Consent, Capacity, and a Pressing Family
A paramedic crew is called to a 78-year-old woman who has fallen at home and has an obvious deformed wrist. She is alert, oriented, and in pain. She declines transport and says she will 'see how it goes.' Her daughter, who arrives during the assessment, insists she must go to hospital and tells the paramedic, 'She has dementia, she doesn't know what she's saying - just take her.' The woman can state her name, the day, where she is, what happened, and that she understands the wrist may be broken and that she is choosing to stay. She also says she is frightened of hospitals because her husband died in one. There is no advance directive and no guardianship order. The daughter is not her substitute decision-maker. The crew's protocol requires a capacity assessment and documentation whenever a patient refuses care, and allows transport without consent only where there is an immediate risk to life or a legal authority to act.
1. Assess the patient's capacity and explain why the daughter's assertion does not settle the question.
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Capacity is decision-specific and time-specific, and it is assessed by the clinician present, not conferred or removed by a relative. The four functional elements are understanding, retention, weighing the information, and communicating a choice.
Applying them: she understands the injury and the option of transport; she retains enough to discuss it; she can communicate a choice; and she shows weighing - she acknowledges the wrist may be broken and gives a reason rooted in her own values (fear after her husband's death). Orientation questions support, but do not prove, capacity; the reasoning is what matters.
A daughter's statement that her mother has dementia is information, not a determination. A diagnosis of dementia does not equal incapacity, and many people with dementia can make specific decisions. The daughter is not the substitute decision-maker and has no legal authority to consent on her mother's behalf here. The paramedic should thank the daughter for her concern, explain that he must assess the patient herself, and not let the daughter answer for her.
2. The patient still refuses. What must the paramedic do, say, and document?
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Do: complete and record the capacity assessment; explain the risks of an untreated fracture in plain terms (pain, loss of function, nerve or vessel compromise, and which symptoms mean call an ambulance immediately); offer alternatives - analgesia within protocol, splinting, a next-day clinic or GP, a follow-up call, written safety-net advice; confirm she has someone to check on her; and, if she agrees, involve the daughter in the safety plan.
Say: something close to - 'You've shown me you understand the injury and you've made a clear choice. I think you should be seen, and I'd like you to go. I can't take you against your will. What I can do is splint it, treat your pain, and tell you exactly what should make you call us back.' To the daughter: 'I understand you're frightened for her. She has made her own decision and I have to respect it; here is what we've put in place and what to watch for.'
Document: the capacity assessment and her answers, the risks explained, the refusal in her words, the alternatives offered, the daughter's concerns, the safety net, and the signature or witnessed refusal.
The protocol's exceptions - immediate risk to life or legal authority - are not met: the injury is serious but not immediately life-threatening, and there is no guardianship order.
3. Suppose the patient had instead been drowsy, disoriented, and unable to say where she was. How would the analysis change?
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It changes at every step. If she cannot understand or retain the information, she lacks capacity for this decision, and refusal is not a valid refusal. The paramedic may then treat and transport on the basis of necessity - acting in the patient's best interests to prevent serious harm - and must use the least restrictive option.
The daughter's role also changes: where the patient lacks capacity and there is no guardian or advance directive, the daughter is likely the person to be consulted about the patient's known wishes and best interests, though in most frameworks she is consulted rather than giving formal consent to emergency treatment. The crew should still transport, treat pain as protocol allows, look for a reversible cause of the confusion (hypoglycaemia, head injury, infection, medication), and document the capacity findings that justify acting without consent.
The contrast is the teaching point: the same refusal, the same daughter, and the same injury produce opposite lawful actions depending on the capacity assessment. That is why the assessment must be done and recorded, not assumed from a diagnosis or a relative's opinion.