Assessing capacity and obtaining consent for thrombolysis for acute stroke

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					■ OCCASIONAL PAPERS                                                                     Clinical Medicine 2009, Vol 9, No 3: 239–41




Assessing capacity and obtaining consent for thrombolysis
for acute stroke

Jonathan Akinsanya, Paul Diggory, Elizabeth Heitz and Valerie Jones

ABSTRACT – When offering treatment to a patient with                 arrival, fearing that he might die and not see them again. His wife
capacity they should be informed of the risks and benefits           was on her way to hospital (arriving at 15.35) and not available by
of therapy and consent should be obtained. For patients              telephone. After further discussion JA consented to thrombolysis
without capacity, treatment is given in their ‘best interests’.      and was given thrombolytic therapy at 15:15 with rapid improve-
Achieving and assessing capacity to consent for treatment            ment in hemiplegia, visual disturbance and speech symptoms. His
in the presence of acute illness can be difficult and espe-          NIHSS score improved to four at 17.00 and one at 22.00.
cially so in patients suffering with acute stroke. This article
presents patients’ and doctors’ perspectives on assessing
capacity to consent to thrombolytic therapy for stroke.              Ethical and legal aspects
                                                                     The principle of autonomy, professional duty and the common
KEY WORDS: acute illness, capacity, consent, thrombolysis
                                                                     law require doctors to obtain consent before giving treatment.2
for acute stroke
                                                                     Consent provides a ‘flak jacket’ that protects the doctor from the
                                                                     fire of litigation.3 English law does not recognise the doctrine of
A 47-year-old, right-handed, barrister (JA) arrived in accident      ‘informed consent’, where all risks and benefits are explained, and
and emergency at 13:45 having collapsed, without loss of con-        in the tort of battery (assault) consent must confer understanding
sciousness, at 12.40 while playing golf. He had no speech diffi-     only of the nature and purpose of the procedure.4 In the civil tort
culty but could not get up because of weakness. At 12.53 London      of negligence it must also cover possible outcomes and complica-
Ambulance Service recorded ‘slight asymmetry towards right           tions.5 A procedure must be adequately explained and the patient
side of mouth’ and a Glasgow Coma Score of 15/15. He was able        must have capacity to consent. If a patient does not have capacity,
to stand and walk to the ambulance trolley. His previous med-        treatment is given in their ‘best interests’.
ical history was arthroscopic knee surgery and he was taking no         The law on capacity is governed by the Mental Capacity Act
medication. He felt unwell, with intermittent headache but           2005. There is a rebuttable presumption that everyone has
noticed no weakness or speech defect. During triage, at 13:55, he    capacity until proved otherwise.6 A person is deemed to lack
became dysphasic with right facial weakness.                         capacity:
   Diagnosis at 14:23 was stroke with mild expressive dysphasia
and right hemiplegia, with a National Institute of Health Stroke      if at the material time he is unable to make a decision for himself in
Score (NIHSS) of six.1 His wife was told of his condition by tele-    relation to the matter because of an impairment of, or a disturbance in
phone. Computed tomography, at 14.45, was normal with main-           the functioning of, the mind or brain.7
tenance of grey/white matter differentiation and no evidence of         It does not matter whether the impairment or disturbance is
intracranial haemorrhage.                                            permanent or temporary.8 To determine whether a person lacks
   On route to the scanner the patient deteriorated neurologi-       capacity or not the following must be established:
cally. By 14.50 he had right face, arm and leg weakness with right
                                                                        Is the person able to:
sensory inattention, right hemianopia, mild expressive dys-
                                                                       (a) understand the information relevant to the decision
phasia without receptive component and a NIHSS score of 17.
                                                                       (b) retain that information
   Considered a candidate for thrombolysis, the nature, risks and
                                                                       (c) use or weigh that information as part of the process of
benefits were discussed with him. It was explained treatment was
                                                                      
				
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