Flashcards in Geriatrics - The law and older people Deck (16):
What is mental capacity?
Mental capacity is the ability to make decisions and understand their consequences. A key principle is that everyone is assumed to have mental capacity until proven otherwise. Mental capacity enables individuals to make reckless decisions, even if they are deemed unwise by others provided they retain the capacity to understand the consequences of their actions.
What are the 5 principles of the mental capacity act?
The mental capacity act was introduced in 2005 and protects the rights of adults in the UK to make decision for themselves. The 5 key principles are:
1) capacity is assumed
2) people should be helped to be able to decide
3) people are allowed to be unwise
4) treat people in their best interest
5) use the least restrictive option
What are the 4 aspects of capacity assessment?
To show capacity to make a decision, a patient must
i) understand the information being given to them
ii) retain the information long enough to
iii) weigh up the pros and cons
iv) communicate a firm decision
Anyone who is qualified can assess the capacity of an individual, but it should ideally be done by an individual who has the best knowledge about the decision a patient is making (i.e. doctors for healthcare decisions)
What things should be done to help improve a patients ability to make a decision?
Removing barriers - e.g. treating medical problems, S<, glasses, interpreters, and hearing aids - can help maximise a patients ability to make decisions.
Remember that capacity is decision specific so may fluctuate.
What happens if a patient lacks capacity?
In this instance patients should be treated according to their best interest. In an emergency situation, this can be done by the doctor treating the patient. In non emergency situations its good practice to have a best interest meeting. This should include the patient if possible and involve their relatives and carers. It should aim to make the least restrictive decision possible and bear in mind the patients previous wishes.
For example, if a patient has made it clear that they wish to go home but struggles with their activities of daily living, a trial at home with support may be better than care in a residential home.
What is a deprivation of liberty safeguard (DoLS)?
In some circumstances, the only way to treat a patient who lacks capacity safely is by depriving them of their liberty. For example, by restricting their movements on the ward or for a period of 24 hours.
If this is the case a deprivation of liberty safeguard assessment should be arranged, provided the person must lack capacity, be over the age of 18 and not sectioned under the mental health act.
How long can a DoLS last and who is in charge of maintaining it?
DoLS can last for up to 12 months and each trust appoints a safeguard to oversee patients detained under it. These make sure the assessment is lawful. If a patient dies whilst under a DoLS the coronary MUST be informed.
What is a lasting power of attorney?
This is a special situation that applies to the mental capacity act. Individuals (who are over 18) can appoint a named person to make decisions on either their health or welfare should they lose the capacity to do so. In these circumstances, the lasting power of attorney makes decision on behalf of the patient.
What is an advanced directive?
This is an advanced decision to REFUSE treatment. It expresses what a patient would not like to happen should they lose capacity, and should be followed. It is important that this is seen by the medical team caring for a patient.
What are IMCAs?
These should be appointed to "unbefriended" individuals i.e. those patients who do not have friends or relatives to take part in a best interest decision meeting. IMCAs are independent mental capacity advocates.
What is the best way to raise CPR issues?
Where possible, talk to the patient in advance about CPR decisions whilst they are relatively stable. It may be easier to broach as part of a wider discussion about advanced planning and what the patient would want to happen at the end of their life.
It is a good idea to have people who know the patient (e.g. relatives or carers) present at the time, provided the patient consents. And discussion should be led by the healthcare professional that knows the patient.
What happens if you can't reach a patients relatives regarding DNACPR decisions?
DNACPR decisions should NOT be postponed because the relatives cannot be reached.
In emergency situations, you CAN make DNACPR decisions if the patient is likely to arrest imminently and it is not in their best interest to undergo resuscitation. But you should contact the relatives at the earliest opportunity.
Likewise, if you cannot contact relatives or legal representatives you CAN make DNACPR decisions, but document all the steps you have taken to try and contact them.
Who should you discuss DNACPR with?
The resuscitation council guidelines state that you should ask yourself "is the patient likely to have a cardiac or respiratory arrest in the forseeable future?". If the patient is low risk, there is no need to discuss CPR unless they wish to do so.
But if you feel the risk is higher, the next step is to make an assessment as to whether you think CPR is likely to be successful for the patient. This should be done by an experienced, senior clinician.
The factors that influence the decision process behind CPR are multifactorial but can include:
- terminal illness - e.g. cancer or heart failure
- last days of life
- current clinical condition - e.g. overwhelming sepsis
- medical history
It is important that factors such as a patients age, disability and blanket policies do not influence DNACPR decisions.
Ultimately, whose decision is it to determine whether CPR is likely to be successful?
It is the doctors decision to determine whether CPR is deemed medically futile or not. Doctors cannot be forced to perform inappropriate CPR. This comes from a landmark case from Tracey vs Cambridge University Hospitals NHS Trust.
However, it is important that this decision is communicated to the patient and their loved ones, or any legal representative if the patient lacks capacity. If the family disagree it is useful to offer a second opinion.
The only circumstances where the relative should not be told is if it would cause serious physical or psychological harm.
If a patient has capacity, is at risk of cardiac arrest, and CPR could be appropriate then what should happen?
The question to ask is whether the patient consents to discussing their wishes regarding CPR. If yes, then have the discussion with the patient. If no then it is important to respect this and act in their best interests.