Case Studies

Case 16: Complications associated with diabetes

Hugh, a 74-year-old man, has a mild learning disability, and diabetes has caused gangrene in one of his toes. He lives in a flat within a block of flats and support is available on a needs-led basis, which he often refuses. The Health Facilitation Service was asked to support Hugh to access healthcare services. He was seen at his local acute hospital with regard to his diabetes and necrosis, and a course of treatment was planned which involved him being admitted to the acute hospital as an inpatient in order to receive antibiotic therapy. Hugh refused to be admitted. A mental capacity assessment was completed, and he was found to have capacity and therefore able to make his own decision. However after some work with the team Hugh decided to attend the hospital to receive his intravenous antibiotic therapy three times a day. He made decisions about not attending on occasion even with the support of his carers at home and members of the Health Facilitation Service would be called upon to assist. The antibiotic therapy course was completed but limited success achieved.

Hugh also developed a pressure ulcer on his sacral area which required treatment from the district nurse. The necrosis in his toe worsened, and the decision was made by the clinical team in the acute hospital that he would need to be admitted for radical treatment and again, Hugh refused. It was agreed that a mental capacity assessment would need to be completed to ensure he had full understanding of his physical condition and the treatment he required. A home visit was completed by the vascular surgeon and the Health Facilitation Service in order to complete the mental capacity assessment. Again Hugh was deemed to have capacity, but this time he agreed to attend the acute hospital.

• 1. Which members of the Health Facilitation Service would support Hugh at home?

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  Correct answer: The Primary Health Facilitators would be the members of the Health Facilitation Service supporting him at home.

• 2. Who should lead on the completion of the mental capacity assessment in this situation?

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  Correct answer: The lead clinicians will always take the lead on the completion of a mental capacity assessment as they are responsible for the planned treatment. When completing a mental capacity assessment the people who know the person well and, where possible, the invividual should be consulted.

• 3. Who would be responsible for supporting Hugh to access treatment?

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  Correct answer: The carers within a social care environment do have a duty of care to each person living within the service and should take reasonable actions to support access to healthcare. On this occasion, the reasonable steps included involving the Health Facilitation Service.

• 4. Can a person refuse treatment?

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  Correct answer: Within the framework of the Mental Capacity Act, all people are assumed to have capacity unless there is reason to believe they do not. If there are grounds to believe the person does not have capacity then a mental capacity assessment is completed. If the person is deemed to have capacity, then the person’s choice to refuse treatment is followed which is known as an unwise decision. However this does not mean the Health Facilitation Service would not work with them.

• 5. Who would support Hugh in the acute setting?

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  Correct answer: The clinical staff would support Hugh with the input support and help of the learning disability liaison nurses.

• 6. If he continues to refuse treatment can the healthcare professionals overturn his decision?

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  Correct answer: Under the Mental Capacity Act, anyone can make an unwise decision whilst they have capacity. If Hugh lost capacity, even temporarily, a best interest decision can be made in order for treatment to be given; but once capacity is regained, treatment can be refused. Decisions are specific to the one area of care and if another issue arises then this may need further consideration.