Level 2 of 6Must-remember

Medico-legal principles in acute care

Assess, manage and stay safe — enough on its own

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The card — assess, manage, caution

Assessment— look, ask, measure

Presume capacity in every adult until there is evidence otherwise, and assess it as decision-specific, time-specific and task-oriented — a patient may have capacity to refuse a venepuncture and lack it to refuse a laparotomy.
Apply the two-stage functional test and document both stages: stage 1, is there a demonstrable impairment or disturbance of the mind or brain (delirium, dementia, head injury, intoxication, hypoxaemia, hypoglycaemia, sepsis, acute psychosis, severe pain); stage 2, because of that impairment is the patient unable to understand, retain, use or weigh, or communicate — failure of any one suffices, and both stages must be positive for incapacity.
Measure the reversible physiological drivers before you judge: capillary glucose below 4 mmol/L, SpO2 below 92%, hypercapnia, temperature above 38.5 °C or below 35 °C — correct them and reassess, because capacity assessed during hypoglycaemia is invalid.
Look for the red flags that mean a decision cannot be taken at face value: refusal of clearly life-saving treatment; intoxication with alcohol or drugs; fluctuating conscious level, GCS below 15, agitation or inattention; head injury with any altered consciousness; and an accompanying adult who answers for the patient or resists private interview.
Screen for delirium (4AT, CAM, attention testing) but understand what it proves: a positive screen satisfies stage 1 but does not establish incapacity — stage 2 must still be tested.
Never use a cognitive screen alone: MMSE and MoCA correlate poorly with decision-specific capacity, and a Mini-Mental State Examination score is not a capacity assessment.
Toxicology shows exposure, not impairment: the presence of a substance never establishes incapacity, only the functional test does, and a patient with a high alcohol level may retain capacity.
Ask which of the four functional abilities is failing, because each has a different remedy: understanding fails with attention and working memory (delirium, hypoxaemia, hypercapnia, hypoglycaemia, sedative burden); retention fails with hippocampal and medial temporal dysfunction (Wernicke–Korsakoff, dementia, post-ictal states, benzodiazepine amnesia); using or weighing is the frontal-executive element and fails most often and least visibly; communication fails with aphasia, dysarthria, locked-in states, profound deafness, intubation and neuromuscular weakness — a failure of channel, not of mind.
Recognise the presentations that are medico-legal from arrival: assault or alleged assault; injury the patient will not explain; road traffic collision and workplace injury; poisoning, overdose and all self-harm; burns, drowning, hanging and strangulation; alleged sexual assault; any patient in police custody; suspected child abuse, elder abuse, domestic violence or neglect; every death and every patient brought in dead; any patient who wishes to leave against advice; and any unidentified patient who cannot give a history.
Take a safeguarding history in every case: injury inconsistent with the stated mechanism, a changing history, delayed presentation, injuries of different ages, and bruising in a child not independently mobile.
Interview the patient alone where a third party answers, monitors or benefits — coercion and undue influence invalidate consent for want of voluntariness, not capacity, and the account often changes when the patient is seen alone.
Remember the atypical presentation that looks purely clinical until the end: the "aggressive drunk" with an extradural haematoma, the "anxious" patient who is hypoxaemic, the "psychotic" patient who is hypoglycaemic.
In a child, ask who holds parental responsibility and verify it — it is not automatically whoever brought the child — and assess competence by function, not age (the Gillick principle); in the UK a child of 16 is treated as an adult for consent purposes, with exceptions for advance decision-making and appointing an attorney.
Check any advance decision against its criteria: valid only if made with capacity, voluntarily, on appropriate information, and specific and applicable to the situation now; refusal of life-sustaining treatment must additionally be in writing, witnessed, and state explicitly that it applies even where life is at risk.
Record the encounter as you assess it: date, time in 24-hour clock, writer's name in full, signature and designation — recollection of a busy shift degrades within hours, and a note written at the bedside with a time on it is the only artefact that fixes the encounter.
Describe injuries objectively — site, size in centimetres, shape, edges, colour and depth on a body diagram — and do not record opinions on weapon, direction, sequence or age of injury.

Management— do this, in order

Resuscitate first: no form, relative or third party precedes airway, breathing and circulation, and treatment delayed while a form was sought is the commonest avoidable medico-legal disaster in acute care.
Optimise before you judge, then choose the least restrictive effective option, and document contemporaneously — these are the four principles that order everything else.
Treat pain: paracetamol 1 g orally or IV six-hourly, maximum 4 g/24 h in adults ≥50 kg, and 15 mg/kg per dose in children to a maximum of 60 mg/kg/24 h; morphine 1–2 mg IV titrated every 5 minutes in adults, 0.05–0.1 mg/kg IV in children.Doctor / Nurse
Correct hypoglycaemia: adults 100–200 mL of 10% glucose IV, or glucagon 1 mg IM if there is no access; children 2 mL/kg of 10% glucose IV.Doctor / Nurse
Give oxygen to a target saturation, relieve urinary retention, return hearing aids, glasses and dentures, obtain a professional interpreter rather than a relative for any serious decision, reduce noise, allow time for slowed processing, and speak in short sentences without jargon.
Take valid consent as a conversation, not a signature: provide the information a reasonable person in this patient's position would want — the working diagnosis, what is proposed, realistic benefits, significant risks including those this patient would care about, the alternatives including no treatment, and the uncertainty, disclosed rather than smoothed over — and invite and answer questions.
Treat without consent in an emergency where the patient cannot consent (unconscious, seizing, shocked, delirious or intoxicated to incoherence) and delay while surrogates are contacted would jeopardise life or health; record why the patient could not consent, the harm delay would have caused, and that no valid advance refusal was known.
Where capacity is absent, work through a fixed sequence: (1) can the decision safely wait — postpone and revisit if impairment is fluctuating or reversible; (2) is there a valid and applicable advance decision — and where there is any ambiguity about existence, validity or applicability, the presumption is to save life; (3) is there a lawfully appointed proxy — follow their decision; (4) otherwise act in best interests, asking those close to the patient what the patient valued, feared and previously said.
Handle refusal and departure against advice properly: address the reversible reasons first (pain, nicotine withdrawal, dependants at home, cost, fear of a procedure), assess and record capacity for that specific decision, explain the risk in concrete terms, and offer the best available compromise — the treatment that will be accepted, an early review, written safety-netting, and an explicit statement that the patient may return at any time and will be seen without reproach.
If the patient declines to sign a refusal form that is their right — record that it was offered and declined, and who witnessed the conversation.
Before any sedative, check capillary glucose and SpO2 and have oxygen, suction, a bag–valve–mask and a benzodiazepine antagonist to hand; monitor SpO2, respiratory rate, pulse and blood pressure continuously until the patient is rousable and stable, and obtain an electrocardiogram when practicable, as antipsychotics prolong the QT interval.Doctor / Nurse
Rapid tranquillisation doses: lorazepam 1–2 mg IM or slow IV, repeated once after 30–45 min, maximum 4 mg/24 h (elderly or frail 0.5–1 mg, maximum 2 mg/24 h; paediatric 0.05–0.1 mg/kg, maximum 2 mg/dose, a specialist decision); haloperidol 2.5–5 mg IM, repeated after 30–60 min, maximum 12 mg/24 h (elderly 0.5–2 mg IM); midazolam 2.5–5 mg IM titrated (elderly 1–2.5 mg IM); promethazine 25–50 mg IM (elderly 25 mg IM).Doctor / Nurse
Reverse what you cause: for acute dystonia give procyclidine 5–10 mg IM/IV; for benzodiazepine-related respiratory depression support ventilation first, then flumazenil 200 micrograms IV over 15 seconds followed by 100 micrograms at 60-second intervals to a usual maximum of 1 mg; for opioid-related respiratory depression give naloxone 100–400 micrograms IV titrated in adults or 10 micrograms/kg IV in children.Doctor / Nurse
Share information on one of three bases, in descending order of preference: the patient consents; sharing is in the patient's best interests and it is impracticable to seek consent (telephoning the general practitioner of an unconscious patient for drug history, allergies or an advance decision); or disclosure is in the public interest as a last resort — and even then share only with those who need to know, and only what they need to know.
Write the note at the bedside with a time on it, recording facts and reasoning rather than conclusions — "states he was struck on the head with a stick", not "assault" — with the patient's own words in quotation marks, and record relevant negatives, because a note without negatives reads as an examination that was not performed.
Correct an error the lawful way: draw a single line through it so it remains legible, write the correction beside it, and time, date and sign it; a late entry is legitimate and labelled as such, giving both the time of writing and the time of the events described.
Confirm death personally and record how: no response to voice or pain, no central pulse and no heart sounds over a sustained period, no respiratory effort on auscultation, and fixed unreactive pupils — an asystolic monitor trace supports but does not replace examination.
When something goes wrong, disclose it: explain, apologise, remedy the harm where possible, and report the event so the system can be improved; an apology is an expression of regret, not an admission of negligence.

Caution— what harms

Refusal is not incapacity: an adult with capacity may make an eccentric, unwise or fatal decision — probe it for misunderstanding, correct what is wrong, persuade, then respect it; persuasion is legitimate, coercion is not.
Treating an incapacitous refusal as valid is the classic fatal error: intoxication impairs use-and-weigh disproportionately to apparent fluency, and the extradural haematoma missed because an intoxicated refusal was accepted is the paradigm harm.
A head injury with any altered consciousness may be in a lucid interval — a "competent" refusal may precede rapid deterioration, and CT head is a mandatory consideration in any intoxicated patient with head injury or unexplained confusion before a refusal is accepted.Not available at your setup — CT scan.
A diagnosis alone never establishes incapacity: dementia is chronic and non-fluctuating and often retains capacity for simpler decisions; a positive delirium screen satisfies only stage 1; and decision-making capacity limited to medical circumstances must be distinguished from declaring a patient legally "incompetent" for all decisions, which is reserved for the courts.
Aphasia, deafness, absence of a shared language and intubation are not incapacity until every communication aid and a professional interpreter have failed — the channel is blocked, not the mind — and processing speed slows with age, so an older adult given insufficient time may be misclassified when the deficit is one of pace alone.
A patient who lacks capacity cannot self-discharge, and where departure would carry serious risk they must be kept safe by the least restrictive means available.
Sedating agitation without excluding its cause kills: exclude hypoglycaemia, hypoxaemia, head injury, sepsis, alcohol or benzodiazepine withdrawal, anticholinergic and sympathomimetic poisoning, hyperthermia, urinary retention and pain before any chemical restraint.
Physical restraint must never be applied to the neck, chest or abdomen, nor in the prone position — death from prone restraint in an exhausted, hyperthermic or acidotic patient is a recognised complication — and restraint must be proportionate to the likelihood and seriousness of the harm and the least restrictive option that works.
Avoid haloperidol in known long QT interval, Parkinson's disease and dementia with Lewy bodies, and in suspected anticholinergic or sympathomimetic poisoning, where a benzodiazepine is preferred.
Flumazenil is reserved for significant compromise and avoided where seizures or tricyclic co-ingestion are likely — support ventilation first.
Never alter a record: one reconstructed later is worth a fraction of a contemporaneous note, and one altered after a complaint is worth less than nothing, since tampering destroys the credibility of the whole record.
Never record forensic opinion — no conclusions on weapon, direction, sequence or age of injury — and take photography only with separate, explicit, written consent.
Do not certify a cause of death that has not been established, and do not certify at all where the death may be unnatural — deaths following injury, poisoning, burns, drowning, hanging, alleged assault, in custody, during or shortly after a procedure, or of unknown cause, are referred rather than certified.
Never discuss cases or photograph patients or radiographs on social media or messaging groups, and beware the inadvertent breaches that predominate: conversations in lifts and corridors, handover sheets left in pockets, whiteboards visible from waiting areas, unlocked screens, and a curtain that is not a wall; decline requests that require deception, such as a certificate for a period not observed or a back-dated document.

Refer / escalate

Escalate early and record it — lack of experience is not a defence, so a timed request for senior, psychiatric or ethics input with what was asked and what was advised is both the best clinical decision and the strongest protection; where disagreement about a patient who lacks capacity cannot be resolved, use clinical ethics consultation, a second opinion and psychiatric assessment, and where conflict remains unresolvable consult a court, judges being available even in emergencies in the UK.

The card — assess, manage, caution

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