Delusions erode capacity

An update from a regular series written by Mr Robert Wheeler, director, department of clinical law, where he considers various aspects of clinical law that our nursing and medical staff rely on when caring for patients.

It is intuitive. That delusional illness impairs patients’ capacity. But equally, we are now well aware of the danger of discriminating against people on the basis of irrelevant considerations, as embodied in the Equality Act 2010. A recent case provides a rare explicit example of how delusions can be relevant in compromising a person’s capacity.

TS is 81; one of four siblings and no longer married, he lives by himself and has no particular friends or family involved in his care. In March 2021 he alleged that he had been poisoned by the police; thereafter presenting with agitation, irritability and paranoia. He was subsequently detained under the Mental Health Act 1983. A few days later he suffered some chest pain; heart block was diagnosed. TS’ doctors were concerned that he might, untreated, suffer cardiac dysrhythmia or standstill.

He initially agreed to the provision of a pacemaker, but two days later withdrew his consent. For this reason, the Trusts involved sought a declaration from the Court of Protection; that TS lacked capacity to make this decision due to his delusional illness; and that it was in his best interests to have a pacemaker implanted.

The judge spoke to TS on two occasions and heard evidence from the medical staff. TS believed that he is, and has been for many years persecuted by the police, the council and more recently the hospital staff; all engaged in a conspiracy against him. In 2015 he had told a judge (during a tenancy matter) that the police had dug a tunnel from the police station thence underneath his flat to gain access to his property. And later, that neighbours were listening to his calls, following him. For these and other reasons he covered his windows with metal foil to deny prying cameras a view. In hospital he would only accept food and medication from sealed packages, lest they had been tampered with.

In his evidence to the court, TS referred to a number of instances of council and police interferences, including the poisoning of his water supply. When asked what toxicological analysis of his water had revealed, he said ’...they didn’t. The police got to them too’. He survived, he said, only because he had an antidote to the toxin.

He believed that his cardiac complaint was the result of torture perpetrated by both the local authority and the police. Many other instances of attacks, raids, persecutions and unlawful state activity were described; the court found that there was no evidence that these had ever taken place.

But TS remained unwilling to consent for (and then undergo) the pacemaker implantation until he received reassurances that these conspiratorial activities would stop.

The court heard that his delusional illness could be treated with antipsychotics; and that it was plausible to believe that his capacity would thus be restored. However, the medication required could not be administered until the pacemaker provided certainty of cardiac rhythm.

Looking at the world through the eyes of an unmedicated TS, one can see what a frightening place it must be. His distrust of medical services (as agents of the state) and of authority in general was all-pervasive. He wanted the council and police stopped in their interference and persecution by reporting them to the Home Office. This was perfectly understandable through his perspective. TS did not object to implantation of the pacemaker per se; the ‘…real issue (was) timing…’, wanting the police and council dealt with first. Perhaps feeling that the malign hand of the state would reach into hospital, he wanted the pacemaker inserted at home.

The court found that TS did not believe that he was mentally ill...which meant that ‘...he could not weigh and balance the decision to have a pacemaker. In particular the physical benefits of pacing, and that he would then be able to receive antipsychotic medication’. The court held that TS’ paranoid beliefs generated a resistance to the placement of the pacemaker, and rendered him unable to decide to consent until such a time that the persecution he was suffering ended. Potentially an indefinite timescale, since the condition he imposed could never be fulfilled.

Accordingly, the court found that he lacked capacity to make this decision, and that it was in his best interests to have the pacemaker implanted; the risks of so doing were low, whilst the risks of non-treatment severe, and potentially imminent.

Whilst TS’ mistaken beliefs were outlandish, the profound effect they had on him were beyond doubt. His case illustrates how a delusional illness, if applicable to the treatment decision that the patient faces, can endanger life, due to negation of capacity.

Robert Wheeler
Department of clinical law, July 2021