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ITS MAKE YOUR MIND UP TIME !! ADVENTURES IN MENTAL CAPACITY DR E C KOMOCKI CONSULTANT IN OLD AGE PSYCHIATRIST.

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Presentation on theme: "ITS MAKE YOUR MIND UP TIME !! ADVENTURES IN MENTAL CAPACITY DR E C KOMOCKI CONSULTANT IN OLD AGE PSYCHIATRIST."— Presentation transcript:

1 ITS MAKE YOUR MIND UP TIME !! ADVENTURES IN MENTAL CAPACITY DR E C KOMOCKI CONSULTANT IN OLD AGE PSYCHIATRIST

2 CASE EXAMPLE - BT 80yr old lady with mild LD Lives with son + friend – both with LD too!! IDDM with bilateral gangrenous legs Needs hospital but refuses GP asks for assessment and HELP!!! Seen at home – squalid and malodorous This is my chair and I want to die in it…I know my time has come…not going to have my legs off…Ill die of blood poisoning!!! What do you do now?

3 THE DILEMAS OF CAPACITY ALL ASSUMED TO HAVE CAPACITY CAPACITY IS DECISION-SPECIFIC ASSESSORS TASK IS TO DETERMINE WHETHER CAPACITY MAY BE IMPAIRED THOSE WITH CAPACITY MAKE DECISIONS FOR THEMSELVES, REGARDLESS OF HOW ECCENTRIC, DANGEROUS OR LIFE-THREATENING THAT DECISION MAY BE AUTONOMY OVERRIDES SANCTITY OF LIFE!! AUTONOMY OVERRIDES SANCTITY OF LIFE!! NO CAPACITY THEN TAKE HEED!!!

4 THE THEORIES BEHIND CAPACITY ASSESSMENTS FUNCTIONAL Components of decision-making process analysed Components of decision-making process analysedOUTCOME Quality of decision based on projected consequences of that particular course of action Quality of decision based on projected consequences of that particular course of actionSTATUS Quality of decision based upon an attribute Quality of decision based upon an attribute LAW COMMISSION STATES FUNCTIONAL Law Commission (1995), Bellhouse et al (2001) Law Commission (1995), Bellhouse et al (2001)

5 Case Example - PI 72yr old lady with long psychiatric history Now living with relatives 12/12 Hx of abdominal swelling Gynaecology assessment needs surgery Refuses so psychiatric opinion sought No evidence of psychosis until - Those arent my legs!!! Further questions uncovered anatomically- specific delusions!!

6 CASE EXAMPLE - PI STATUS ASSESSMENT - Psychiatric patient so no capacity OR Psychiatric patient so no capacity OR No evidence of psychosis so has capacity No evidence of psychosis so has capacity OUTCOME ASSESSMENT – Probable carcinoma and poor quality of life Probable carcinoma and poor quality of life 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!!)

7 THE PRINCIPLES OF CAPACITY ASSESSMENTS 1 UNDERSTAND AND BELIEVE THE INFORMATION GIVEN EXPLANATION IN BROAD MEDICAL TERMS Nature of intervention Nature of intervention Purpose of intervention Purpose of intervention Risks/benefits of intervention Risks/benefits of intervention Risks/benefits of non-intervention Risks/benefits of non-intervention Risks/benefits of alternative therapies Risks/benefits of alternative therapies CASE EXAMPLE – PI Bellhouse et al (2001), Jones (2006) Bellhouse et al (2001), Jones (2006)

8 PRINCIPLES OF CAPACITY ASSESSMENTS 2 RETAIN THE INFORMATION LONG ENOUGH TO REACH A DECISION SHORT TERM MEMORY LOSS DOES NOT NECESSARILY IMPLY INCAPACITY CASE EXAMPLE – RW Solicitor unhappy with decision to give POA Solicitor unhappy with decision to give POA Joint meeting…satisfied requirements of capacity Joint 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 Jones (2006) Consistent every time so POA agreed Jones (2006)

9 PRINCIPLES OF CAPACITY ASSESSMENT 3 USE AND WEIGH UP INFORMATION RELEVANT TO THE DECISION BEWARE - Circumstances influencing decision-making Circumstances influencing decision-making Lack of adherence to perceived Best Interests Lack of adherence to perceived Best Interests Undue influence of others Undue influence of others PERSON-CENTRED APPROACH Bridson et al (2003), Jones (2006) Bridson et al (2003), Jones (2006)

10 CASE EXAMPLE - RH 72yr old male referred by A+E OD following charge of raping grand-daughter Family circumstances Informal admission for assessment No evidence of mental illness Discharge ward round with all involved Concerns – future prospects, family influence and Cotmanhay Had full capacity so discharged with support Outcome?

11 PRINCIPLES OF CAPACITY ASSESSMENT 4 COMMUNICATE THE DECISION BY WHATEVER MEANS POSSIBLE Verbal Verbal Written Written Sign language Sign language Even by the controlled flicker of a muscle!! Even by the controlled flicker of a muscle!! Jones (2006) Jones (2006)

12 PRINCIPLES OF CAPACITY ASSESSMENT 5 STRATEGIES TO ENHANCE ASSESSMENT Communication Communication Simplify information Simplify information Treat temporary physical/psychiatric conditions Treat temporary physical/psychiatric conditions Accommodate spiritual beliefs Accommodate spiritual beliefs Avoid therapeutic coercion Avoid therapeutic coercion ENSURE GOOD RECORD-KEEPING Reasoning not just facts Reasoning not just facts Bellhouse et al (2001), Bridson et al (2003) Bellhouse et al (2001), Bridson et al (2003)

13 CASE EXAMPLE - BT Has capacity despite LD Ive got diabetes and gangrene Youre a nice lad Edward! Call again!! I know I might die, but this is my chair! And you can tell the Sister of f**king Mercy that as well!! Son and friend vacantly nodding!! So, she stays at home!!

14 THE NEW MENTAL CAPACITY ACT 1 WHAT DOES THE NEW ACT DO? Determines decision-making responsibility for health, welfare and financial issues Determines decision-making responsibility for health, welfare and financial issues Maintains right of capable over 16yr olds to make autonomous decisions Maintains right of capable over 16yr olds to make autonomous decisions Allows decisions to be made in advance of incapacity Allows decisions to be made in advance of incapacity Incapable and no prior decisions – best interests Incapable and no prior decisions – best interests New criminal offence – neglect/abuse of the incapable New criminal offence – neglect/abuse of the incapable NEW ACT DOES NOT – Allow euthanasia or assisted suicide Allow euthanasia or assisted suicide Jones (2006), Hopkinson (2006) Jones (2006), Hopkinson (2006)

15 THE NEW MENTAL CAPACITY ACT 2 MAIN NEW DEVELOPMENTS – CLARIFICATION OF BEST INTERESTS CLARIFICATION OF BEST INTERESTS ADVICE ON RESTRAINT ADVICE ON RESTRAINT LASTING POWER OF ATTORNEY LASTING POWER OF ATTORNEY POWER OF COURT OF PROTECTION POWER OF COURT OF PROTECTION INDEPENDENT MENTAL CAPACITY ADVOCATES INDEPENDENT MENTAL CAPACITY ADVOCATES ADVANCE DECISION-MAKING ADVANCE DECISION-MAKING

16 BEST INTERESTS FOR PERSONS LACKING CAPACITY 1 ST STEP – WILL THEY REGAIN CAPACITY? CONSIDER – Wishes/feelings previously expressed Wishes/feelings previously expressed Beliefs/values which might influence decision Beliefs/values which might influence decision New circumstantial factors New circumstantial factors ENGAGE AND CONSULT WITH – Named person/present carer/LPA/COP deputy Named person/present carer/LPA/COP deputy DECIDE AS THEY WOULD HAVE DONE Jones (2005), Jones (2006) Jones (2005), Jones (2006)

17 CASE EXAMPLE - KB 64yr old lady with profound Alzheimers Disease Marked challenging behaviours Develops rectal prolapse Initially reducible – now irreducible, bleeding and causing pain and distress Worsening in challenging behaviours Previously expressed fear of operations Confirmed by husband REFER FOR SURGERY?

18 ADVANCE-DECISION MAKING 1 IN PREPARATION – Have capacity Have capacity Refusal of specific treatment + circumstances Refusal 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 – Patient becomes incapable Patient becomes incapable Clinical circumstances arise Clinical circumstances arise AD followed even if life is at risk AD followed even if life is at risk Other unspecified treatments – Best Interests Other unspecified treatments – Best Interests Williams et al (2004),Jones (2006), Hopkinson (2006) Williams et al (2004),Jones (2006), Hopkinson (2006)

19 ADVANCE-DECISION MAKING 2 INVALIDATED – Doubts expressed about capacity when drawn up Doubts expressed about capacity when drawn up Withdrawn when capable Withdrawn when capable Capable when treatment needed Capable when treatment needed New circumstances/treatments not anticipated New circumstances/treatments not anticipated Psychiatric treatment to be given under MHA (1983) Psychiatric treatment to be given under MHA (1983) DISPUTES REFERRED TO COP QUESTION – HOW FAR DO YOU GO TO 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)

20 CASE EXAMPLE - ?? Reported in BMJ Elderly lady found collapsed Taken to A+E and resuscitated FURIOUS!!! Had AD specifying DNAR!!! Self-discharge Some time later, same circumstances!! Rushed to A+E to be resuscitated Tattooed on chest DNAR!!! Similar case – covered with sticking plaster!!!

21 CASE EXAMPLE - BT Maybe some ambivalence Gangrene develops – delirious and so lacking in capacity Could admit under Common Law OR, remains opposed Becomes delirious Cannot admit as previous wishes clearly stated when capacity was intact

22 SUMMARY ASSESSMENT OF CAPACITY WILL BE EVERYBODYS BUSINESS REFERRAL TO PSYCHIATRIST IF CONTENTIOUS/DIFFICULT URGENT SITUATIONS – USE BEST INTERESTS WITHOUT FEAR OF LITIGATION ALWAYS CHECK FOR THE TATTOO!!

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