Assessing capacity in an emergency

1. Assessing Capacity in an
Emergency
Dr Wendy Matthews
EM Consultant Imperial Healthcare
NHS Trust

2. Mental Capacity Act 2005
Key Points
• Every Person must be assumed to have capacity unless
proved otherwise.
– Every adult has the right to make a decision for themselves
– Every person has the right to be supported to make decisions
• Capacity can only be determined in relation to a particular
decision at a particular time
• An unwise decision is not proof of incapacity
– Every adult has the right to make an unwise or strange decision
• Any act done or decision made on behalf of somebody who
lacks capacity must be in their best interests and
• Should be the least restrictive (human rights and freedom
of action)

3. Lack of Capacity
• A Person lacks capacity in relation to a matter
if at the material time he is unable to make a
decision for himself in relation to the matter
because of an impairment of or a disturbance
in the function of the mind or brain

4. Test of Capacity
• Lack of understanding of risks or inability to weigh up the
information.
– Does the person have an understanding of the decision and why they
need to make it
– Does the person have an understanding of the consequences or not of
making the decision
– Is the person able to understand, use, retain and weigh up the
information relevant to the decision
– Is the person able to communicate their decision
• Person assessing capacity has ‘reasonable belief’ - not based on
– Age
– Appearance
– Assumptions
– Aspects of behaviour

5. Issues
• Who can assess capacity
• Duty of Care
• Deprivation of Liberty vs Safety
• Advanced Directives
• Lasting Power of Attorney
• Court of Protection (Deputy)
• Best Interests Checklist
• Any restraint necessary must be proportional to
likelihood of harm
• Major medical treatment (not an emergency) IMCA

6. Best Interests Checklist
• Consider all the circumstances relevant to the
patient
– Is the lack of capacity temporary
– Does the decision need to be made now
– Is the person likely to regain capacity
– Who has cared or is caring for the person
– Consider wishes and beliefs expressed by the
person prior to losing capacity

7. Best Interests contd
• Consider the views of carers, family, people
appointed to act for the person
• Support to enable the person to be involved in
decisions.
– Allow different forms of communication
– Simple language
– Repeat the conversation
– May be at different times of day or in different
environment
– Different people who know the patient

8. Case 1 Mrs AB
82 F AB Lives alone with her daughter providing support with
shopping, cooking and personal care.
She has a diagnosis of early dementia and MI in 2010
Her daughter is away on holiday.
Her neighbour calls an ambulance because she has heard calls
for help through the wall
Ambulance service arrives and AB has fallen in the bathroom
On assessment she appears to have no significant injury and is
able to walk unaided when helped to her feet, but her ECG
looks abnormal with possible ischaemic changes.
Mrs AB does not want to go to hospital.

9. Case 2 Mr BC
85M Mr BC
Brought to hospital by his daughter because he has
chest pain.
His troponin (cardiac enzyme) is elevated.
The ‘medical team’ want to admit him and treat for
a cardiac event
Mr BC doesn’t want to stay in hospital.
He believes God will look after him
His daughter says you are holding him against his
will

10. Case 3 Mr DE
76M Mr DE
Recently moved to supported housing from a bedsit.
3x week support
Concerns raised to his warden and forwarded to his GP.
Ambulance called because he has fallen and his nose is
bleeding
His feet are in a poor condition with fungal infection
He appears not to have washed since moving in to new
accommodation
Carers have been unable to get him in the shower

11. Case 4 Mrs FG/Mr HI
Ambulance are called to a ‘choking episode’
Mr HI has recently been discharged from hospital
following a CVA. He had significant swallowing difficulties
and is now on ‘thickened foods’
An ambulance was called because while having a cup of
tea given by his wife he choked and went blue
He has now recovered
His wife Mrs FG doesn’t want him conveyed to hospital
because they will only keep him in and he had such
problems with a chest infection and pressure sores and it
is such a long way for her to visit.

12. Case 5 Mrs JK
Mrs JK lives in a residential home.
She has become increasingly confused over the previous
two days and is now refusing her tablets which include
digoxin for AF, metformin for diabetes and aspirin. The
staff have called an ambulance because they have
recorded a heart rate of 135 on a set of observations.
On arrival to hospital the ambulance staff have been
unable to do observations because she is agitated and
resisting.
How will you treat her?
What will you document?

13. Case 6 Mr IL
Mr IL 95 lives at home cared for by his family
He has become increasingly unresponsive over two days.
His mobility has increasing reduced over the previous six months.
He fell from bed two days ago
His son has Lasting power of attorney
His GP and ambulance staff meet at his home
All agree that he is extremely unwell and this is a terminal illness.
The clinical staff are concerned that he has a subdural and advise he
should go to hospital
His son wants him to stay at home
How will you assess the situation and what would be your advice?
What will you document?

14. Case 7 Mrs MN
Mrs MN 65F with schizophrenia resident in a
long-stay MH ward.
She has fallen and sustained a head wound
which is bleeding profusely
She is rejecting all efforts to treat the wound
What is your approach?
What will you document?

15. Summary
• Capacity definition and assessment
• Best interests checklist
• Documentation of ‘reasonable belief’ and
actions taken

16. ?