ITS MAKE YOUR MIND UP TIME !! ADVENTURES IN MENTAL CAPACITY DR E C KOMOCKI CONSULTANT IN OLD AGE...
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Transcript of ITS MAKE YOUR MIND UP TIME !! ADVENTURES IN MENTAL CAPACITY DR E C KOMOCKI CONSULTANT IN OLD AGE...
IT’S MAKE YOUR MIND IT’S MAKE YOUR MIND UP TIME !!UP TIME !!
ADVENTURES IN MENTAL ADVENTURES IN MENTAL CAPACITYCAPACITY
DR E C KOMOCKIDR E C KOMOCKI
CONSULTANT IN OLD AGE PSYCHIATRISTCONSULTANT IN OLD AGE PSYCHIATRIST
CASE EXAMPLE - BTCASE EXAMPLE - BT80yr old lady with mild LD80yr old lady with mild LD
Lives with son + friend – both with LD too!!Lives with son + friend – both with LD too!!
IDDM with bilateral gangrenous legsIDDM with bilateral gangrenous legs
Needs hospital but refusesNeeds hospital but refuses
GP asks for assessment and “HELP!!!”GP asks for assessment and “HELP!!!”
Seen at home – squalid and malodorousSeen at home – squalid and malodorous
““This is my chair and I want to die in it…I know my This is my chair and I want to die in it…I know my time has come…not going to have my legs off…I’ll time has come…not going to have my legs off…I’ll die of blood poisoning!!!”die of blood poisoning!!!”
What do you do now?What do you do now?
THE DILEMAS OF CAPACITYTHE DILEMAS OF CAPACITY
ALL ASSUMED TO HAVE CAPACITYALL ASSUMED TO HAVE CAPACITY
CAPACITY IS DECISION-SPECIFICCAPACITY IS DECISION-SPECIFIC
ASSESSOR’S TASK IS TO DETERMINE WHETHER ASSESSOR’S TASK IS TO DETERMINE WHETHER CAPACITY MAY BE IMPAIREDCAPACITY MAY BE IMPAIRED
THOSE WITH CAPACITY MAKE DECISIONS FOR THOSE WITH CAPACITY MAKE DECISIONS FOR THEMSELVES, REGARDLESS OF HOW ECCENTRIC, THEMSELVES, REGARDLESS OF HOW ECCENTRIC,
DANGEROUS OR LIFE-THREATENING THAT DECISION DANGEROUS OR LIFE-THREATENING THAT DECISION MAY BEMAY BE
AUTONOMY OVERRIDES SANCTITY OF LIFE!!AUTONOMY OVERRIDES SANCTITY OF LIFE!!
NO CAPACITY THEN TAKE HEED!!!NO CAPACITY THEN TAKE HEED!!!
THE THEORIES BEHIND THE THEORIES BEHIND CAPACITY ASSESSMENTS CAPACITY ASSESSMENTS
FUNCTIONALFUNCTIONAL Components of decision-making process analysedComponents of decision-making process analysed
OUTCOMEOUTCOME
Quality of decision based on projected consequences of Quality of decision based on projected consequences of that particular course of action that particular course of action
STATUSSTATUS
Quality of decision based upon an attributeQuality of decision based upon an attribute
LAW COMMISSION STATES “FUNCTIONAL”LAW COMMISSION STATES “FUNCTIONAL”
Law Commission (1995), Bellhouse et al (2001)Law Commission (1995), Bellhouse et al (2001)
Case Example - PICase Example - PI
72yr old lady with long psychiatric history72yr old lady with long psychiatric history
Now living with relativesNow living with relatives
12/12 Hx of abdominal swelling12/12 Hx of abdominal swelling
Gynaecology assessment “needs surgery”Gynaecology assessment “needs surgery”
Refuses so psychiatric opinion soughtRefuses so psychiatric opinion sought
No evidence of psychosis until - “Those aren’t No evidence of psychosis until - “Those aren’t my legs!!!”my legs!!!”
Further questions uncovered anatomically-Further questions uncovered anatomically-specific delusions!! specific delusions!!
CASE EXAMPLE - PICASE EXAMPLE - PI
STATUS ASSESSMENT STATUS ASSESSMENT --
“ “Psychiatric patient so no capacity” ORPsychiatric patient so no capacity” OR
“ “No evidence of psychosis so has capacity”No evidence of psychosis so has capacity”
OUTCOME ASSESSMENT OUTCOME ASSESSMENT ––
“ “Probable carcinoma and poor quality of life”Probable carcinoma and poor quality of life”
FUNCTIONAL ASSESSMENT FUNCTIONAL ASSESSMENT ––
“ “Does not believe the information so no capacity”Does not believe the information so no capacity”
Had surgery under Common Law (and protest!!)Had surgery under Common Law (and protest!!)
THE PRINCIPLES OF CAPACITY THE PRINCIPLES OF CAPACITY ASSESSMENTS 1ASSESSMENTS 1
UNDERSTAND AND BELIEVE THE INFORMATION UNDERSTAND AND BELIEVE THE INFORMATION GIVENGIVEN
EXPLANATION IN BROAD MEDICAL TERMSEXPLANATION IN BROAD MEDICAL TERMS
Nature of interventionNature of intervention
Purpose of interventionPurpose of intervention
Risks/benefits of interventionRisks/benefits of intervention
Risks/benefits of non-interventionRisks/benefits of non-intervention
Risks/benefits of alternative therapiesRisks/benefits of alternative therapies
CASE EXAMPLE – PICASE EXAMPLE – PI Bellhouse et al (2001), Jones (2006)Bellhouse et al (2001), Jones (2006)
PRINCIPLES OF CAPACITY PRINCIPLES OF CAPACITY ASSESSMENTS 2ASSESSMENTS 2
RETAIN THE INFORMATION LONG ENOUGH TO RETAIN THE INFORMATION LONG ENOUGH TO REACH A DECISIONREACH A DECISION
SHORT TERM MEMORY LOSS DOES NOT SHORT TERM MEMORY LOSS DOES NOT NECESSARILY IMPLY INCAPACITYNECESSARILY IMPLY INCAPACITY
CASE EXAMPLE – RWCASE EXAMPLE – RW
Solicitor unhappy with decision to give POASolicitor unhappy with decision to give POA
Joint meeting…satisfied requirements of capacityJoint meeting…satisfied requirements of capacity
5 mins later…”Who ARE you?!!”5 mins later…”Who ARE you?!!”
Repeated whole process…FOUR times!!Repeated whole process…FOUR times!!
Consistent every time so POA agreed Consistent every time so POA agreed Jones (2006)Jones (2006)
PRINCIPLES OF CAPACITY PRINCIPLES OF CAPACITY ASSESSMENT 3ASSESSMENT 3
USE AND WEIGH UP INFORMATION USE AND WEIGH UP INFORMATION RELEVANT TO THE DECISIONRELEVANT TO THE DECISION
BEWARE -BEWARE -
Circumstances influencing decision-makingCircumstances influencing decision-making
Lack of adherence to perceived “Best Interests”Lack of adherence to perceived “Best Interests”
Undue influence of othersUndue influence of others
PERSON-CENTRED APPROACHPERSON-CENTRED APPROACH
Bridson et al (2003), Jones (2006)Bridson et al (2003), Jones (2006)
CASE EXAMPLE - RHCASE EXAMPLE - RH72yr old male referred by A+E72yr old male referred by A+E
OD following charge of raping grand-daughterOD following charge of raping grand-daughter
Family circumstancesFamily circumstances
Informal admission for assessmentInformal admission for assessment
No evidence of mental illness No evidence of mental illness
Discharge ward round with all involvedDischarge ward round with all involved
Concerns – future prospects, family influence and Concerns – future prospects, family influence and CotmanhayCotmanhay
Had full capacity so discharged with supportHad full capacity so discharged with support
Outcome?Outcome?
PRINCIPLES OF CAPACITY PRINCIPLES OF CAPACITY ASSESSMENT 4ASSESSMENT 4
COMMUNICATE THE DECISION BY COMMUNICATE THE DECISION BY WHATEVER MEANS POSSIBLEWHATEVER MEANS POSSIBLE
VerbalVerbal
WrittenWritten
Sign languageSign language
“ “Even by the controlled flicker of a muscle!!”Even by the controlled flicker of a muscle!!”
Jones (2006)Jones (2006)
PRINCIPLES OF CAPACITY PRINCIPLES OF CAPACITY ASSESSMENT 5ASSESSMENT 5
STRATEGIES TO ENHANCE ASSESSMENTSTRATEGIES TO ENHANCE ASSESSMENT
CommunicationCommunication
Simplify informationSimplify information
Treat temporary physical/psychiatric conditionsTreat temporary physical/psychiatric conditions
Accommodate spiritual beliefsAccommodate spiritual beliefs
Avoid therapeutic coercionAvoid therapeutic coercion
ENSURE GOOD RECORD-KEEPINGENSURE GOOD RECORD-KEEPING
Reasoning not just factsReasoning not just facts
Bellhouse et al (2001), Bridson et al (2003)Bellhouse et al (2001), Bridson et al (2003)
CASE EXAMPLE - BTCASE EXAMPLE - BT
Has capacity despite LDHas capacity despite LD
““I’ve got diabetes and gangrene”I’ve got diabetes and gangrene”
““You’re a nice lad Edward! Call again!!”You’re a nice lad Edward! Call again!!”
““I know I might die, but this is my chair!”I know I might die, but this is my chair!”
““And you can tell the ‘Sister of f**king And you can tell the ‘Sister of f**king Mercy’ that as well!!”Mercy’ that as well!!”
Son and friend vacantly nodding!!Son and friend vacantly nodding!!
So, she stays at home!!So, she stays at home!!
THE NEW MENTAL CAPACITY THE NEW MENTAL CAPACITY ACT 1 ACT 1
WHAT DOES THE NEW ACT DO?WHAT DOES THE NEW ACT DO?
Determines decision-making responsibility for health, welfare Determines decision-making responsibility for health, welfare and financial issuesand financial issues
Maintains right of capable over 16yr olds to make Maintains right of capable over 16yr olds to make autonomous decisionsautonomous decisions
Allows decisions to be made in advance of incapacityAllows decisions to be made in advance of incapacity
Incapable and no prior decisions – best interestsIncapable and no prior decisions – best interests
New criminal offence – neglect/abuse of the incapableNew criminal offence – neglect/abuse of the incapable
NEW ACT DOES NOT –NEW ACT DOES NOT –
Allow euthanasia or assisted suicideAllow euthanasia or assisted suicide
Jones (2006), Hopkinson (2006)Jones (2006), Hopkinson (2006)
THE NEW MENTAL CAPACITY THE NEW MENTAL CAPACITY ACT 2ACT 2
MAIN NEW DEVELOPMENTS –MAIN NEW DEVELOPMENTS –
CLARIFICATION OF BEST INTERESTSCLARIFICATION OF BEST INTERESTS
ADVICE ON RESTRAINTADVICE ON RESTRAINT
LASTING POWER OF ATTORNEY LASTING POWER OF ATTORNEY
POWER OF COURT OF PROTECTIONPOWER OF COURT OF PROTECTION
INDEPENDENT MENTAL CAPACITY ADVOCATESINDEPENDENT MENTAL CAPACITY ADVOCATES
ADVANCE DECISION-MAKINGADVANCE DECISION-MAKING
BEST INTERESTSBEST INTERESTS
FOR PERSONS LACKING CAPACITYFOR PERSONS LACKING CAPACITY
11STST STEP – WILL THEY REGAIN CAPACITY? STEP – WILL THEY REGAIN CAPACITY?
CONSIDER –CONSIDER –
Wishes/feelings previously expressedWishes/feelings previously expressed
Beliefs/values which might influence decisionBeliefs/values which might influence decision
New circumstantial factorsNew circumstantial factors
ENGAGE AND CONSULT WITH –ENGAGE AND CONSULT WITH –
Named person/present carer/LPA/COP deputyNamed person/present carer/LPA/COP deputy
DECIDE “AS THEY WOULD HAVE DONE”DECIDE “AS THEY WOULD HAVE DONE”
Jones (2005), Jones (2006)Jones (2005), Jones (2006)
CASE EXAMPLE - KBCASE EXAMPLE - KB
64yr old lady with profound Alzheimers Disease64yr old lady with profound Alzheimers Disease
Marked challenging behavioursMarked challenging behaviours
Develops rectal prolapseDevelops rectal prolapse
Initially reducible – now irreducible, bleeding and Initially reducible – now irreducible, bleeding and causing pain and distresscausing pain and distress
Worsening in challenging behavioursWorsening in challenging behaviours
Previously expressed “fear of operations”Previously expressed “fear of operations”
Confirmed by husbandConfirmed by husband
REFER FOR SURGERY?REFER FOR SURGERY?
ADVANCE-DECISION MAKING 1ADVANCE-DECISION MAKING 1IN PREPARATION –IN PREPARATION –
Have capacityHave capacity
Refusal of specific treatment + circumstancesRefusal of specific treatment + circumstances
Oral or written (preferably with witnesses)Oral or written (preferably with witnesses)
Can contain treatment “desired” but doctor not obliged Can contain treatment “desired” but doctor not obliged
INITIATED –INITIATED –
Patient becomes incapablePatient becomes incapable
Clinical circumstances ariseClinical circumstances arise
AD followed “even if life is at risk”AD followed “even if life is at risk”
Other unspecified treatments – Best InterestsOther unspecified treatments – Best Interests
Williams et al (2004),Jones (2006), Hopkinson (2006)Williams et al (2004),Jones (2006), Hopkinson (2006)
ADVANCE-DECISION MAKING 2ADVANCE-DECISION MAKING 2
INVALIDATED –INVALIDATED –
Doubts expressed about capacity when drawn upDoubts expressed about capacity when drawn up
Withdrawn when capableWithdrawn when capable
Capable when treatment neededCapable when treatment needed
New circumstances/treatments not anticipatedNew circumstances/treatments not anticipated
Psychiatric treatment to be given under MHA (1983)Psychiatric treatment to be given under MHA (1983)
DISPUTES REFERRED TO COPDISPUTES REFERRED TO COP
QUESTION – HOW FAR DO YOU GO TO QUESTION – HOW FAR DO YOU GO TO DETERMINE THE EXISTANCE OF AN AD?DETERMINE THE EXISTANCE OF AN AD?
Williams et al (2004), Thomas et al (2004), Jones (2005)Williams et al (2004), Thomas et al (2004), Jones (2005)
CASE EXAMPLE - ??CASE EXAMPLE - ??
Reported in BMJReported in BMJ
Elderly lady found collapsedElderly lady found collapsed
Taken to A+E and resuscitatedTaken to A+E and resuscitated
FURIOUS!!! Had AD specifying DNAR!!!FURIOUS!!! Had AD specifying DNAR!!!
Self-dischargeSelf-discharge
Some time later, same circumstances!!Some time later, same circumstances!!
Rushed to A+E to be resuscitatedRushed to A+E to be resuscitated
Tattooed on chest “DNAR”!!!Tattooed on chest “DNAR”!!!
Similar case – covered with sticking plaster!!!Similar case – covered with sticking plaster!!!
CASE EXAMPLE - BTCASE EXAMPLE - BT
Maybe some ambivalenceMaybe some ambivalence
Gangrene develops – delirious and so Gangrene develops – delirious and so lacking in capacitylacking in capacity
Could admit under Common LawCould admit under Common Law
OR, remains opposedOR, remains opposed
Becomes deliriousBecomes delirious
Cannot admit as previous wishes clearly Cannot admit as previous wishes clearly stated when capacity was intactstated when capacity was intact
SUMMARYSUMMARY
ASSESSMENT OF CAPACITY WILL BE ASSESSMENT OF CAPACITY WILL BE EVERYBODY’S BUSINESSEVERYBODY’S BUSINESS
REFERRAL TO PSYCHIATRIST IF REFERRAL TO PSYCHIATRIST IF CONTENTIOUS/DIFFICULTCONTENTIOUS/DIFFICULT
URGENT SITUATIONS – USE BEST INTERESTS URGENT SITUATIONS – USE BEST INTERESTS WITHOUT FEAR OF LITIGATIONWITHOUT FEAR OF LITIGATION
ALWAYS CHECK FOR THE TATTOO!!ALWAYS CHECK FOR THE TATTOO!!