Mentally incapacitated and without kin? Docs will take jab decision for them
Under the Mental Capacity Act, the person deciding for a mentally incapacitated patient should, among other things, consider the patient's past and present wishes and feelings, and beliefs and values.
Without any known next of kin, and with cognitive impairment, Madam Tan (not her real name), 73, poses a quandary for her carers.
She has dementia, previously had a stroke, and lacks the mental capacity to make her own decisions, Thye Hua Kwan Nursing Home @ Hougang told The Straits Times.
So, when the Covid-19 vaccine is made available to the nursing home, who decides whether she should receive it?
Six nursing homes in Singapore started vaccinating their residents late last month.
In response to queries from ST, the Ministry of Health said registered medical practitioners may make the assessment on whether to vaccinate individuals who are incapable of making decisions on their own, and have no known next of kin or deputies.
This is in accordance with the Singapore Medical Council's Ethical Code and Ethical Guidelines, and practitioners should act in the best interests of the individual.
Mr Ardi S. Hardjoe, chief executive of Thye Hua Kwan Nursing Home, said that according to an advisory from the Agency for Integrated Care early last month, the nursing home doctor can authorise vaccination according to his best judgment of the patient's best interests, for such vulnerable individuals.
A person may lose his ability to decide on matters due to disability, mental illness or brain diseases such as Alzheimer's.
Under the Mental Capacity Act, the person deciding for a mentally incapacitated patient such as Madam Tan should, among other things, consider the patient's past and present wishes and feelings, and beliefs and values.
Mr Chandra Mohan Rethnam, a partner at Rajah & Tann, said: "You have to consider things such as the person's age, the fact that he is living in a communal facility, and if he can protect himself by wearing a mask or washing his hands regularly.
"If the individual can't do these things to protect himself, then perhaps a vaccination is clearly in his best interest."
Law professor Kumaralingam Amirthalingam of the National University of Singapore (NUS) said that in their assessments, doctors should balance the vulnerable person's risk of contracting Covid-19 against vaccine side effects if the person is already health-compromised.
In a joint reply, Dr Sumytra Menon and Assistant Professor Voo Teck Chuan from the Centre for Biomedical Ethics at NUS said legal advice should be sought if healthcare professionals cannot agree on whether vaccination would be in a patient's best interests.
Mr Chandra stressed that healthcare professionals should take all practical steps to help the individual make the decision himself. If that is not possible, then the healthcare professional can decide.
Prof Voo said: "Even... (when some individuals) lack capacity because they are unable to weigh the risks and benefits - which may happen in the case of an intellectually disabled person or a person with a mental disorder - they may likely be able to understand what is happening. So it would be respectful for healthcare professionals to explain about the vaccination before carrying it out."
In an ST Forum letter last Tuesday, Associate Professor Lim Poh Lian, who sits on the expert committee on Covid-19 vaccination, said the vaccine is generally safe for those with medical conditions.
These conditions include kidney disease, chronic HIV and cancer in remission. But those who have untreated cancer, or are undergoing treatment such as chemotherapy, should defer vaccination, she said.
So, how can vulnerable individuals with no kin be protected if they are unsuitable to receive the jab?
Infectious diseases expert Ooi Eng Eong from the Duke-NUS Medical School said such people can be protected if their caregivers, such as doctors, nurses and allied health professionals, get vaccinated.
But Prof Kumaralingam noted that those who are vaccinated may still spread the disease.
It is still unclear if vaccines can curb the spread of Sars-CoV-2, which is the virus that causes the Covid-19 disease.
Professor Ooi said: "Even if the vaccine only prevents Covid-19 but does not fully prevent Sars-CoV-2 infection, the likelihood of transmission would be greatly reduced compared with someone with symptomatic illness.
"Vaccination of caregivers could thus reduce the risk of infection among those who are unable to provide informed consent."
VACCINATING CAREGIVERS CRUCIAL
Even if the vaccine only prevents Covid-19 but does not fully prevent Sars-CoV-2 infection, the likelihood of transmission would be greatly reduced compared with someone with symptomatic illness. Vaccination of caregivers could thus reduce the risk of infection among those who are unable to provide informed consent.
PROFESSOR OOI ENG EONG, infectious diseases expert from Duke-NUS Medical School.
Source: Straits Times © Singapore Press Holdings Ltd. Permission required for reproduction.