Assessment Of Mental Capacity Research Articles

Practical implications of overlapping mental capacity assessments.

Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers the practical implications of undertaking mental capacity assessments with a person across a range of different decisions.

Mental capacity assessment in the multi-professional real world: a qualitative study of six areas of uncertainty.

The Mental Capacity Act 2005 of England and Wales is a ground-breaking piece of legislation with reach into healthcare, social care and legal settings. Professionals have needed to develop skills to assess mental capacity and handle malign influence, but it is unclear how assessments are implemented in real world settings. Our previously reported survey found professionals juggling competing resources in complex systems, often struggling to stay up to date with law.The current follow-up study uses one-to-one interviews of professionals to characterise in detail six areas of uncertainty faced when assessing mental capacity, whilst suggesting ways to make improvements. Forty-four healthcare, social care and legal professionals were interviewed, using a semi-structured topic guide. Transcripts were analysed using framework analysis: a qualitative technique built to investigate healthcare policy. Our topic guide generated 21 themes. In relation to the six areas of uncertainty: 1) Many participants stressed the importance of capturing a holistic view, adding that their own profession was best-placed for this - although a medical diagnosis was often needed. 2) The presumption of capacity was a laudable aim, though not always easy to operationalise and occasionally being open to abuse. 3) There was cautious interest in psychometric testing, providing a cognitive context for decisions. 4) Undue influence was infrequent, but remained under-emphasised in training. 5) Multi-professional assessments were common, despite doubts about fitting these within local resources and the law. 6) Remote assessment was generally acceptable, if inadequate for identifying coercion. Practical constraints and competing demands were reported by professionals working within real world systems. Assessment processes must be versatile, equally applicable in routine and emergency settings, across diverse decisional types, for both generalist and specialist assessors, and able to handle coercion. Recognising these challenges will guide development of best practices in assessment and associated policy.

A97Applying the Mental Capacity Act through multi-disciplinary simulation - A successful pilot

An assessment of mental capacity involves determining if a person can make a decision, or whether this needs to be done in their best interests [1]. The Mental Capacity Act (MCA) 2005, provides a legal framework that protects people who might not be able to make decisions for themselves and guides professionals during their practice. Research has shown inconsistencies on how the Mental Capacity Act is applied in health and social care settings [2], therefore ensuring that professionals have are provided with the right support to confidently apply the act should be a priority. Simulation has been effectively used in healthcare education [3] and could also be implemented to support this area of practice. The Homerton Healthcare NHS Foundation Trust’s Simulation Team and Adult Safeguarding Team, jointly worked in developing a simulation-based session which focused on mental capacity assessments in different situations. The aim of these sessions was to increase participants’ confidence to assess mental capacity and to manage challenging conversations during assessment. Scenarios were designed for hospital and community settings, the topics covered included consent to treatment, self-discharge, compliance with treatment, substance misuse, mental health problems, dementia and learning disability. The target audience was senior healthcare professionals that are regularly involved in making decisions related to mental capacity. Scenarios were designed to be flexible and adaptable according to the attendants’ needs, for example the learning disability scenarios involved the use of easy read information that was specifically provided or created. Actors were used for the role of patients or relatives, and members of the adult safeguarding team were part of the faculty to support or lead the debrief process. Between January 2023 and February 2023, the faculty delivered 3 sessions, with a total of 20 participants from different professional groups including doctors, nurses and allied health professionals. Anonymous feedback was collected at the end of each session, with 84.62% ( Studies have shown that healthcare professionals’ confidence in applying the mental capacity act can vary [2]. Solely focusing on traditional forms of education might not be enough to prepare our workforce, in this case simulation-based training has provided a valuable tool to enhance participant’s abilities in relation to the mental capacity act and its application in healthcare practice. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

A115Developing a simulation course for Advanced Clinical Practice-Challenges of designing for a diverse interprofessional group

There is increased availability and development of the advanced clinical practitioner (ACP) course to upskill allied health professionals in clinical, leadership and supervision areas [1]. Locally, ACPs and ACPs in training have not previously had simulation integrated into their training for this role despite this being considered an effective learning method for communication skills [2]. The simulation department was approached with funding to develop a course to add variation to their development programme and enhance learning in areas better targeted through simulation. A survey was sent to the ACP cohort to ascertain their desired learning objectives from simulation training. Then the team met a focus group of ACP trainees to further explore their varied roles and the expected changes moving to the ACP role. From this research, a 1-day course was developed to include scenarios with themes felt to be widely applicable across the umbrella of ‘advanced clinical practice’. Examples included; managing patient expectations, challenging hierarchy, safeguarding, learning disability, mental capacity assessment, difficult supervision. Two courses have been completed with a mix of ACP roles, and scenarios adapted to apply to the specific participants. The debriefs explored how the scenario theme could be applied cross discipline and gave an opportunity for these senior healthcare professionals to share experiences and their individual management strategies. This was a stimulating but challenging course to develop given the seniority and multidisciplinary background of the target group. This required significant creativity and adaptability from the organizing team and multiple scenarios to be designed for participants. The courses generated valuable discussion and all candidates reported the day to be a useful experience with specific learning and development taken from the day. Limitations included some allocated scenarios were felt to be outside the usual job remit of the allocated participant, which could impact on the authenticity and psychological safety of the scenario for that candidate. Despite this, useful discussion of the intended themes was still possible, and this was reinforced by the experience brought from the candidates present. Even though ACPs may have similar more complex learning needs in line with their required capabilities, this is challenging to translate into a transferable and valuable simulation course when targeting multiple disciplines with varying amounts of senior experience. We reflect on ways to approach this in the future and would be open to opinions from our esteemed education colleagues. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Capacity, belief and impairment of the mind or brain.

Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers the implications of a recent Court of Protection ruling for nurses who undertake mental capacity assessments.

Psychiatric Assessment of Mental Capacity

Psychiatric Assessment of Mental Capacity

Legal Review of Wills Based on Civil Law

Creating a will, also known as a testament, is a crucial legal process through which an individual shapes the destiny of their assets posthumously. Inheritances frequently give rise to a multitude of legal and social complications, necessitating the implementation of clear-cut regulations in accordance with prevailing legal norms. Wills serve as a vital instrument in averting conflicts among heirs, enabling the fulfillment of the deceased's final wishes. This process allows for a structured distribution of assets, thereby minimizing disputes and familial discord. However, the formulation of a will is subject to specific limitations and constraints, mandating adherence to relevant statutory provisions. These constraints may include requirements for witnesses, mental capacity assessments, and the legal age at which one can create a will. Discrepancies between legal statutes and societal customs regarding wills cast doubt on the continued suitability of existing regulations within the evolving legal landscape. Therefore, delving into the regulation of wills as stipulated in the Civil Code (Kitab Undang-Undang Hukum Perdata) is imperative to gain insight into the contemporary legal framework governing this matter in Indonesia. Thorough research into these legal provisions will shed light on their applicability and efficacy, aiding in the development of a more relevant and coherent legal framework for wills in Indonesian society. Such an updated framework would serve to better protect the rights and interests of individuals, ensuring that their final wishes are carried out smoothly and justly, while also reducing the potential for legal disputes and societal conflicts.

Decision-making capacity in older medical in-patients: frequency of assessment and rates of incapacity by decision-type and underlying brain/mind impairment.

Hospital clinicians find mental capacity assessment challenging and may lack the necessary skills. Given high rates of cognitive impairment, data on mental capacity assessment in real-world hospital cohorts are required to inform the need for staff training and workforce planning. In unselected medical inpatients, we determined the rate and outcome of mental capacity assessment by decision type and underlying brain/mind disorder, and recorded the discipline of the assessor. We included consecutive patients (October-November 2018; November-December 2019) admitted to the complex medicine unit providing acute multidisciplinary care for multi-morbid patients (age ≥ 16years, average age > 80years). Audit data were collected at ward multidisciplinary meetings and extracted from electronic patient records. Among 892 patients (mean/SD age = 82.8/8.6, 465 male), 140 (16%) required mental capacity assessment (40/140 (29%) had ≥2 assessments) with 203 assessments in total of which 162 (80%) were done by doctors. Capacity was deemed lacking in 124 (61%) assessments, most commonly in delirium with/without other co-morbid conditions (94/114, 82%) or dementia (9/12, 75%) with lower rates in other disorders (15/27, 56%), and no formal diagnosis of brain/mind disorder (6/50, 12%). Cognitive test scores were overall lower in those lacking capacity (mean/SD abbreviated-mental-test-score = 5.2/2.6, range = 0-10 versus 6.8/2.8, P = 0.001, range = 1-10). Decisions involving discharge planning were most often assessed (48%) followed by treatment (29%), discharge against medical advice (12%) and others (11%). Mental capacity assessments were performed frequently and often repeated, justifying the need for robust training in the practical application of the principles of capacity assessment for staff managing complex older patients.

Section 48 orders in the Court of Protection: undermining autonomy or an honest account of interim judging?

ABSTRACT This case note considers the role of section 48 orders under the Mental Capacity Act 2005 following the decision by Mostyn J in A Local Authority v LD and RD [2023] EWHC 1258 (Fam). The case concerned an application for removal from home for a man in his 40s with learning disability, autism and Down’s Syndrome for the purposes of assessment of mental capacity. The case note considers the role and function of interim orders under section 48 as well as the wider problem of removing adults from their own home in the name of safeguarding.

‘Informed consent is a bit of a joke to me’: lived experiences of insight, coercion, and capabilities in mental health care settings

AbstractThe Independent Review of the Mental Health Act 1983 found that people’s experiences and self-knowledge were mislabelled as a ‘lack of insight’. Insight, a psychiatric concept, is defined as an ability to recognise one’s mental illness, awareness of one’s symptoms and compliance with treatment. Across different jurisdictions, legal scholars have raised concerns about the influence of insight on legal provisions for psychiatric care and mental capacity assessments, given its prevalent use in psychiatry and its absence from statutory criteria. However, outside of these findings, little is known about people’s lived experiences of ‘insight’ and the law. This article draws on narrative and photo-elicitation interviews with psychiatric survivors to argue that insight is an extra-legislative proxy for regulating involuntary detention and other coercion masked as consent. Finally, this article draws on the capabilities approach to deliver a justice argument for creating real opportunities to provide informed consent in mental health settings.

Development, use and evaluation of a web based mental capacity assessment tool for staff working with people with learning disabilities

PurposeThis paper aims to describe the development, use and evaluation of a web-based mental capacity assessment tool (MCA WAT) within the Learning Disabilities division of a Mental Health and Learning Disabilities Trust in England.Design/methodology/approachThe MCA WAT was developed to ensure there was contemporaneous recording of each capacity assessment; help staff improve their knowledge, confidence and satisfaction in completing assessments of capacity; and analyse the number and type of capacity assessments completed. Three questionnaires were developed: a 12-item multiple-choice knowledge questionnaire, a nine-item confidence questionnaire and a 10-item satisfaction questionnaire, which reflect the five core principles of the MCA (2005). Eight-five health and social care staff who were trained to use the MCA WAT and had used it at least once had their scores from pre- and post-use of the questionnaires analysed using Wilcoxon signed-ranks tests. Data on the use of the MCA WAT was analysed.FindingsResults showed a significant increase in knowledge, confidence and satisfaction from pre- to post-questionnaires. Concerns remain regarding staff understanding of who is the decision maker and the use of communication aids to enhance capacity. These issues are being addressed through training and updating the information boxes in the MCA WAT. The MCA WAT has been used to complete 3,645 capacity assessments over a five-year time scale, covering a wide range of decisions.Originality/valueThis project demonstrates the effectiveness of a contemporaneous method of conducting and recording MCA assessments.

Mental capacity in practice part 2: capacity and the suicidal patient

SUMMARYThis article is the second of two looking at assessment of mental capacity in clinical practice. In it, we explore capacity assessments in the context of suicidal thoughts and acts. The laws governing doctors’ responsibility to suicidal patients in England and Wales are poorly understood, with tensions at the interface between the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). Dynamics of the clinical encounter (including the countertransference) further exacerbate uncertainty about how clinicians should balance patients’ autonomy with protection of life. We use a case example of a patient presenting with suicidality to describe good practice, based on a balance of legal and clinical principles and up-to-date case law. We discuss the difficulty in applying the MCA in relation to patients who appear to lack a consistent and coherent sense of self and others and consider whether the MCA is fit for purpose in determining whether someone with a personality disorder diagnosis should be permitted to end their own life.

1215 IMPROVING THE QUALITY OF ANTICIPATORY CARE PLANNING FOR PATIENTS WITH RECURRENT ASPIRATION PNEUMONIA

Abstract Introduction Recurrent episodes of aspiration pneumonia (RAP) are a significant problem in frail patients leading to high re-hospitalization and mortality. Anticipatory care planning (ACP) enables improved quality of life and end of life care. We reviewed the assessment, ACP discussions and communication with Primary Care in these patients. Methods We used a PDSA methodology, reviewing 116 patients with RAP referred to Speech and Language Therapy (SLT) in Elderly Medicine wards over six months, including the winter. Educational interventions were implemented. An illustrative case and pre-intervention results were presented at an online hospital-wide seminar and subsequently at an online departmental medical staff teaching session. Post-intervention analysis of 10 patients with RAP admitted over two summer months was conducted. The second round of interventions included departmental induction teaching for newly rotated doctors and creating an electronic ACP document (RAP ACP) for inclusion within the medical record. Results Baseline data was collected from 116 patients (mean age 85, 47% female). After the educational interventions, data was collected from 10 patients (mean age 88, 70% female). Data is being collected from winter months after the second intervention. This will be available before the conference. Baseline data demonstrated the need for improvements in documentation of Mental Capacity Assessment (MCA) specific to feeding (21.5%), ACP completion (26.7%) and flagging patients suitable for the Gold Standards Framework (GSF) on discharge (15%). Following educational interventions, there was a substantial improvement in MCA documentation (80%). Furthermore, there was a marked improvement in the completion of ACP discussions (70%). Communication of patients eligible for GSF was similar (14.2%) post-intervention. Conclusions Educational interventions substantially improved the quality of individualised care provided to patients with RAP. Mortality was high in both groups, yet documentation of eligibility for GSF was low, prompting further interventions targeting discharge communication.

Opportunities and risks of self-binding directives: A qualitative study involving stakeholders and researchers in Germany.

Self-binding directives (SBDs) are a special type of psychiatric advance directive in which mental health service users can consent in advance to involuntary hospital admission and involuntary treatment during future mental health crises. This study presents opportunities and risks of SBDs reported by users with bipolar disorder, family members of people with bipolar disorder, professionals working with people with bipolar disorder and researchers with expertise in mental health ethics and law. Seventeen semi-structured interviews with users, family members and professionals, and one focus group with five researchers were conducted. The data was analyzed using qualitative content analysis. Six opportunities and five risks of SBDs were identified. The opportunities were promotion of autonomy and self-efficacy of users, relief of responsibility for family members, early intervention, reduction of (perceived) coercion, positive impact on the therapeutic relationship and enhancement of professionals' confidence in decision-making. The risks were problems in the assessment of mental capacity, inaccurate information or misinterpretation, increase of coercion through misuse, negative impact on the therapeutic relationship due to noncompliance with SBDs, and restricted therapeutic flexibility and less reflection on medical decision-making. Stakeholders tended to think that the opportunities of SBDs outweigh their risks, provided that appropriate control and monitoring mechanisms are in place, support is provided during the drafting process and the respective mental healthcare setting is sufficiently prepared to implement SBDs in practice. The fact that stakeholders consider SBDs as an opportunity to improve personalized crisis care for people with bipolar disorder indicates that a debate about the legal and clinical implementation of SBDs in Germany and beyond is necessary.

The assessment of mental capacity in occupational health

Rarely there maybe a need for occupational health professionals (OHPs) to assess mental capacity such as in a worker who has dementia or brain injury but more commonly OHPs need to understand how they are conducted. The Mental Capacity Act 2005 (MCA) is designed ‘to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment.’ It applies to people aged 16 and over in England and Wales but not in Scotland which has its own legislation. It sets out five ‘statutory principles’, ‘a person must be assumed to have capacity unless it is established that they lack capacity, a person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success, a person is not to be treated as unable to make a decision merely...

Key components of the mental capacity assessment of patients with anorexia nervosa: a study of three countries

BackgroundPatients with anorexia nervosa (AN) often refuse treatment despite their extremely low nutritional status. This study investigated the methods of assessing the mental capacity of patients with anorexia nervosa (AN) who refuse treatment by physicians in Japan, the United Kingdom (UK), and the United States (USA). It also identified the key points of the assessment.MethodsA questionnaire survey using a case vignette was conducted among physicians (Japan, n = 53; UK, n = 85; USA, n = 85) who treat eating disorders.ResultsA total of 23% of physicians in Japan, 32% in the UK, and 35% in the USA reported that they believe patients with AN lack the capacity to make appropriate decisions. Physicians who considered patients with AN to have an impaired mental capacity placed significantly more emphasis on the level of psychopathological values, which are values caused by AN (and can be changed by recovery) that affect the ability to be rational, when assessing the mental capacity of these patients. Conversely, physicians who considered patients with AN to have full mental capacity placed significantly more weight on the ability to express a choice or preference.ConclusionsIt may be necessary to add the level of psychopathological values to the assessment of the mental capacity in relation to obesity fears and emotional disturbances of Patients with AN because emotions caused by psychopathological values strongly influence decision-making. By considering the level of psychopathological values, it may be feasible to reflect the actual situation during the assessment of the mental capacity of those who refuse AN treatment, thus making it more likely to overcome ethical dilemmas.

182 Mental capacity assessment: a descriptive, cross-sectional study of what doctors think, know and do

BackgroundThe Mental Capacity Act (MCA) (2005) was enacted in 2007 in England and Wales, but the assessment of mental capacity still remains an area of professional concern. Doctors’ compliance with legal and professional standards is inconsistent, but the reasons for poor compliance are not well understood. This preliminary study investigates doctors’ experiences of and attitudes toward mental capacity assessment (MCAx).MethodsThis is a descriptive, cross-sectional study where a two-domain, study-specific structured questionnaire was developed, piloted and digitally disseminated to doctors at differing career stages employed in a large, multi-site National Health Service Trust in London over 4 months in 2018. Descriptive statistics and frequency tables adjusted for missing data were generated and secondary analysis was conducted.ResultsParticipants (n=92) were predominantly UK trained (82%), female (58%) and between the ages of 30 and 44 years (45%). Less than half (45%) of the participants reported receiving formal MCAx training. Only one-third (32%) of the participants self-rated themselves as very competent (29%) or extremely competent (4%). Self-reported MCA confidence was significantly affected by career stage with Consultants with over 10 years of experience reporting lowest confidence (p=0.001).ConclusionsThis study describes significant variation in practice by doctors and low self-confidence in the practice of MCAx. These results raise concerns that MCAx continues to be inconsistently performed by doctors despite appropriate awareness of the law and professional guidance on best practice.dexter.penn.14@ucl.ac.uk

781 IMPROVING THE QUALITY OF DO NOT ATTEMPT CARDIO-PULMONARY RESUSCITATION (DNACPR) FORM COMPLETION

Abstract Introduction The completion of a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form represents an important part of patient care. However, this can be a sensitive process that has gained national media interest. The aim of this Quality Improvement (QI) Project was to improve the quality of DNACPR form completion in a Care of the Elderly Department. Methods The QI project ran from May 2019 to January 2021 and was overseen by a multi-disciplinary team (including patient representation). DNACPR forms on the Care of the Elderly wards were audited monthly against 7 standards which correspond to key sections on the DNACPR form. During the data collection process, interventions were implemented using Plan-Do-Study-Act cycles. Interventions included: appointing ‘DNACPR Champions’ to complete monthly audits and provide personalised clinician feedback, the introduction of a new mandatory e-learning module, the creation of an alert system on nerve centre (the Trust’s electronic handover system) and the development of new DNACPR patient information including webpage development, videos and leaflets. Results The project has led to sustained improvements in majority of the 7 standards. The biggest improvements were seen in the inclusion of a review date, correct completion of the mental capacity assessment and the use of patient information leaflets. The documentation of discussions with patient and relatives remained below the audit standards and was largely unchanged during the QI project. Conclusion A multi-disciplinary and multi-faceted QI approach has shown to improve the quality of DNACPR form completion. Further work is needed to continue this process and a focus on staff training and ward-level processes will be the priority.

Mental Capacity Assessment, LPA, Court Appointed Deputy Application, and Ethical Issues related to Mental Capacity Act – 2022 UPDATE

Mental Capacity Assessment, LPA, Court Appointed Deputy Application, and Ethical Issues related to Mental Capacity Act – 2022 UPDATE

Interface of Law and Psychiatric Problems in the Elderly.

Interface of Law and Psychiatric Problems in the Elderly.