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Consent and capacity

Case study: Consent and capacity

Karen, a new RMT, has just started providing care for seniors in a local retirement residence. The Director of Care noted in her interview that Karen is polite, soft-spoken, and shy; it took some time for Karen to open up about her interests and skills. Karen is excited about the prospect of working with seniors because she shares a close relationship with her grandparents. She really enjoyed her experiences treating seniors during her massage therapy training and especially liked listening to all the patients’ stories. After a few weeks on this job, however, Karen realizes that being in practice is quite different from being a student in school. Unlike her grandparents who seem really sharp and aware, the seniors in this residence appear to be living in various stages of dementia. In addition, unlike her training experience, there is no supervisor here to help her with clinical decision-making.

One resident named John, an American veteran of the Vietnam war, tells Karen war stories while she massages his legs. John doesn’t pay much attention when Karen asks him about his leg pain other than to say that it is awful and that he has lived with it for many years. John doesn’t want Karen to move his legs around because they hurt so much. She is unsure whether John’s pain relates to an old injury, nerve damage, or circulatory problems. Feeling shy and unsure, Karen has not been able to interrupt John’s stories and ask about the quality or character of John’s pain.

One day Karen arrives at John’s suite and he appears angry and upset. She enters the suite and asks John if he wants a massage treatment. John doesn’t seem to notice that Karen is in the room. Not knowing what to do, Karen approaches John as she usually does. She kneels by his chair, putting her hands on his legs to comfort him, and waits for him to notice her. Strangely, it is as if John cannot even feel Karen’s hands on his legs; he is completely unresponsive to her presence. Without knowing what else to do, Karen massages John’s legs, hoping that her actions might bring him out of this fog.

Do Karen’s actions meet the consent standard of practice?

No. Although Karen is excited about working with seniors, she has not embraced her professional role and responsibilities. Being polite, soft-spoken, and shy means that Karen needs to work harder at communicating her intentions. She has not found a way to assess capacity or to establish informed consent for patients living with dementia. She does not know if John has the capacity to comprehend her treatment approach, or if she should seek consent from a substitute decision-maker, and she has not been able to negotiate an effective assessment for John’s leg pain. Determining whether John’s leg pain stems from an old injury, nerve issues, a circulatory problem, or from something else, is essential to providing appropriate care.

When faced with John’s lack of awareness, Karen does not seek help from other healthcare professionals on staff. She begins to treat John’s legs in the hope that he will regain awareness.

She does not appear to realize that continuing treatment without John’s express consent puts him at risk. Since John is unaware of her presence, treatment is contraindicated until Karen can obtain consent from a substitute decision-maker.

Establishing informed consent requires that an individual or their substitute decision maker fully comprehends what is proposed so that they can consent to any assessment and treatment. In this case, Karen felt responsible and committed to providing John’s care, but she never found a way to confirm that he wanted or understood what she offered.

Consent standard of practice case studies

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