Case 1

This case will include an actor playing the role of the patient, who has delirium and wishes to leave the ward.

Anita Attlee is a (60–80) year old patient admitted overnight with a urinary tract infection who wishes to leave hospital. Nursing staff are concerned because the patient appears confused and has been attempting to remove her cannula.

Students should recognise that the patient is likely experiencing delirium, appreciate that confusion does not automatically mean a lack of capacity, and undertake a focused assessment before deciding whether the patient can leave.

This is not intended to be a formal Mental Capacity Act assessment. Rather, students should demonstrate safe clinical reasoning, compassionate communication, and know when to seek senior help.

• Chair
• Patient in casual clothes

Case 1

You are the medical student attached to the ward.

A nurse has asked you to speak with Mrs Anita Attlee / Mr Alan Attlee .

She has repeatedly stated she wishes to leave hospital.

The nurse is worried because the patient seems confused today. For example, she keeps asking to see her husband, even though she is widowed.

You are not expected to make a final legal decision regarding capacity. Instead, demonstrate safe assessment and appropriate escalation.

Consultation time: 10 minutes

• Speak to the patient.
• Understand why they wish to leave.
• Assess whether they understand the situation.
• Decide whether it is safe for her to leave.
• Explain what you would do next.

NEWS 3

Urine Dip

Blood Tests

Temp 38.3°C

Leucocytes ++

CRP 145

Pulse 108

Nitrites +

WBC 16.2

BP 124/72

U&Es Normal

SpO₂ 97%

Glucose Normal

Case 1

Patient Name: Mrs Anita Attlee / Mr Alan Attlee

• ••• Date of Birth: 14th August 19___ (around 60–80y)
• Occupation: Retired primary school teacher
• Marital Status: Widowed, lives independently

• Occasionally lose track of conversation.
• Repeat questions.
• Become distracted by noises.
• Ask where you are.
• Become mildly frustrated if repeatedly questioned.
• If the student is calm and reassuring, gradually become more cooperative.

• Social: Lives alone, normally independent, sees friends at weekends, drives locally, manages own finances.
• Diet: Home cooks meals, healthy balanced diet, does own food shopping.
• Alcohol: None
• Sleep: Very poor last night. Usually 7 hours.

Case 1

If asked specifically “What things?”, reply: “I need to cook dinner for my husband.” (Then after a pause…) “Oh goodness… I’ve forgotten again.”

If asked “What have the doctors told you?”, reply “Something about an infection”

If asked “What treatment are you receiving?”, reply “Antibiotics”

If asked “Why do you want to stop treatment?”, reply “I don’t like hospitals”

If student says “I don’t think it’s safe for you to leave”, become mildly annoyed: “You can’t keep me here!” and continue being irritable

• If asked today’s date: get this wrong
• If asked about memory: “Normally I’m absolutely fine”
• If asked where you are: “I’m at my GP surgery… (then later…) “Oh no wait, this is a hospital, isn’t it?”
• If asked why you want to leave: “I’ve got things to do.”
• ••• If explanation is calm and empathetic, remain irritable at first but eventually become accepting if they remain calm: “Alright then… maybe I’ll stay a little longer”

• Hypertension
• Osteoarthritis
• Previous UTI 2 years ago
• No dementia diagnosis, no previous stroke

• Ramipril
• Paracetamol
• No anticoagulants
• No allergies

• Father had type 2 diabetes (diagnosed in his 50s).
• Mother had hypertension.

Case 1

What to Look For in the Student’s Consultation

• Used open question and listened without interruption
• Showed empathy

• Asked what patient understands
• Asked about proposed treatment
• Explored consequences of leaving
• Assessed ability to weigh information

• Did not promise discharge due to safety concerns
• Suggested senior review
• Mentioned involving nursing staff

• Calm, Respectful, Patient-centred

• Assuming confusion automatically means no capacity
• Launching into a “memory test” without first building rapport
• Arguing with the patient (“You’re wrong, your husband died”)
• Using jargon (“You lack capacity”)
• Making promises about discharge
• Failing to ask about the patient’s baseline level of function
• Ignoring the nursing team’s concerns