiple lasting powers of attorney to make decisions jointly or even separately. Now, um, the power of the attorney has a duty to act or make decisions for the person who's made the lasting power of attorney in the person's best interests. Ok? Has to be in their best interests. There are generally two types of lasting powers of attorney. The first is personal, personal welfare, lasting power of attorney. And that is an attorney who can make decisions about both health and personal welfare. This is generally the one that you'll probably come across in hospitals and the one you'll be needing input from, um, to do with, you know, health and medical decisions. Number two is somebody, uh, a, a property and affairs lasting power of attorney and this is somebody that can make decisions about financial matters and those are two separate things. So whenever somebody tells you, they have less than power of attorney, you need to make sure which type of power of attorney that they have because someone that just has it for the financial matters cannot make decisions about health and personal welfare. Um, now for a lasting power of attorney to be valid, it needs to be on a specific form and everything on the form needs to be correct and, and on that form, there needs to be information about the nature and extent of the lasting power of attorney needs to be signed by the individual who's making it the attorney as well as a third party. Additionally, that lasting power of attorney needs to be registered with the office of the Public Card in before it can be used for it to be valid. So these are things that when, when you're, when some, when somebody's making a decision based of being your lasting power of attorney, you need to make sure, actually, is that lasting power of attorney valid? And these are some of the things that you need to look out for. And generally, again, as an F I one who's potentially never looked at a lasting power of attorney before again, I would be seeking senior support and to look into that as well, making sure it's correct. Now, these are some again, some of the finer details to do with the lasting power of attorney and I thought I'd just briefly go over some of them. Now, a personal welfare, this is this is to do with someone who's making decisions specifically on health and welfare. They have no power to consent to consent or refuse treatment when the person has capacity. So if a person has capacity, the person that they've appointed as the lasting power of attorney can't make decisions on their behalf because that person still has capacity. Um that is um contrary to the um lasting power of attorney who makes decisions for um financial matters, the person um that lasting power of attorney can make decisions on financial matters whilst the patient still, whilst the patient still has capacity, ok. Now, if the person lack capacity, that personal welfare, lasting power of attorney is the decision maker on all matters relating to person's care and treatment unless there are limitations specified in that lasting power of attorney. So again, you need to have a look at what the lasting power of attorney says or what they can and cannot do. Generally, the lasting power of attorney cannot make decisions on life sustaining treatments unless the lasting power of attorney specifies it clearly. Ok, They cannot consent to a treatment the person has made er when the person has already made a valid and applicable advanced decision to refuse after creation of that lasting power of attorney. So say for example, an older gentleman um makes their son a lasting power of attorney for the health and welfare. But then after appointing their son, they also then make an advanced decision and that they want, you know, they want to refuse treatment later on because he's already made that advanced decision after appointing lasing power of attorney if he loses capacity er about making that decision that lasing power VSE can't override that advanced decision to refuse that treatment. Ok? And they cannot consent or sing power of attorney cannot consent or refuse treatment for a mental health disorder where a person is detained under the mental Health Act has separate rules. OK? A lasting power of attorney cannot also demand specific treatment from health professionals that the health professionals consider not necessarily appropriate for the person's particular condition. So I know that's quite a lot of information there, but I thought I would just mention them again, these are things you're probably not going to retain right now, but the things that you possibly want to look up when you're potentially dealing with this in real life. Ok. Now, if you feel if you're concerned that a health and welfare lasting power of attorney is making decisions on behalf of somebody and the lack capacity that's not in their best interests, you can take steps um against that. So you can make an application to the court of protection to look into that. Um But again, that's quite advanced and you'd be involving a senior in that circumstance. So that's just a sort of whistle stop tour to do some of those finer aspects to do the lasting power of attorney. I want to now briefly discuss DN CPR and this is something as an F I one you will be commonly dealing with when you're dealing with brown and elderly patients, especially, you know, patients are unwell postoperatively. So what I would say is when it comes to DNA CPR discussions in the frail and elderly is that you, you should ideally be having them as early as possible. Ok. The, the actual decision for whether somebody is not for resuscitation or not, is technically not yours as a junior doctor that is, you know, a registrar or consultant level decision. Um at some places, I think even the forms they want a consultant only and even registrars need to kind of sign. But again, depends where you, where you work and things, I think normally, but what you can do as a junior doctor is you can have discussions regarding them if your seniors are happy with that. Um But any DNS apr decision you made is not valid unless it's obviously can't signed by a senior. And again, I would say that you should not be making that decision generally the way it should work is that your senior should be saying that actually, I think ad A CPR here is appropriate and I'd like you to discuss it with either the patient or the family members. And then you need to get the account assigned by the senior. It's important for planning for the future. Um There are, and you'll, you'll come across this yourselves when you start working in fy ones in circumstances where a patient, a elderly patient is very unwell and they've not had that discussion in the past. And now because they're so unwell, then you, this is difficult to have that discussion at that time and things can often be a lot easier if you have that in advance and it's already in place, it makes things a little bit easier. Um, and a line that I like to use is when patients are coming all through the front door and you know, the frail and elderly is asking them if they've already had any thoughts? So, have you thought about what you would want to happen in the future if your heart were to stop or you stop breathing and you tell them, you know, it's not something that you think is going to happen imminently, but if in the future it were to happen, what are your thoughts about it? It's quite an open ended, open ended question, they may say, you know, oh no, I would definitely want resuscitating or they may actually say actually no doctor, I thought about it and I, I've had a discussion with my family and actually I think if I was that unwell, I, I wouldn't want resuscitating. And in that circumstance, you can then take that to your senior and say, look, I've had this conversation with them. They have said this, you know, are you happy for, you know, the DC to go in place and they'll be like they'll say, you know, OK, that's fine, document that and sign the form and I can sign that DNA CPR conversations can be tricky and they can be difficult. Sometimes people are very adamant they don't want a DNA CPR. Sometimes it's their family members and not the patient themselves. OK. So it can be quite tricky. What does the GMC guidance on? What is the GMC guidance on the NS CPR? And I've, I've copy pasted this paragraph that they have here and I'll put a link there as well for the GMC guidance. If you just Google it, it'll come up. But this is actually a very good line and it actually has some really useful things that you can actually tell patients and their relatives about giving CPR. So it's this line here. So generally CPR has a very low success rate. There are burdens of risks of CPR which include damage to internal organs, rib fractures, adverse clinical outcomes for the patient. Things like hypoxic brain damage, increasing physical disability. If CPR is not successful in restarting the heart of breathing or in restoring circulation, it may mean that the patient dies in an undignified and traumatic manner. So you as F I ones or you know, junior doctors, you'll find your own way of sort of conveying this information, but it is information that you need to portray to people when you're discussing DNA CPR. Now it's quite a common misconception. But actually the GMC says that the DN CPR is, it's not legally binding. Ad N CPR is actually a clinical assessment and decision to guide immediate clinical decision making in the event of a patient's arrest. OK. Discussion should be had with the patient and you have to try and take their wishes and preferences into account as well. You have to try and approach the discussion sensitively and if they lack capacity to make that decision on the N CPR as well, you have to consult those close to them or any legal proxy. So the legal proxy in this circumstance might be a lasting power of attorney. But again, if it's the lasting power of attorney for health and welfare, the lasting power of attorney needs to give them the power to actually discuss things like the N A CPR. And when it comes to things specifically what the GMC says about, when you, when you consider that giving CPR, it would not be clinically appropriate and the patient has capacity. Um but they, they still want DNA, they still want CPR. So it says here, if after discussion, you still consider that CPR will not be clinically appropriate, there is no obligation to provide it in the circumstances. You must explain your reasons and any other options available, including the right to seek a second opinion. So if you still deem CPR not to be clinically appropriate, but the patient, you know, is still saying that they want CPR in that circumstance, you need to be escalating to your seniors and potentially offering them a second opinion. And again, you need to approach, approach it, sensitivity and try to explain your rationale. So why, why is it that you as a medical team? Why do you feel that that CPR would not be in their best interests and going through all of that and explaining it? And often when you explain it and break it down, exactly, you know, the rationale that you have often patients will come around and say actually, you know, a doctor had thought about it in that way, actually sounds quite reasonable. There are circumstances that doesn't happen. But again, in that CNN, you need to escalate it and again, I put it in right there. So you need to make sure you're doing that. Now, what do you do when a pa when a patient uh when you still consider that CPR is not clinically appropriate. But in this circumstance, the patient lacks capacity. So in that circumstance, you need to consult any legal proxy if they have one. So again, a lesson, power of attorney, you can from war if they have one and again, you do the same process that you the same discussion that you probably have with the patient, you'd explain it to the, you know, um the legal proxy explaining it sensitively what it involves the like the outcomes, try to understand what their reasons are and what their opinions are. Now, if a patient doesn't have a legal proxy, you need to discuss it with those close to the patient and the wider health care team um to try and again, get an understanding for a best interest decision and again, try to have that discussion early. But in this case where you're discussing with family members, people who don't have a legal proxy and people, you're just sort of getting an input on to what the patient's patient might have wanted themselves. Ok? You have to be clear on that, on their role, the people that you're speaking to, they do not have authority to make the decision. Their role is pure purely to advise you and the team on what they think the patient's wishes and preferences might have been so that you can make a decision on whether CPR will be overall benefit or not. Ok. And that's quite important because sometimes you'll have a discussion with a relative who's, you know, potentially not, doesn't have lasting power of attorney. They may just be a relative and you stop talking about DNA CPR and they get very concerned. Er, they get very, very worried because they think that, oh my God, I had to make the decision now whether they're gonna get DN CPR or not, that's not the case. You have to be very clear that it is a medical decision and you're just getting their input on what they think the patient might have wanted. Ok. Now again, I've just copy pasted this paragraph and again, this is just detailing that when you think that CPR would not be clinically appropriate for the patient and their legal proxy in this circumstance thinks that, you know, they still would want CPR. Again, you, you know, explain it to them, break it down for them. Um But again, the GMC guidance on this says that there's no obligation to provide in the circumstances envisaged you should explain your reasons and any other options that may be available to the legal proxy, including their rights to a second opinion. So the same case as I described, if the patient has capacity and they say that it still want CPR same rules apply. So again, um you would then want to involve a senior and potentially offer a second opinion again and again, the same conversation that you would have with someone with the capacity you'd have with that legal proxy explaining why you think it's not clinically appropriate to give them CPR and again, escalate to your senior in that circumstance. Um You will find that there are certain relatives or you'll come across it occasionally where, where they can often become quite difficult. Um they can become quite emotionally charged, you know, when a relative is unwell, quite sick and you know, potentially there are risks of arresting, it can be quite traumatic and alarming by their relatives. So again, approach it sensitivity and go through the steps. So in summary, delirium, coming back to delirium can present in many ways, you have to consider the underlying cause and treat them according to that. If there's multiple causes, again, I would be cautious in looking out for hypoactive delirium, which can often be missed as part of their treatment for delirium. You need to make sure you're optimizing all the other factors and you need to try and involve family and relatives. Coming back to the mental capacity act of the principles that you need to be aware of as a junior doctor dealing with it. Er, number one of pres, you know, a presumption of capacity, someone has capacity until proven otherwise. Um Number two maximizing their decision making capacity. So again, taking all steps necessary to make sure that they can understand things and things like, you know, make sure they have the hearing aids in using visual aids, et cetera. Number three person has freedom to make wise decisions, it doesn't mean they lack capacity. Number four, any decision that you make on behalf of somebody that lacks capacity or you deemed to lack capacity needs to be in their best interests. Ok. And number five, the fifth principle is um you need to consider if there's a less restrictive alternative, the decision that you're making in their best interests. Now, if you feel that the necessary care or treatment that you're wanting to give a patient who left capacity in their best interests will involve a deprivation of liberty. Again, you can use the acid test that I described earlier, um ensure that a deprivation of liberty, safeguard procedures are carried out. So, submitting a do application needed. And of course, in that circumstance, discussing it with your senior er a personal welfare, lasting power of attorney can make decisions on behalf of a person who lacks capacity, but only within the scope that's defined on their lasting power of attorney. And you need to ensure that if someone, if the lasting power of attorney is making decisions. Their lasting power of attorney is actually valid. Ok? When it comes to the NSE pr conversations, the conversations you should be ideally be having as early as possible, be open and honest and if there's any issues escalate to your senior. Ok. Um Thank you very much for listening guys. I know that was quite a lot of information, but I just wanted to cover the salient points. A lot of that you may have not fully be retaining. So I've included the useful resources and I found these actually really useful. They don't take long to read. The B M's mental toolkit is quite, you know, concise covering the salient points. Um This document on the government U K's website about making decisions for people who work in health and social care. I find that quite concise as well and the Mental Capacity Act Code of practice is actually something that they recommend and you need to actually be familiar with if you're dealing as a healthcare professional with the Mental Capacity Act. So your ID actually should be reading through that and be familiar with it. And finally, there is an example of a dolls form um to look at, you know, some of the things I've got onto that if you want that as well. Um Thanks very much guys and um if you wouldn't mind providing feedback just by using that QR Code, I'm happy to take any questions and um I can't guarantee I'll be able to give you a definite answer. Um I may need you to email me so I can look into it and get back to you but feel free to email me on my email address. That's on the screen. That thanks. Thank you very much, Hanser. So that is the end of this lecture and the end to the Fy Survival Guide series. And thank you all for joining, especially to those who've been coming along to our series over the past four weeks. Er, as Hala said, we've really appreciate if you fill out the feedback form which you can find in the chat as well. So we've got loads of exciting and useful webinars lined up for you this year with our next one being the SFP interview preparation series sometime late October. So do make sure to follow our socials for more updates otherwise, thank you guys and hope you have a great evening just having a look at some of the comments. Um I think from Dr Addy, I think the first question on hypertensive vascular path. Um I think that question is probably how the wrong with his presentation. I don't think I can answer that. I'm afraid. Um The second question on would haloperidol treatment be too risky in a patient who has undiagnosed Parkinson's disease and is asymptomatic on presentation with no, no, no known Parkinson's disease history. Um So again, it, it's a judgment call there. And again, it depends on, you know, if, if, if they're not showing any signs and symptoms of Parkinson's disease, you don't have any suspicion that they've got Parkinson's disease, then you might want to consider haloperidol there. Um, again, I'd be getting your registrar involved, especially when you're giving sedatives to double check with them. Make sure because there might be other things in their history, other medications are on, um other other, other things to take into account there. And they may say that actually LORazepam may be safer. So again, in that circumstance, I would be just looking up, looking through the patient's history um and looking at the B NF. So the BN if you look at Haloperidol has quite a lot of all of the contraindications and things on there as well. Sarah. So if somebody is needing restraint, would you do that first and then fill in a Doles form? So the Doles form, obviously, you can't, you can't, you can't fill a dolls form be that it's quite a lengthy document. You can't fill a dolls form in first and then, you know, restrain a patient again. So when you, when you're giving a patient restraint, don't you only need to fill out a dolls form if that restraint amounts to deprivation of number one and number two, to answer your question. So, um you, if you feel that that restraint is necessary, it is in the patient's best interest in their lack of capacity and is to prevent them from coming to harm. Um er, then you would, you would give that restraint clearly document that as well. Um And if, if it no man to deprivation of liberty, then you would um submit a Doles Doles form as well. Cool. Uh If there's nothing else. Uh All right, great. Thank you. Um Cool. I'm going to come off the video now guys. But again, if there's any further questions, please feel free to email me. I may not know the answer immediately, but I can always have a look and direct you to the right resource as well. Cheers.