The Mental Capacity Act and adult...

01/12/2016

SteveChamberlain 1

TheMentalCapacityActandadultsafeguarding

Steve Chamberlain

Scheduleforthesession

• Adultsafeguarding– Typesofabuseandresponsibilities

• Context– HouseofLordspost-legislativereport

• Supportingdecisionmaking,assessingcapacity• Bestinterests• Restraint,includingmedication• Deprivationofliberty• IndependentMentalCapacityAdvocates• Advancecareplanning

©SteveChamberlain2016

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Safeguardinginitsdifferentforms• Safeguardingagainstabuseandneglect

– CareAct2014– Adultsafeguardingprocedures

• Safeguardingpeople’shumanrights– Dutyofcareandrightstoautonomy– EuropeanConventiononHumanRights

• Article2:righttolife• Article3:righttofreedomfrominhumananddegradingtreatment

• Article5:righttoliberty• Article8:righttoprivateandfamilylife©SteveChamberlain2016

ADULTSAFEGUARDING


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Underpinningprinciples

• Empowerment– Supportandencouragepeopletomaketheirowndecisions

– Informedconsent• Prevention

– Bettertotakeactionbeforeharmoccurs

• Proportionality– Theleastintrusiveresponseappropriatetotherisk– Professionalswillonlygetinvolvedasmuchasneeded


Underpinningprinciples

• Protection– Supportandrepresentationforthoseingreatestneed

• Partnership– Localsolutionsthroughservicesworkingwithcommunities– Treatingpersonalandsensitiveinformationinconfidence

• Accountability– Accountabilityandtransparencyindeliveringsafeguarding


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Whathaschangedaboutadultsafeguarding?

• Pre-CareAct– Nostatutorydutytoinvestigate– Riskofabusewasoneelementofeligibility

• CareAct2014(s42)– …wherealocalauthorityhasreasonablecausetosuspectthatanadultin

itsareaa) hasneedsforcareandsupport(whetherornottheauthorityis

meetinganyofthoseneeds),b) isexperiencing,orisatriskof,abuseorneglect,andc) asaresultofthoseneedsisunabletoprotecthimselforherself

againsttheabuseorneglectortheriskofit.– (2)Thelocalauthoritymustmake(orcausetobemade)whateverenquiries

itthinksnecessarytoenableittodecidewhetheranyactionshouldbetakenintheadult’scaseand,ifso,whatandbywhom.


Typesofabuseandneglect

• Physicalabuse– Incl.misuseofmedication,inappropriaterestraint

• Domesticviolence– Incl.‘honour-based’violence

• Sexualabuse• Psychologicalabuse

– Incl.coercion,cyberbullying,deprivationofcontact

• Financialormaterialabuse– Incl.coercioninrelationtofinancialaffairs


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Typesofabuseandneglect

• Modernslavery– Humantrafficking,forcedlabour,domesticservitude

• Discriminatoryabuse• Organisationalabuse

– Incl.neglectandfailuretoprovideforneedsthroughorganisationalpoliciesandpractices

• Selfneglect– Incl.hoarding,failuretocareforpersonalhygiene,environment

– Maynotautomaticallytriggeras42investigation– Shouldbeconsideredonacase-by-casebasis


Consentandsafeguarding

• Doesthepersonhavementalcapacitytomakedecisionsabouttheirownprotection?– Supporttomakeowndecision,or– Bestinterestsdecision


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Overridingobjectionstosharinginformation?

• Inwhatcircumstances?– Thepersonlackscapacity– bestinterestsdecision– Emergencyorlife-threateningsituation– Otherpeopleare,ormaybe,atrisk,includingchildren

– Sharinginformationcouldpreventaseriouscrime– Seriouscrimehasbeencommitted– Riskisunreasonablyhigh– caseconferenceneeded– Staffareimplicated– Courtorderorotherlegalauthoritytoshare


Doesthepersonneedsupport?

• Hascapacitytomakedecisions• Hascapacitybut

– has‘substantialdifficulty’understanding,retaining,weighing,communicating,and

– nosuitablepersontorepresentandsupport• Independentadvocate(CareActs67)

• Lackscapacitytomakedecisionsregardingprotection

• IndependentMentalCapacityAdvocate(IMCA)


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MakingSafeguardingPersonal

• ‘Shouldbeperson-led,outcome-focused’• ‘Enhancesinvolvement,choiceandcontrol’• ‘Improvesqualityoflife,well-being,safety’

CareActstatutoryguidance14.15

• Adultssupportedtomaketheirowndecisions• Adultshaveageneralrighttoindependence,choiceandself-determination,includingcontroloverinformationaboutthemselves


Currentprocedures

• Concern• Enquiry• Safeguardingplanandreview• Closingtheenquiry


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Concern

• …anyworryaboutanadultwhohasorappearstohavecareandsupportneeds,thattheymaybesubjectto,ormaybeatriskof,abuseandneglectandmaybeunabletoprotectthemselvesagainstthis.

• Canberaisedbyanyone


LBWANDSWORTHTHRESHOLDGUIDANCE


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PhysicalIsolatedincident:notsafeguarding• Staffcausingnoharme.g.

frictionmarkonskinduetoillfittinghoistsling

• Minoreventsthatstillmeetthecriteriafor“incidentreporting”

• Bruisingcausedbyfamily/carerduetopoorliftingandhandlingtechnique.Noharmintended,immediatelyresolvedwhengivencorrectadvice/equipment

Possiblesafeguarding• Inexplicableminormarking

foundwherethereisnoclearexplanationastohowtheinjuryoccurred.

• Unwantedphysicalcontactfrom‘informal’carer– noharmandquicklyresolved


Physical(medication)Isolatedincident:notsafeguarding• Adultdoesnotreceive

prescribedmedication(missedorwrongdose)– noharmoccurs

Significant:safeguardingresponseneeded• Recurrentmissedmedication

oradministrationerrorsthataffectmorethanoneadultand/orresultinharm

• Time-critical/dose-criticalerror

• CovertadministrationwithoutpropermedicalsupervisionoroutsidetheMentalCapacityAct


Possiblesafeguarding• Recurrentmissed

medicationoradministrationerrorsinrelationtooneserviceuserthatcausednoharm

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Referencesandcontacts

• LBWandsworthadultsafeguardingthresholdguidance2016– http://www.wandsworth.gov.uk/downloads/file/12136/safeguarding_threshold_guidance_2016

• Adultsocialcaresafeguardingcontactdetails– 02088717707– [email protected] (notsecureemail)

• Communitymentalhealthteamcontactdetails– 02087673411– [email protected] (notsecureemail)


Safeguardingandcapacity?

• Mentalcapacity≠Safeguarding• Whatdotheyhavetodowitheachother?

– Choiceandcontrol– Abilitytokeepselfsafefromharm– Autonomyandrisk-taking– Dutyofcare– Protectingvulnerableadultsfromharm

• Whatdoes“vulnerable”mean?• Vulnerable≠incapacitated


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MENTALCAPACITY


CodesofPractice


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HouseofLordspost-legislativescrutinyreport(Mar14)

• TheAct…continuestobeheldinhighregard– but…

• …theprevailingculturesofpaternalism(inhealth)andrisk-aversion(insocialcare)havepreventedtheActfrombecomingwidelyknownorembedded.

• Theempoweringethoshasnotbeendelivered.


Thepresumptionofcapacity

“Evidencetothisinquirysuggeststhattheimplementationofthisprincipleispatchy,atbest.Theprincipalreasonsforthisareatendencyamonghealthandsocialcarestafftomakeassumptionsbasedonimpairment;thefailuretoconductassessmentswhennecessary;thepoorqualityofassessmentsgenerally,andthefailuretotakeintoaccounttheimpactofspecificconditionsonassessment.”


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Thepresumptionofcapacity

“…patientsaredeemedtolackcapacityon‘assumptions’ofprofessionalsbecauseofamentalillness,deafness,appearance,age”.

AdvocacyServiceCymru

Peoplewerebeingfoundtolackcapacity“forreasonswhichtheActdoesnotallow,i.e.ablanketassumptionbasedupondiagnosisoranunwisedecision”.

MentalHealthFoundation

Inmedicalsettingsespecially“theretendstobeanimmediateassumptionoflackofcapacity”.

Sense©SteveChamberlain2016

Assessingcapacity

A BestInterestsAssessor,describeda“strongreluctance”bysomenursesandsocialworkerstoundertakeanassessmentduetoafearthattheirdecision“mightbetestedbythelegalprofessioninacourtoflaw”.WealsoreceivedevidencefromaGP,whoarguedthatcapacityassessmentsassetoutbytheActrequiredalegalratherthanmedicaldecision,whichwas“disruptivetomedicalassessment”and“liabletocauseconfusion”.


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Assisteddecision-making

“…thereisstillatendencytounderstandtheActasaframeworkformakingdecisionsfororonbehalfofapersonratherthanencouragingandmaximising theirparticipationinthedecisionmaking.”

BristolMindIMCAservice

“…thefocuscontinuestobeonprotectionratherthanenablement,andonbestinterestdecisionmakingasopposedtosupporteddecision-makingbytheimpairedperson.”

LawSociety


Unwisedecisions“…thereisstillatendencytoactinapaternalistic/authoritarianfashionandmakedecisionsbasedonthestaff’sperception”.

BritishPsychologicalSociety

A“protectionimperative”oftenexisted,especiallyinhospitalsettings.

GloucestershireMCAgovernancegroup

Astudyofhealthcarestafffoundapaternalisticmodelofcarewherebestinterestsdecisionswerefavouredoversomeonebeingfoundtohavecapacityandmakinganunwisedecision.

UniversityofLiverpool©SteveChamberlain2016

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Bestinterests

“…professionalspickandchoosewhentoinvolve[carers]”TheCarers’ Trust

“Thecentralityoftheperson’swishes,beliefs,valuesandhistorywithinabestinterestviewisverygood.However,alltoooften‘bestinterests’isinterpretedinamedical/paternalisticsensewhichiswhollyatoddswiththatsetoutintheAct”

BritishInstituteofLearningDisabilities


5keyprinciples(MCAs1)

1. Assumptionofcapacity2. Supportingpeopletomaketheirown

decisions3. Therighttomakeunwisedecisions4. Anythingdonefororonbehalfofpeople

mustbeintheirbestinterests5. Theleastrestrictiveintervention


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Thenatureofmentalcapacity

Capacityisdecision-specific– Veryfew(conscious)peoplehave‘nocapacity’– “Mrs Joneslackscapacity”- ???– “Mr Smithhasnocapacity”- ???

Capacityistime-specific– Deterioration(dementia,MND,etc.)– Recovery(fromstroke,braininjury)– Fluctuations(e.g.Korsakoff’s)

NB.TheMCAappliesto≥16yearolds– ExceptLPA,Advancedecisions,DoLS(all18yrs)


Supporteddecision-making

• Allreasonablestepsmusthavebeentakentohelpthepersonbeforeconcludingthattheylackcapacity(MCAs1(3))

– Communicationmethods– Timeofday– Location– Thepresenceofatrustedother– Helptounderstandtheinformation


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Assessingcapacity

• Twoparttest1. Doesthepersonhaveanimpairmentor

disturbanceofthemindorbrain,and2. Aretheyableto…

• Understandtheinformation,and• Retainit,and• Useorweighitinthebalancetocometoadecision,and• Communicatethedecision

• Theinabilitymustbebecauseoftheimpairment


Understandingtheinformation

• Thepersonneedstounderstandthe‘salientfactors’– Whatinformationisrelevanttothedecision?– Notnecessarilyeverydetail

• Thelevelofunderstandingshouldnotbesettoohigh.

• Donotstartwitha‘blankcanvas’– Peopleneedtheopportunitytoweighuptheactualoptionsavailable


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‘Relevant’information?

• “Thenatureandpurposeoftheproposedtreatment,thelastoftheseentailinganunderstandingofthebenefitsandrisksofdecidingtohaveornotthehaveoneoftheotherofthe[interventions],orofnotmakingadecisionatall”

• “Abroad,generalunderstandingofthekindthatisexpectedfromthepopulationatlarge.”

• “Commonstrategiesfordealingwithunpalatabledilemmas(indecision,avoidanceorvacillation)arenottobeconfusedwithincapacity.”HeartofEnglandNHSFoundationTrustvJB [2014]EWCOP342


Retainingtheinformation

• Thefactthatapersonisabletoretaintheinformationrelevanttoadecisionforashortperiodonlydoesnotpreventhimfrombeingregardedasabletomakethedecision. (MCAs3(3))

• Theabilitytomakethedecision‘atthematerialtime’


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Usingandweighingtheinformation

• “Thecapacityactuallytoengageinthedecision-makingprocessitselfandtobeabletoseethevariouspartsoftheargumentandtorelatetheonetoanother.”ThePCTVP,AH&thelocalauthority[2009]EWMisc 10(COP)

• Anapparentlyirrationaldecisionisnotthesameasaninabilitytomakeadecision


Communicatingthedecision

• Anyresidualabilitytocommunicate• Anymeansofmakingoneselfunderstood.• Relevanttoolstofacilitatecommunication

– Signlanguage– Pictureboards– Facialexpressions


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Whentoassesscapacity?“…itisvitalthatwishesandfeelingsarestrictlyconfinedtothebestinterestsanalysisanddonotactsubtlytoundermineacapacityassessment.Where…thereisnodoubtaboutincapacitythenthewishesandfeelingsofthe[patient]cannotalterthatfacteveniftheyhappentoalignexactlywitharational,"capacitous",decision.CDcannotmakesuchadecision.Ithastobemadeforher.Inreachingthatdecisiontheremustbeanobjectiveanalysisofwhatisbestforher;andinthisregardwhatshewantsisveryimportantbutbynomeansdecisive.”

AhospitaltrustvCD[2015]EWCOP74


Bestinterests(MCAs4)

• Thereisnosuchthingasbestinterestsuntilandunlessthepersonhasbeenestablishedaslackingcapacitytomakethedecision

• Bestinterestsisdeterminedbythedecision-maker

• …afterconsiderationofthestatutory checklistfordeterminationofbestinterests


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Bestinterestschecklist(MCAs4)

• Donotdiscriminateonbasisofage,appearance,diagnosis,etc.• Considerallrelevantcircumstances• Isthepersonlikelytoregaincapacity?• Encourageandfacilitateparticipation• Life-sustainingtreatment:decisionmustnotbemotivatedbya

desiretobringaboutdeath• Considerpastandpresentwishesandfeelings,beliefsandvalues• Consultandtakeintoconsiderationtheviewsof

– Anyonecaringforthepersonorinterestedintheirwelfare– Anyonenamedbytheperson– Anyattorneyordeputyappointedbythecourt


Wishesandfeelings• Theclosertotheborderline,themoreweightinprincipletobegiventotheperson’swishes

• ThestrengthandconsistencyofviewsITWvZ&M

• Needtoconsidermattersfromthepatient’spointofview• “…insofarasitispossibletoascertainthepatient’swishesandfeelings,hisbeliefsandvaluesorthethingswhichwereimportanttohim,itisthosewhichshouldbetakenintoaccountbecausetheyareacomponentinmakingthechoicewhichisrightforhimasanindividualhumanbeing.”

Aintree UniversityHospitalvJames©SteveChamberlain2016

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Whatisrestraint?

• Theuseofforce,orthreatofforce,tomakesomeonedosomethingtheyareresistingOr

• Therestrictionofaperson’sfreedomofmovement,whethertheyareresistingornot.

• Sorestraintcanbeseentobeanyrestrictivepractice

• Restraintisnotabadthingperse©SteveChamberlain2016

Whencanrestraintbeused?

• NotexplicitlypermittedbytheAct• Butprotectionfromliabilityifcertainconditionsaresatisfied:– Thepersonlackscapacitytomakethedecision,and– Theactionisintheperson’sbestinterests,and– Thepersonisatriskofharm(tothemselves),and– Therestraintisproportionate tothelikelihoodandseriousnessoftheharm


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MEDICATION,RESTRAINTANDDEPRIVATIONOFLIBERTY


NHSEngland“urgentpledge”

• Urgentactionpledgedonover-medicationofpeoplewithlearningdisabilities (14/07/2015)– “NHSEnglandhastodaypromisedrapidandsustainedactiontotackletheover-prescribingofpsychotropicdrugsto[PWLD]afterthreeseparatereportshighlightedtheneedforchange”

• Prescribinginprimarycare (PHEJune2015)– 29.5%ofadultswithLDandautism(excl.inpatients)beingprescribedantipsychotics/antidepressants/moodstabilisers/anxiolytics/hypnotics

– 58%receivingantipsychoticsand32%prescribedantidepressantshadnorelevantindicationsrecorded


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Dementiaandantipsychotics

• DHreportbyProf. Sube Banerjee(Oct2009)– 180,000peoplewithdementiaonantipsychoticsp.a.– Ofthose,≤ 36,000derivesomebenefit– Negativeeffects

• Additional1,800deathsp.a.• Additional1,620cerebrovascularadverseeventsp.a.

• Theproportionoftheseprescriptionswhichwouldbeunnecessaryifappropriatesupportwereavailableisunclear…butmaywellbeintheorderoftwothirdsoverall


Guidelines

• ”Low-doseantipsychoticsinpeoplewithdementia”– NICE/SCIEguidelinesondementiabeingupdated– dueSeptember2017

• Consultationwiththeperson,theirfamilyandcarers• Antipsychoticscanbewithdrawnwithoutdetrimentaleffectsonbehaviourinmanypeople

• Prescriptionideallyforupto12weeks• Treatmentshouldbereviewedatleastmonthlywithreductionorcessationactivelyconsideredateachreview


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BMJOpenASzczepura etal(20/09/2016)

• 4-yearstudylookingatimpactofNationalDementiaStrategy(2009)onprescribingofanti-psychoticsinL/Tresidentialcare– Nostatisticaldifferenceinoverallprescribingoverthe4-yearperiod

– Nosignificantshifttonewerantipsychotics– Dosagesabovemaximumindicatedin1.3%cases– Durationofprescribingexcessivein69.7%cases

http://bmjopen.bmj.com/content/6/9/e009882.full


Sedativemedicationanddeprivationofliberty

“Inmyviewtheadministrationtoapersonofmedication,inanyrateofantipsychoticdrugsandothertranquilisers,isalwaysapointertowardstheexistenceof[deprivationofliberty]:foritsuppressesherlibertytoexpressherselfasshewouldotherwisewish.”

LordJusticeWilson,CourtofAppeal(2011)“Inassessingwhetherheisatliberty,itisalsoimportanttonotethatEhasbeenprescribedHaloperidol…toreducehisagitationandmorechallengingbehaviour.Hehasnocontrolovertheadministrationofthatmedication.”

GvEandothers,CourtofProtection(2010)©SteveChamberlain2016

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CovertMedication

• NICEguidelines(March2015)– Onlyinexceptionalcircumstances– InaccordancewiththeMentalCapacityAct– Following

• Anassessmentofcapacity,and• Abestinterestsmeetinginvolvingcarehomestaff,prescriber,pharmacist,family/advocate

– Planonhowthemedicationcanbecovertlyadministeredsafely

– Regularreviewsbuiltintotheplan


DEPRIVATIONOFLIBERTY


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Wherecanitoccur?

• Carehomesandhospitals– DeprivationofLibertySafeguards(DoLS)– ≥18yearsold

• If<18years,needcourtauthorisation

• Communitysettings– Requirescourtauthorisation– ≥16yearsold


Howlongbeforerestraintbecomesadeprivationofliberty?

• Restrictionsmustbefora‘notnegligiblelengthoftime’

• Butthereisnosettimethreshold• Dependsontheintensityoftherestrictivemeasuresandtheimpactontheindividual

• Asintensityandimpactincrease,thenrestraintwillturntodeprivationoflibertymorerapidly

• Unlikelyunderanycircumstancestoextendbeyond2-3days


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Deprivationofliberty:“theacidtest”

• Article5(EuropeanConventiononHumanRights:ECHR)– Righttoliberty

• Deprivationoflibertyoccursiftheperson…1. Lackscapacitytoconsenttotheiraccommodationforthe

purposeofcareandtreatment,andtheyare2. undercontinuoussupervisionandcontrol,and3. notfreetoleave

• Deprivationoflibertymustbeauthorised,by– TheDeprivationofLibertySafeguards(DoLS),or– TheMentalHealthAct1983– Bycourtorder


Continuoussupervisionandcontrol

• Whatis‘continuoussupervisionandcontrol’?– Doesnotneedtobe‘lineofsight’supervision– Thepatientdoesnotneedtobe‘specialled’– Controloverday-to-dayactivities:sleep,meals,24hourcare

• ‘Ruleofthumb’questionstoask– Doyoubroadly knowwherethepersonisandwhattheyaredoingatalltimes?

– Isthereaplaninplaceregardingwhatwouldhappenifyoudidnotknowwherethepersonis?

– Ifbothanswersareyes,pointstowardscontinuoussupervisionandcontrol


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Freedomtoleave

• Whatisnotrelevant?– Notbeingphysicallycapableofleaving– Notaskingtoleaveorshowingsignsofwantingtoleave– Thepresence,orlackofalockorkeypad– Nothavinganywhereelsetogo

• ‘Ruleofthumb’questionstoask– Wouldthepersonbeallowedtoleaveiftheywantedto,ortriedto

– Orifafamilymembercametoremovethem?


TheDoLSprocess

• Six-partassessment– Age(mustbeover18years)– Mentalcapacity(lackscapacityforhospitalisation)– Mentalhealth(hasamentaldisorder– asperMHA1983)– Norefusals(NoadvancedecisionorattorneywhichwouldpreventthetreatmentorDoLSfromproceeding)

– Eligibility(Arethey‘eligible’forDoLS,orshoulditbeMHA?– Bestinterests

• isitadeprivationofliberty?• Isitintheirbestinterests?


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Deathsandthecoroner• CoronermustbenotifiedofanyonewhodiessubjecttoaDoLSauthorisation

• ChiefCoronerconfirmsitisadeath‘instatedetention’• Coronermustholdinquest• Doesnothavetobejuryinquestifnaturalcauses

– “Inmanycasesofthiskindwhichareuncontroversialtheinquestmaybea‘paper’inquest,decidedinopencourtbutonthepaperswithoutwitnesseshavingtoattend.Intelligentanalysisofrelevantinformation(withouttheneedforapost-mortemexamination)maybethebestapproach.Bereavedfamiliesshouldhaveallofthisexplainedtotheminadvance.”

ChiefCoroner’sGuidanceNo.16(Dec2014)


Updateoncoroner’srules


• Nov2016:GovernmentacceptedamendmenttoPolicingandCrimeBill2016

• DetentionunderMCAwillnolongerbeconsideredstatedetentionforthepurposestheCoroner’sandJusticeAct2009

• WillnolongerbemandatoryinquestforalldeathsunderDoLS(whenActcomesintoforce)

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IMCAs• Mandatorycriteria

– Thepersonlackscapacitytomakethedecision,and– Hasnofamilyorfriendsavailableorappropriatetoconsult

• NOT wherefamilyorfriendsdisagreewithdecision

• “Relevantdecisions”– Movingaccommodationformorethan8weeks– Hospitalisedformorethan28days– Seriousmedicaltreatmentisproposed


Seriousmedicaltreatment

• Provision,withholdingorwithdrawaloftreatment

• Whatisseriousmedicaltreatment(SMT)?– Ifasingletreatment,thereisafinebalancebetweenthelikelybenefitsandburdens

– Finelybalancedchoicebetweentreatments– Proposedtreatmentlikelytohaveseriousconsequences

• Seriousmedicaltreatmentcanbegiveninurgentsituations(butneedtorecordwhy)


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IMCAs

• Discretionarycriteria– Adultsafeguarding

• Whenprotectivemeasuresareproposed• IfthepersonmaybenefitfromanIMCA• Eveniftherearefamilyandfriendstoconsult

– Care(accommodation)reviews• Andnofamilyorfriendstoconsult

• DeprivationofLibertySafeguards(DoLS)– Duringtheprocess– Tosupportthepersonafteranauthorisation


Advancecareplanning• LastingPowersofAttorney(LPA)

– Healthandwelfare– Propertyandaffairs

• Advancedecisionstorefusetreatment• Writtenstatementsofwishes

• Maximisingchoiceandcontrol• Planningforprotection


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Advancedecisions• Legallybinding,if ‘validandapplicable’• Ifrelatingto life-sustainingtreatment,mustbe…

– Inwriting,and– Signedandwitnessed,and– Clearlystatethatthedecisionapplieseveniflifeisatrisk

• Isitvalidandapplicable?– HasPdoneanythingthatgoesagainstit?– HasPwithdrawnit?(whencapacitated)– HasPsubsequentlyconferredthepowerontoanotherperson?(e.g.LPA)

– WouldPhavechangedthedecisionwithmoreinformationaboutthecurrentcircumstances?(e.g.advancesintreatment)


Whatwehavecovered

• Adultsafeguarding– Responsibilitiesandtypesofabuse– Wandsworth’s thresholdguidance

• MentalCapacityAct:whereareweatnow?• Supporteddecision-makingandassessingcapacity• Bestinterests• Restraint,medication• Deprivationofliberty• IMCAsandadvancecareplanning


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