Consent, capacity and a patient who wants to leave
Mr Okafor, 54, is on a surgical ward day 2 after an emergency laparotomy. Overnight he became agitated and confused (4AT score 7, suggesting possible delirium). He is pulling at his IV line and nasogastric tube and says he wants to go home 'right now'. His observations are stable except mild tachycardia (pulse 104) and a temperature of 37.9°C. His daughter says he has no diagnosed cognitive impairment and 'has never been like this'. He has capacity to make most decisions when well. He is refusing blood tests and wants the cannula removed. The surgical registrar is in clinic for the next hour.
1. How do you assess whether Mr Okafor has capacity to decide to leave, and what should you do if he lacks capacity for this decision?
Read the worked answer
Capacity is decision-specific and time-specific; assess it now, for this decision.
Use the four-stage functional test (Mental Capacity Act 2005):
- Understand the information - does he understand he has had major surgery, has a cannula and NG tube, and why they are needed?
- Retain the information long enough to decide.
- Weigh the information as part of the decision (risks of leaving vs staying).
- Communicate his decision by any means.
Support before concluding: treat reversible causes of delirium first - check glucose, pain, constipation, urinary retention, infection (temperature 37.9°C, tachycardia), hypoxia, medication. Use short sentences, one question at a time, involve his daughter for background, use a quiet environment. Reassess after interventions.
If he lacks capacity for this decision:
- Act in his best interests, choosing the least restrictive option. That does not automatically mean locking doors or restraining him; it may mean close observation, a specialing nurse, removing only what is unsafe, and treating the delirium.
- Consult the MDT, family (as those who know him), and use an IMCA if he has no one appropriate to consult and the decision is serious.
- Document the assessment, the reasoning, and the best-interests decision.
- Escalate to the registrar/consultant now; do not wait an hour if he is attempting to leave.
If he does have capacity, he may refuse treatment and leave; you must ensure he understands the risks, offer support, document, and inform the team. Do not detain a capacitous patient.
2. He attempts to walk out with the cannula in situ. What is your immediate response and what are the limits of restraint?
Read the worked answer
Immediate priorities: safety, least restrictive intervention, escalation.
- Do not physically block or restrain him unless there is an immediate risk of serious harm and you are following policy. Physical restraint is a last resort, must be proportionate, for the shortest time, and must be documented. Restricting a patient who may lack capacity must be in their best interests and the least restrictive option.
- Try verbal de-escalation first. Calm tone, use his name, explain simply: 'Mr Okafor, the tube in your hand is giving you fluid and antibiotics. If you pull it out you may become more unwell. Can we sit down and talk for two minutes?' Offer a drink, pain relief, toileting - common delirium triggers.
- Call for help. Ask a colleague to call the registrar/outreach and the nurse in charge. A confused post-operative patient leaving the ward is a medical emergency risk (falls, bleeding, sepsis, line infection).
- Consider a Deprivation of Liberty Safeguards/DoLS or equivalent authorisation if he needs to be kept on the ward for his safety and lacks capacity - discuss with the consultant and trust legal team urgently; do not improvise.
- If he leaves, ensure he is safe: offer to call family, give him contact details, inform the team and security per policy, document, and follow up.
- Remove the cannula only if it is unsafe to leave in and he refuses - a peripheral cannula left in a patient who leaves is a risk; discuss with the registrar.
Standards: NMC Code - preserve safety, act in the person's best interests, respect autonomy, work within the law (MCA 2005), and be accountable for restraint decisions. Restraint is never a first-line response to confusion; treat the cause.