Medical kidnap? Discuss

If you're interested: Mayo Clinic claims CNN did not fully and accurately portray the situation in their article.

You can read Mayo Clinic's response here Mayo Clinic responds to false, sensational CNN story - Mayo Clinic News Network , including the rebuttal they sent to CNN https://newsnetwork.mayoclinic.org/CNN-Letter-08-15-2018.pdf

This is kind of how I imagined it occured.

This is really frightening. Why were the parents banned?

Won't public court documents show why Mayo sought guardianship? Would Mayo have been the guardian or the State/Court?

I imagine the parents were banned due to escalating threates to staff (RNS, MD, RTs, SW, etc) they probably did not follow hospital rules (touching machines, not following orders, yelling, screaming at staff).

Usually in cases with a vulnerable adult it is a state appointed GAL.

This is kind of how I imagined it occured.

I have read both articles with an open mind not leaning toward either side because I have seen how situations can escalate into a power struggle especially when you have a doctor, hospital and nurses ready to defend what they have already decided is the best care without actually including the patient and family in the decision so that everyone is on the same page. All the family is seeing is that their child, spouse, mother or father are wanting out of situation they are in and cannot understand once a request has been made it is not honored after the life threatening situation has been handled. She was 18 years old she has a right to make a choice of what happens to her body after the situation has been explained in commonsense language that the patient understands.

I am sure that some of the information in the original article is affected by the emotional turmoil and lasting trauma that this ordeal has had on the patient and the family.

My question is this in todays world where everyone says it is important for everyone to stay connected I see no mention as to why the patient's phone and tablet were taken by a nurse/doctor. I also see where the hospital is now saying they were afraid of an abusive situation at home although her parents made sure she was taken to what they consider was the "best" hospital to care for their daughter.

If she was in rehabilitation that implies that she was past the life-saving portion of her care and was on her way to recovery. Again, if she is an adult and requests to be transferred to an accredited hospital/rehab facility what's the problem? Was this a rehab center that was connected with Mayo Clinic thus Mayo and their physicians/physical therapists/technicians would be receiving insurance payments? Again why was her phone and tablet taken from her preventing her to be able toreach out to her family? These are all questions that have not been answered and probably never will be.

I just skimmed the whole article (both parts), and wow ... although I think we're still not getting the total story from both sides, it sounds like the Mayo was at fault. A pretty bizarre story.

Yeah, after reading Mayo's rebuttal - although they didn't, and couldn't, provide specifics - I feel like it's in 'we'll never know exactly what happened' territory.

If you're interested: Mayo Clinic claims CNN did not fully and accurately portray the situation in their article.

Every article/story from every news organization has a particular angle to it. In the case of the CNN article, they angle is the hospital was in the wrong, and the family was right. (Part of it, I'm guessing, has to do with the hospital declining to comment on the case.) Either way, 2 reasonable people can look at the evidence and reach 2 entirely different conclusion.

Here's another source regarding Mayo's stance.

Bullet by bullet, Mayo Clinic refutes claims made in 'sensational' CNN report - Med City Beat

These are all questions that have not been answered and probably never will be.

You're right. But at least we now have Mayo's side of the story (or some of it).

As has been said many times, there are 3 sides to every story. In this case, they would be the clinic's side (probably best for them not to comment in depth on this situation--and, no, I don't view that as some kind of admission of guilt), the family's story, and the truth. The truth is usually somewhere in between the 2 other stories.

Although we don't know whose version of events is closer to the truth, their accounts have raised the important issues of medical child abuse as well as medical paternalism.

As nurses (or future nurses), it is important that we are aware of and alert to the incidence and signs of medical child abuse. We also have to preserve the patient's (and patient's family's) autonomy in making medical decisions. It's interesting where we draw the line between reasonable medical choices that we will respect, and choices we deem "medical child abuse".

Where does CNN get off with "veiled threats" to the nursing staff of the hospital? Good for the for not relaying any information.

I'm assuming you posted the uptodate link because it supports your position on this, but one can't read the article unless one is a subscriber. However, elsewhere in the literature:

Clinical capacity is specific to a particular health care decision and thus is limited to that decision. The level of clinical capacity needed to make a health care decision depends on the complexity of that decision. A patient with some decrease in capacity, even one with fairly severe cognitive deficits, may still have enough capacity to make simple health care decisions, such as whether to allow a rectal examination or placement of an IV. However, the same patient may lack the capacity to decide whether to participate in a clinical trial.

Capacity (Competence) and Incapacity - Special Subjects - Merck Manuals Professional Edition

Decision-making capacity, medical or otherwise, is always specific to the task requiring the decision.1,4 Certain patients may be able to decide some aspects of their care, but not others. For example, a patient with mild-tomoderate Alzheimer's disease who experiences chest pain may be able to understand the need for antibiotics to fight pneumonia but not the indications for, or the risks and benefits of, cardiac catheterization and angioplasty for coronary artery disease.

Can the Patient Decide? Evaluating Patient Capacity in Practice - - American Family Physician

Table 1. Ten Myths About Capacity

1.Decision-making capacity = competency.

2.Against medical advice = lack of decision-making capacity.

3.There's no need to assess decision-making capacity unless a patient goes against medical advice.

4.Decision-making capacity is all or nothing.

5.Cognitive impairment = no decision- making capacity.

6.Lack of decision-making capacity is permanent.

7.Patients who have not been given relevant information about their condition can lack decision-making capacity.

8.All patients with certain psychiatric disorders lack decision-making capacity.

9.All institutionalized patients lack decision-making capacity.

10.Only psychiatrists and psychologists can assess decision-making capacity.

How Do I Determine if My Patient has Decision-Making Capacity? | The Hospitalist (Bolding mine)

A physician must recognize that capacity to make reasoned decisions is task-specific. Therefore, it is conceivable that a patient might lack capacity to make reasoned medical decisions, but may be fully capable of selecting a proxy.

Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians

One of the most common reasons medical colleagues seek consultation with a psychiatrist is to address the question of capacity. Indeed, this referral question often is posed as, "Is the patient competent?" This referral question is incomplete and incorrectly phrased. The question should include the domain in which capacity is being questioned-for example, "Is the patient competent to refuse surgery?" Specifically identifying the area in which competency is questioned is necessary because a person might be competent in one area and incompetent in another.

Performing capacity evaluations: What's expected from your consult | MDedge Psychiatry (The article goes on to explain, also, that "capacity" is the correct term in this context, not "competency.")

Decision-making capacity is decided by clinicians regarding a specific question, while competence is decided by a court and is implemented over a functional domain, such as finances or medical decisions ... Decision-making capacity is not an all or none phenomenon. All of us can have decision-making capacity for some decisions but not for other decisions.

Psychiatry Online

Decision-making capacity is protocol-specific and situation-specific. Thus a subject may have capacity to consent to a low-risk research protocol in usual circumstances, but not have the capacity to consent to a high-risk protocol or when he or she is confused or under duress.

UCSD Human Research Protection Program - Decision Making Capacity Guidelines

•Capacity is time and decision specific. This means you should assess a patient's ability to make a specific decision at the time the decision needs to be made.

Assessing capacity - The MDU

It is important to remember that this capacity relates to the specific medical decision at hand and does not imply a global ability to make any or all decisions about health care or other matters. Only a court can deem a patient incapable of making global health care decisions.

Decision Making Capacity

Shall I go on? There are plenty more sources out there. Frankly, I'm surprised that you found a source that would support your position. Does the uptodate article specifically say that capacity is a global concept that applies to all healthcare decisions, or does it just not specify? I'm finding articles that discuss the process for determining capacity to refuse surgery, dialysis, whatever, but don't come out and specifically say that capacity is situation-specific and not a global concept.

And that's certainly an idea that comes up now and then in our ethics committee reviews of cases, but it's only really applicable to psych-based capacity issues, in the context of capacity for medical decision making there's a differentiation between capacity and a knowledge deficit, which are two very different things. If a person has the capacity to understand the basic benefit vs risk of a simple procedure then they have the capacity to process a risk vs benefit decision, which is what capacity refers to. A more complex procedure may require more education about the procedure and/or the indication for the procedure, but the capacity is still there. If, for instance, a patient is able to understand the indications of a heart cath and the risks of declining and declines the procedure, that doesn't mean we can say we are going to a bypass surgery instead because that's too complicated of a procedure for the patient to comprehend and therefore can't decline.

In this case however, there has been no contention that the patient didn't have the capacity to refuse any care, much less to leave.

It's not "double speak," it's the way capacity works. We're all "capable of making some kinds of decisions, but not others," depending on our knowledge and understanding of the risks/benefits/alternatives involved in a specific decision, and how well we can manipulate that info to arrive at a decision, which is what is evaluated when determining capacity. And the "bar" for having capacity to make a decision is higher or lower depending on the import of the particular decision. To offer an extreme example, you can have capacity to refuse blood draws or vital signs, but lack the capacity to refuse life-saving surgery. And, yes, capacity mostly comes into question when someone is refusing something that the professionals agree is necessary. If people are agreeing to treatment, providers don't usually question that, or their capacity to make that decision.

Sorry but no. If someone is conscious, mentally competent, not under the influence of drugs or alcohol they can in fact refuse life saving surgery, chemo or any other treatment they wish to. Even if unconscious if they have the proper legal documentation in place, such as a DNR, they can refuse.

On the flip side there are plenty of people who have no say in their medical treatment, we call them children. If a parent and doctor agree a child needs a specific treatment or surgery, what the child thinks about it really doesnt matter legally or otherwise.

Courts are the sole arbiter of competency and what if any limits can be placed on it. There are laws in place to restrict people for emergency reasons from self or other harm, such as the Baker Act in Florida, but eventually if that person's freedom remains restricted (beyond 72 hours) it will be a judge deciding not the hospital or a doctor.

I'm assuming you posted the uptodate link because it supports your position on this, but one can't read the article unless one is a subscriber. However, elsewhere in the literature:

Clinical capacity is specific to a particular health care decision and thus is limited to that decision. The level of clinical capacity needed to make a health care decision depends on the complexity of that decision. A patient with some decrease in capacity, even one with fairly severe cognitive deficits, may still have enough capacity to make simple health care decisions, such as whether to allow a rectal examination or placement of an IV. However, the same patient may lack the capacity to decide whether to participate in a clinical trial.

Capacity (Competence) and Incapacity - Special Subjects - Merck Manuals Professional Edition

Decision-making capacity, medical or otherwise, is always specific to the task requiring the decision.1,4 Certain patients may be able to decide some aspects of their care, but not others. For example, a patient with mild-tomoderate Alzheimer's disease who experiences chest pain may be able to understand the need for antibiotics to fight pneumonia but not the indications for, or the risks and benefits of, cardiac catheterization and angioplasty for coronary artery disease.

Can the Patient Decide? Evaluating Patient Capacity in Practice - - American Family Physician

Table 1. Ten Myths About Capacity

1.Decision-making capacity = competency.

2.Against medical advice = lack of decision-making capacity.

3.There's no need to assess decision-making capacity unless a patient goes against medical advice.

4.Decision-making capacity is all or nothing.

5.Cognitive impairment = no decision- making capacity.

6.Lack of decision-making capacity is permanent.

7.Patients who have not been given relevant information about their condition can lack decision-making capacity.

8.All patients with certain psychiatric disorders lack decision-making capacity.

9.All institutionalized patients lack decision-making capacity.

10.Only psychiatrists and psychologists can assess decision-making capacity.

How Do I Determine if My Patient has Decision-Making Capacity? | The Hospitalist (Bolding mine)

A physician must recognize that capacity to make reasoned decisions is task-specific. Therefore, it is conceivable that a patient might lack capacity to make reasoned medical decisions, but may be fully capable of selecting a proxy.

Competency and the Capacity to Make Treatment Decisions: A Primer for Primary Care Physicians

One of the most common reasons medical colleagues seek consultation with a psychiatrist is to address the question of capacity. Indeed, this referral question often is posed as, "Is the patient competent?" This referral question is incomplete and incorrectly phrased. The question should include the domain in which capacity is being questioned-for example, "Is the patient competent to refuse surgery?" Specifically identifying the area in which competency is questioned is necessary because a person might be competent in one area and incompetent in another.

Performing capacity evaluations: What's expected from your consult | MDedge Psychiatry (The article goes on to explain, also, that "capacity" is the correct term in this context, not "competency.")

Decision-making capacity is decided by clinicians regarding a specific question, while competence is decided by a court and is implemented over a functional domain, such as finances or medical decisions ... Decision-making capacity is not an all or none phenomenon. All of us can have decision-making capacity for some decisions but not for other decisions.

Psychiatry Online

Decision-making capacity is protocol-specific and situation-specific. Thus a subject may have capacity to consent to a low-risk research protocol in usual circumstances, but not have the capacity to consent to a high-risk protocol or when he or she is confused or under duress.

UCSD Human Research Protection Program - Decision Making Capacity Guidelines

•Capacity is time and decision specific. This means you should assess a patient's ability to make a specific decision at the time the decision needs to be made.

Assessing capacity - The MDU

It is important to remember that this capacity relates to the specific medical decision at hand and does not imply a global ability to make any or all decisions about health care or other matters. Only a court can deem a patient incapable of making global health care decisions.

Decision Making Capacity

Shall I go on? There are plenty more sources out there. Frankly, I'm surprised that you found a source that would support your position. Does the uptodate article specifically say that capacity is a global concept that applies to all healthcare decisions, or does it just not specify? I'm finding articles that discuss the process for determining capacity to refuse surgery, dialysis, whatever, but don't come out and specifically say that capacity is situation-specific and not a global concept.

Those are all sources written by people with in the medical field. Where as its been pointed out it doesnt really matter what Merck or some Physician's association say on the matter, competency is solely decided by the courts and any exceptions to that are addressed by state statutes....not the hospitals operating guidelines.

Period.

Unless the patient has an altered mental status due to drugs, alcohol or trauma, or the state specifically allows treatment in cases of diminished capacity (such as New Mexico) the courts ALWAYS side with the patient.

Refer to: 1914, the case of Schloendorff versus the Society of New York Hospital established that: "Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault for which he is liable in damages. This is true except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained."