Capacity

Welcome to this mini-gem. I'm a patient get me out of here, a guided mental capacity assessment. My name is Finula Johnston and I'm a geriatrics trainee in the Northern Deanery. By the end of this mini-gem, I hope that you will know what mental capacity is, why it matters, how to assess it and what to do next if your patient lacks capacity. Mental capacity is the ability to make decisions and understand their consequences. People are allowed to make reckless decisions as long as they don't break the law. In the past, people with the best of intentions have decided that because someone is older has learning difficulties, they are not able to make decisions for themselves. This sometimes resulted in people having their movements and access to loved ones restricted against their wishes. The Mental Capacity Act was established in 2005 and protects the rights of adults of any age to make decisions for themselves. It follows five basic principles. Firstly, capacity is ass Secondly, people should be helped to be able to make decisions for themselves. Thirdly, people are allowed to make unwise decisions. Fourthly, decisions made for people who lack capacity must be made in their best interests. And finally, decisions made in patients' best interests should favour the least restrictive option for the patient. To put the principles of mental capacity into context, I'd Over a hot she began to wander at times and leave the gas on when cooking. She was eventually admitted following a fall, unharmed but unkempt. She had previously been fiercely independent and had said that she would rather die than go into a home. She had a very caring and concerned family who were convinced that she had dementia and that she was unsafe to go home. They felt that she didn't know what was best for her and that they couldn't look after her anymore. They were keen to get her out of hospital as quickly as possible and wanted us to sort out residential care straight away. So what happens next? Should her family decide where she goes? How do we determine whether or not she is able to decide? You've already learned that we must ass To assess her capacity, we need to give her information about the risks and benefits of going home. She must be able to understand and retain the information long enough to weigh it, make a decision and communicate it to us. If she is able to understand, retain, weigh and communicate her decision, then she has capacity. Anyone who is trained to do so may assess capacity. It should be the person with the best understanding of the decision being made. For example, a social worker for financial decisions or a doctor for medical decisions and so on. Our patient had deliri She wasn't able to retain the information long enough to weigh it at first. She was helped to be able to make a decision by optimising her medical treatment. After treatment, she was able to understand, retain and weigh the risks of going back to her own home. She was discharged with a package of care to help her with meals. If you are interested in learning more about deliri Our case showed an example of removing barriers to understanding, retaining, weighing and communicating a decision by treating a medical problem. Other ways of removing barriers are by correcting sensory impairment, providing interpreters or using specialist communication aids. Capacity assessment provides a snapshot of someone's decision-making ability, so it may fluctuate and need to be tested several times. Remember that capacity is decision-specific and if you are not sure, ask for help. Even experienced consultants ask for second opinion sometimes. If despite all your efforts, your patient lacks capacity to make a decision, then the decision should be made for them in their best interest. In an emergency, this can be done by the doctor treating the patient. In non-emergency situations, it is good practice to have a best interest meeting. This should include the patient if possible and someone who knows them such as a relative or friend. The meeting should choose the course of action which is the least restrictive for the patient and should take into account the patient's previous beliefs and wishes. For example, if someone wants to go home but struggles with self-care, a trial at home with support may be less restrictive than residential care. Sometimes the only way to treat someone who lacks capacity safely is to deprive them of their liberty, for example by restricting their movements on the ward or in 24-hour care. If this is necessary, the person who lacks capacity is overeating and not sectioned under the Mental Health Act, a deprivation of liberty safeguard assessment should be arranged. Dolls last for 12 months and are the responsibility of the health board. Most trusts will have someone appointed to initiate this process. In Newcastle University Hospitals Trust, this is the MCA Dolls Lead. If someone dies whilst under a doll, the coroner must be informed. There are some special situations to be aware of when assessing capacity. If the patient lacks capacity but has appointed a lasting power of attorney for health and welfare, then that person should make the decision in question on the patient's behalf. Similarly, if the patient has a valid advanced decision to refuse treatment, then this must be followed. Both of these must be in place before the patient leaves his capacity. People who lack capacity but who do not have friends or relatives to involve in a best interest meeting should be appointed an independent mental capacity advocate to represent their interests. So let's recap. There are five principles to the Mental Capacity Act. Capacity is ass People must be helped to be able to make a decision for themselves. People are allowed to make unwise decisions. If a decision is needed for a patient who lacks capacity, then it should be made in the patient's best interest. And if making a decision in someone's best interest, you should choose the least restrictive option. There are four steps to capacity assessment. Patients must be able to understand, retain, weigh and communicate a decision. Thank you for listening. Here are some resources that I hope you'll find useful.