Patient 2 - Alcohol dependent. Early 50s, British female.
I had been to this patient before and our first clues as to what was happening came from a disgruntled neighbour (who had made the 999 call) who expressed frustration about regular police visits to the property, plus a front door that had signs of recent forced entry by the police.
Inside our patient was lying on a sofa, intoxicated. The duvet and sofa were soiled and the patient was unkempt. Straight away, the patient was abusive towards us. She hadn’t called for help, didn’t want us there and made it extremely clear that she didn’t want to go to hospital. But we have a duty of care.
She refused all observations, though just from talking to her we knew she had a patent airway, was breathing, had a pulse and so nothing needed to be done immediately.
That said, the state of the property and patient indicated a fairly advanced stage of self neglect. The patient stated that she couldn’t walk - this is a red flag for the ambulance service as someone must be able to look after themselves if they remain at home. They must be able to get food and drinks, go to the toilet and be able to get out of the house in case of a fire. There’s also the issue of capacity because patients must have mental capacity and be able to make an informed decision about their care.
A discussion ensued! We stated our intention to take the patient to hospital. We stated that as she was intoxicated and could’t walk, she had to go to hospital. The patient refused, but also refused to prove that she could walk. Despite our best efforts she still refused and the situation persisted for a significant time.
Though intoxicated, a lack of capacity isn’t a given, but it can complicate the issue. So we carried out what’s called a ‘functional test’. Our diagnostic test confirmed that the patient did have an impairment of the function of her mind or brain (due to being intoxicated). But the functional test goes into more detail.
Firstly, we gave the patient details of the reasons that we believed she needed to go to hospital - including self neglect and being unable to walk. Sometimes it’s necessary to be quite brutal in advising the patient and telling them that if they stay at home it could be a fatal decision. She stated that she understood the information.
The next part of the test involves the patient retaining the information and fully understanding it, in order to make an informed decision. Finally, the patient must prove to us that they have weighed up the information, come to that informed decision and communicate that back to us in their own words.
In this case, the patient did pass the test. Once she realised that her being able to walk was the deciding factor, she jumped up and walked to the kitchen and back with no difficulty at all. So, we made the decision to leave her at home.
But our responsibility didn’t end there and we advised the patient that we would be completing a safeguarding report due to her self neglect. This report flags up a patient to Social Services and other agencies with the aim of providing support short or long term, when hospital isn’t the right answer and isn’t the only answer.