Mental Capacity and Best Interests Assessments
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Aim To provide a practical understanding of the central concepts of the Mental Capacity Act using a real case Objectives • Understand concept of Mental Capacity • Know how to assess capacity and apply it practically • Understand the concept of best interests • Be able to describe a best interests assessment
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Mental Capacity and Best Interests Assessments
- 1. Mental Capacity and Best Interests Assessments Dr Dan Bailey MA FRCP Consultant Physician
- 2. Aim and Objectives Aim To provide a practical understanding of the central concepts of the Mental Capacity Act using a real case Objectives • Understand concept of Mental Capacity • Know how to assess capacity and apply it practically • Understand the concept of best interests • Be able to describe a best interests assessment
- 3. Autonomy is one of the “Four Pillars of Medical Ethics”
- 4. Consent is the key to autonomy in healthcare VALIDCONSENT 1 2 3 Voluntary Informed Person has capacity
- 5. Mental Capacity is the ability to make a decision Mental Capacity = Decision Making Capacity = Competence
- 6. Mental Capacity leads to all kinds of questions
- 7. The Mental Capacity Act gave structure to a complex legal situation Replaced “common” (Court) law concerning people who lacked capacity Introduced new tools and powers: Capacity assessment Best Interest Process Advance Decision Making Capacity assessment Best Interest Process
- 8. The Act has 5 Core Principles… 1 Presumption of capacity in people 18+ 5 3 2 Reasonable help to make a decision Allow people to make unwise choices Acts done for/on behalf must be in best interests Best Interests = less restrictive course, respecting rights/freedom of action 4
- 9. It’s time to introduce Daisy 88 Year old Woman Moderate COPD on nebs Anxiety Disorder PD Extra Sheltered Accommodation Walks short distances with frame + 2 QDS DH POC and DN x2 for nebs
- 10. Daisy has several problems… Multiple admissions to hospital with SOB Wants to stay in her flat Does not want to move into care Family think she is better in care 24/7 What do you do?
- 11. Before you test for capacity you must do one thing… KNOW WHAT THE DECISION IS THAT THE PERSON HAS TO MAKE VS
- 12. The test for capacity has 2 stages… Impairment of the functioning of the mind/brain Firstly you must have… If the person does not meet this criterion then they have capacity to make the decision in question GSTT Mental Capacity Assessment – type in MCA on GTi intranet
- 13. The second stage is the functional test… Criterion Understand information Test Risks Benefits All Options No Decision Retain information Duration of conversation Use/Weigh information Show their “working” How did they arrive at the decision? Communicate Through any means
- 14. How sure do you have to be? BALANCE OF PROBABILITIES… Is it more likely than not that the person has capacity?
- 15. How do you record it?
- 16. Daisy did have capacity… Decision Do you want to move into care? Impairment of functioning of mind/brain Understand Retain it Use/Weigh Communicate Daisy had capacity to make the choice to stay at home Anxiety disorder present but not so bad as to make her unable to make the decision
- 17. But what if Daisy had lacked capacity to make the decision? Best Interests Process Best course of action for Daisy Not personal view of decision maker Current/Future Interests Follow the checklist
- 18. Best Interests Meeting can be virtual or in person Know the decision Confirm Capacity Assessment Make a Record
- 19. Whatever you do you must follow the Statutory Checklist Best Interests Checklist Reminder; Avoid discrimination: assumptions should not be made simply on the basis of age, appearance, condition or behaviour of the patient Information is needed, relevant to this decision, about the patient’s; ∙Past and present wishes and feelings ∙Beliefs and values ∙Any other factor the patient would have considered Obtain and record this information (as practical and appropriate) from; ∙The patient ∙Those close to the patient e.g relatives, friends ∙IMCA (if no-one close to the patient) ∙Lasting Power of Attorney/ Enduring Power of Attorney/ Court deputy (if one exists) Ensure ∙Intervention necessary ∙Less restrictive option chosen ∙If temporary loss of capacity- can decision wait? ∙All efforts made to enable patient to contribute to decision ∙If the decision concerns life sustaining treatment, the best interests decision must not be motivated by a desire to bring about the patient’s death
- 20. You must remember to think about the balance between all types of interests Medical Interests Regular support for anxiety and SOB ShouldDaisygointoacarehome? Decision Reduce hospital admission May not prevent admission Reduce medication burden Emotional Interests Less lonely, more company Reassurance on hand 24/7 Reduce anxiety symptoms Fear of care home increases anxiety Welfare Interests Improved Quality of Life Care needs better met Stress of move Depression risk Goes against express wish
- 21. The Real “Daisy”: Conclusion Applied for NHS Continuing Care Approved but no night care available Extra-Sheltered reluctant to take her home Agreed to placement after extensive discussion Advance Care Planning Initiated
- 22. Final Thoughts Think about mental capacity Know what decision has to be made by the patient Remember that the Best Interests Assessment is for all people Must consider less restrictive option MCA opens up a dialogue to answer questions
- 23. Remember this… People ARE individuals… … with competing priorities in life… …and these are often wider in scope than just the best medical course of action So help to empower them
- 24. Work-through Case: Jack 75 year old man CKD Recurrent UTI due to catheter Lives alone Immobile (Bed Bound) DH QDS POC Wants to stay at home but family want him in care
- 25. Questions?