Clinical Scenario

A 15-year-old girl has been out on the town and had a few too many to drink. She has fallen and sustained a deep laceration to her forearm. You decide that the wound needs suturing. She has a friend with her. How do you proceed?

Capacity

In order to give valid consent, the patient must have capacity. In this case there are two main features to consider:

Her age: as she is less than 16 years old, it is not presumed that she has capacity to consent. This would depend on her level of maturity and her ability to understand the planned procedure, including any complications, i.e:

• To weigh up the pros and cons
• To retain the information given
• To communicate her decision

Valid consent: If she is able to do this then she may be able to give valid consent. The history of alcohol ingestion would also need to be taken into account as this would affect her abilities in all the above areas.

Duress

Consent needs to be given freely. If she is a little drunk then there is a fine line to be drawn between persuasion and duress. Persuasion is acceptable whereas duress is not. Such pressure may be exerted by her friend, wanting to get home, or the medical/nursing team wanting to get on to the next patient and meet their time targets.

The parents

As she is only 15, those with parental responsibility can have a say, if they can be contacted.

If the patient has given valid consent and is competent, the parents cannot overrule this, but if she has refused consent then this can be overruled.

If she lacks capacity then the parents give consent. This is always presuming that the parents themselves are competent e.g. not under the influence of drink or drugs.

Delay

The Mental Capacity Act does not apply at this age but one of the principles may be helpful.

Where capacity is lacking, wait until it can be regained. It may be best in a case of refusal of treatment to leave the patient until sober and try again.

In this case, little would be lost by an 8-12 hour delay in suturing.

Best interests

In cases regarding children, the principle is that the child’s best interests are paramount. If there is no-one available with parental responsibility and the girl lacks competence then treatment can proceed in the child’s best interests.

The determination of best interests is not simply what is the proposed treatment but should involve all the circumstances surrounding the patient.