Assessment Of Mental Capacity Research Articles

How do health and social care professionals in England and Wales assess mental capacity? A literature review

Purpose: To review evidence describing how health and social care professionals in England and Wales assess mental capacity, in order to identify ways to improve practice.Methods: A systematised literature review was completed. Electronic databases of published medical, health and social care research and gray literature were searched. Journal articles and research reports published between 2007 and 2018 were included if they met predefined eligibility criteria. Evidence from included studies was synthesized using thematic analysis.Results: 20 studies of variable methodological quality were included. The studies described assessments carried out by a range of multidisciplinary professionals working with different groups of service users in diverse care contexts. Four main themes were identified: preparation for assessment; capacity assessment processes; supported decision-making; interventions to facilitate or improve practice. There was a lack of detailed information describing how professionals provided information to service users and tested their decision-making abilities. Practice reported in studies varied in terms of its conformity to legal requirements.Conclusions: This review synthesized evidence about mental capacity assessment methods and quality in England and Wales and analyzed it to suggest ways in which practice might be improved.Implications for rehabilitationMental capacity assessment practice in England and Wales varies and is not always consistent with legal requirements, risking inconsistent and inaccurate judgements about capacity and exposure to legal action.Interventions have been developed to help professionals to engage in supported decision-making, and improve their mental capacity assessments and documentation in line with legal standards.These interventions include training and practical resources, such as assessment flowcharts, checklists and documentation aids. Such interventions would benefit from robust evaluation before they are implemented more widely.

Improving mental capacity assessments

People have the right to take their own decisions wherever possible. But assessing mental capacity correctly is not always easy, especially in older people. Chloe Ablett and colleagues discuss the implementation of legal protections and make recommendations.

Zwangsbehandlung in der Psychiatrie und Selbstbestimmungsfähigkeit: Anthropologie einer Grenzbegegnung

Whereas from a professional point of view, a medical treatment might seem necessary, this treatment might be refused by the patient. In such cases, the patient's ability to determine his will is the key. Any substitutive medical decision is justified by a specific normative framework. The dialectic between a patient's inability to determine his will and the conviction of physicians about the necessity of a medical intervention is reformulated from a medical-anthropological point of view. This dialectic leads to a substitutive decision-making on the basis of a presumed will beyond the elemental will due to the breakdown of mental capacity/legal competence. After bracketing out legal concepts, assumptions mirroring canonical conceptions of individual autonomy are carved out. Then the medical encounter involving medically necessary treatments rejected by the patients is analyzed from an anthropological point of view. Hereby, both i) the asymmetry in the understanding and implementation of necessary medical measures, and ii) the emotional resonance capability between physician and patient are discussed. Based on these observations, a criticism of a solely individualistic conception of the mentally ill without any consideration of social interconnections will be developed. Finally, criteria for the assessment of mental capacity as well as for a pragmatic and prudent decision-making under uncertainty are proposed. Mental capacity and legal competence as normative concepts mean the autonomy to act towards sustainable self-care. It can be understood as the competence of judging one's own intentions; this competence includes the balanced interpretation of contingencies and forecasting the scope of consequences. The canonical dialectic between self-sufficiency (corresponding to mental capacity) and subsidiarity (according to substitutive decisions) is based, within the framework proposed here, on treatment asymmetry and personal resonance. When considering substitutive decisions, the relevant social micro systems the patient is embedded in should be taken into account. The anthropological examination of the dialectic between autonomy (based on mental capacity) and substitutive decisions leads to a reflection on individual decision-making with uncertain denouement rather than unequivocal, categorical solutions. All stakeholders and relevant others should be taken into account in the decision-making process.

Advance Care Planning for Older People with Cancer and Its Implications in Asia: Highlighting the Mental Capacity and Relational Autonomy.

With dramatically increasing proportions of older people, global ageing has remarkably influenced healthcare services and policy making worldwide. Older people represent the majority of patients with cancer, leading to the increasing demand of healthcare due to more comorbidities and inherent frailty. The preference of older people with cancer are often ignored, and they are considered incapable of making choices for themselves, particularly medical decisions. This might impede the provision of their preferred care and lead to poor healthcare outcomes. Advance care planning (ACP) is considered an effective intervention to assist older people to think ahead and make a choice in accordance with their wishes when they possess capacity to do so. The implementation of ACP can potentially lead to positive impact for patients and families. However, the assessment of mental capacity among older adults with cancer might be a crucial concern when implementing ACP, as loss of mental capacity occurs frequently during disease deterioration and functional decline. This article aims to answer the following questions by exploring the existing evidence. How does ACP develop for older people with cancer? How can we measure mental capacity and what kind of principles for assessment we should apply? What are the facilitators and barriers when implementing an ACP in this population? Furthermore, a discussion about cultural adaptation and relevant legislation in Asia is elucidated for better understanding about its cultural appropriateness and the implications. Finally, recommendations in relation to early intervention with routine monitoring and examination of capacity assessment in clinical practice when delivering ACP, reconciling patient autonomy and family values by applying the concept of relational autonomy, and a corresponding legislation and public education should be in place in Asia. More research on ACP and capacity assessment in different cultural contexts and policy frameworks is highlighted as crucial factors for successful implementation of ACP.

Tools for testing decision-making capacity in dementia.

dementia is a common cause of altered decision-making capacity. Determining whether an individual has the ability to make a specific decision can be very challenging for both clinicians and researchers. The UK legislation requires that we both promote residual capacity where possible, and protect vulnerable adults who cannot make independent decisions. We evaluated published instruments designed to aid in the assessment of capacity, focussing on those meeting the UK legal requirements. We also consider further disease and culture-specific factors which may influence decision making. a search of electronic databases was made for articles published between 2000 and 2017 detailing structured tools for the assessment of mental capacity. These were evaluated against the UK legal requirements. nine tools were identified which fulfilled the UK legal requirements. Their design and structure varied, as did the level of reliability and validity data available. Some instruments can be tailored for a specific decisional scenario, whilst others are designed for use by particular patient groups. a wide range of mental capacity assessment instruments is available, but not all fulfil the UK legal requirements. Healthcare professionals and researchers should be mindful of personal, cultural and disease-specific factors when assessing capacity. No gold standard for capacity assessment exists, which hampers the evaluation of different approaches. A combination of the opinion of a healthcare professional or researcher trained in capacity evaluation, plus the use of a structured assessment tool is the most robust approach.

An evaluation of functional mental capacity in forensic mental health practice: the Dundrum capacity ladders validation study

BackgroundBecause of the potential gravity of finding a person incompetent, assessment of mental capacity is challenging for clinicians. We aimed to test validity of a new structured professional judgement tool designed to assess functional mental capacity in three domains – finances, welfare and healthcare.MethodsFifty-five male forensic psychiatric patients with Schizophrenia were interviewed using the Dundrum Capacity Ladders – a new semi-structured interview, and scores were assigned on a stratified scoring system, measuring ability to understand, reason, appreciate the personal importance of the decision at hand and communicate a decision. Data were also gathered pertaining to level of therapeutic security at the time of interview, diagnosis, neurocognitive function and a validated measure of real world function.ResultsThe results show that internal consistency and inter-rater reliability were high for all items. There were correlations between higher scores of functional mental capacity, neurocognitive function and measures of real world function in this population. Correlations were in the range 0.358 to 0.693, effect sizes that were moderate to high.ConclusionsThe DUNDRUM Capacity Ladders appear to be a valid measure of functional mental capacity in this population. Further prospective studies of functional mental capacity as a measure of recovery are now required.

Assessment of mental capacity to consent to treatment in anorexia nervosa: A comparison of clinical judgment and MacCAT-T and consequences for clinical practice

Informed consent requires adequate mental capacity to consent to treatment. Mental capacity (MC) to consent to treatment refers to the ability to make medical decisions. MC is assessed in a general psychiatric interview, but this clinical assessment is known to overestimate mental capacity in patients and the inter rater reliability is low. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) has emerged as the gold standard to assess mental capacity to consent to treatment. The MacCAT-T is a semi-structured interview designed to aid clinicians in this assessment and has shown good inter rater reliability in patients with schizophrenia and other mental disorders, but has hardly been studied in patients with anorexia nervosa. Patients with anorexia nervosa (AN) regularly avoid treatment, even when severely ill and discussion includes assessing MC to consent to treatment.The aim of this study is to compare clinical judgment and the MacCAT-T in evaluating MC in patients with AN which in turn may influence use of the MacCAT-T in daily practice.In a sample of 70 consecutively referred severely ill patients with AN with a mean BMI of 15.5 kg/m2 and a mean duration of illness of 8.6 years, clinical assessment of MC by experienced psychiatrists and the outcome of the MacCAT-T interview were compared. Agreement (κ-value) was calculated. Agreement between clinical assessment and outcome of the MacCAT-T was questionable (κ 0.23). Unlike in other psychiatric populations, clinicians judged a high proportion of patients with AN as having diminished MC. The MacCAT-T can be useful in assessing MC in AN when used in addition to clinical judgment to aid clinicians in complex cases. Why clinicians judge a relatively high proportion of patients with AN as having diminished MC, in contrast to lower proportions in other psychiatric disorders, is an area in need of further research.

National survey of training of psychiatrists on advance directives to refuse treatment in bipolar disorder.

Aims and method To determine features associated with better perceived quality of training for psychiatrists on advance decision-making in the Mental Capacity Act 2005 (MCA), and whether the quality or amount of training were associated with positive attitudes or use of advance decisions to refuse treatment (ADRTs) by psychiatrists in people with bipolar disorder. An anonymised national survey of 650 trainee and consultant psychiatrists in England and Wales was performed.Results Good or better quality of training was associated with use of case summaries, role-play, ADRTs, assessment of mental capacity and its fluctuation. Good or better quality and two or more sessions of MCA training were associated with more positive attitudes and reported use of ADRTs, although many psychiatrists would never discuss them clinically with people with bipolar disorder.Clinical implications Consistent delivery of better-quality training is required for all psychiatrists to increase use of ADRTs in people with bipolar disorder.

Legal capacity of persons with disabilities in Ethiopia: The need to reform existing legal frameworks

The Convention on the Rights of Persons with Disabilities (CRPD) prohibited deprivation legal capacity of persons with disability based on assessment of mental capacity. The assertion is that, persons with disabilities shall exercise their legal capacity in all aspects of life without any restrictions that are based on mental incapacity (such as, unsoundness of mind, deficit in mental capacity, dotage, etc. This approach signifies a shift from substituted decision making, where another person act on behalf of persons with mental disabilities, to supported decision making where the person with mental disability is assisted in decision making. The rationale for the move lies on the recognition that the right to legal capacity embodies the inherent meaning of what it meant to be human. Without legal capacity a person cannot exercise all other rights and entitlements. Accordingly, States parties to CRPD are required to reform domestic legislations that are based on substituted decision making model and recognize full legal capacity of persons with disabilities in line with supported decision making model. As a Sate party to CRPD, Ethiopia assumed the same obligation. Nonetheless, in its initial report to the Committee on CRPD, the country denies existence of legislation that restricts legal capacity on the grounds of mental incapacity. This research found out that there are restrictions imposed on legal capacity of persons with disabilities on the basis of mental incapacity/disability. The research analyzed the approach employed to restrict legal capacity under the existing legal frameworks of Ethiopia vis-à-vis supported decision-making regime under CRPD. The research is doctrinal and, as such, limited to content analysis of general and specific legal capacity laws of the country (such as, marriage, divorce, will, work and employment, political participation, access to justice and others).

Reduced 30-day gastrostomy placement mortality following the introduction of a multidisciplinary nutrition support team: a cohort study.

Percutaneous endoscopic gastrostomy feeding allows patients with dysphagia to receive adequate nutritional support, although gastrostomy insertion is associated with mortality. A nutrition support team (NST) may improve a gastrostomy service. The present study aimed to evaluate the introduction of a NST for assessment and follow-up of patients referred for gastrostomy. We included adult inpatients referred for gastrostomy insertion consecutively between 1 October 2010 and 31 March 2013. During the first 6months, a multidisciplinary NST assessment service was implemented. Patient characteristics, clinical condition, referral appropriateness and follow-up were documented prospectively. We compared the frequencies of appropriate referrals, 30-day mortality and mental capacity/consent assessment time spent between the 6months implementation phase and 2years following establishment of the assessment service ('established phase'). In total, 309 patients were referred for gastrostomy insertion and 199 (64%) gastrostomies placed. The percentage of appropriate referrals rose from 72% (61/85) during the implementation phase to 87% (194/224) during the established phase (P=0.002). Thirty-day mortality reduced from 10% (5/52) to 2% (3/147) (P=0.01), whereas time allocated to assessment of mental capacity and attainment of informed consent rose from mean 3days (limits of normal variation 0-7) to mean 6 (0-13) days. The introduction of a NST to assess and select patients referred for gastrostomy placement was associated with a rise in the frequency of appropriate referrals and a decrease in 30-day mortality following gastrostomy insertion. Concomitantly, time spent on patient assessment and attainment of informed consent increased.

From dispassionate law to compassionate outcomes in health-care law, or not

AbstractHealth-care law presents numerous challenges to the conception of the law as a dispassionate arbiter of disputes or protector of rights. Issues relating to end-of-life care, the assessment of mental capacity and decision-making for those who lack capacity, amongst others, epitomise the complex nature of health-care law. They also raise globally applicable questions about discrimination, or equal protection, as well as concerns for relief of suffering, the assessment of best interests and the exercise of individual autonomy. This paper will evaluate the extent to which law's traditional objectivity (dispassion) is undermined by the introduction of concerns about compassion into judicial and executive decisions. Focusing primarily on the law in England and Wales, but with reference to multi-jurisdictional case-law and international instruments, it will consider whether the law provides compassionate approaches and outcomes in end-of-life decision-making, and the implications of compassion for legal certainty.

A preventable death? A family’s perspective on an adult safeguarding review regarding an adult with traumatic brain injury

Purpose The purpose of this paper is to review the care management of a man with a traumatic brain injury (TBI) from a family member’s perspective. Design/methodology/approach The paper provides a case history of “Tom” both prior to his TBI and after. Findings Tom was the subject of a safeguarding adults case review in Somerset following his death in 2014. Ultimately the paper highlights the shortcomings and failures in the care Tom received by various organisations which ultimately contributed to his suicide. Practical implications The paper highlights the need for more effective communication between professionals managing the care of those with TBI. Furthermore, professionals need training in the need for mental capacity assessments and improved safeguarding and risk assessments with adults with TBI. Originality/value This paper provides insight into the needs of an adult with TBI from the perspective of a family member who is also a trained psychologist.

Improving capacity and consent to treatment recording in psychiatric inpatient wards: A multi-centre quality improvement project

Assessment of mental capacity provides an ethical and legal framework for care which values patients' autonomy whilst recognising the instances where it is appropriate to act in patients' best interests.Existing...

An exploration of mental capacity assessment within acute hospital and intermediate care settings in England: a focus group study

Purpose: To explore approaches to the assessment of mental capacity within acute hospital and intermediate care settings in England.Methods: Two focus group interviews were conducted with multidisciplinary staff (n = 13) within a large hospital trust. Data were analysed using a Framework approach.Results: Three main themes were identified: (i) the assessment process; (ii) staff experience of assessment; (iii) assessing capacity for patients with communication difficulties. Staff identified the main patient groups, patient decisions and professionals involved in capacity assessment. They described using both formal and informal approaches to assess capacity and specific methods to identify and support the needs of patients with communication difficulties during the assessment process. Most staff reported finding capacity assessment challenging, due to time pressures, a perceived lack of knowledge or skills and encountering practice that is not consistent with legal requirements. Staff stated a need for initiatives to facilitate and improve practice.Conclusions: These findings provide confirmatory evidence that mental capacity assessment is complex and challenging and that staff would benefit from additional support and resources to aid their practice. It provides new evidence about the methods used by staff to assess capacity, particularly for patients with communication difficulties.Implications for RehabilitationThis study contributes to our understanding of how staff assess capacity in hospital and intermediate care settings.Mental capacity assessment is a complex activity and many staff reported finding it challenging.Patients with communication difficulties need additional support during capacity assessments but may not always receive this.Current practice needs to be improved and staff need support and resources to achieve this.

The conduct and process of mental capacity assessments in home health care settings.

The assessment of capacity to consent to treatment is key to shared practitioner-patient decision-making. It is the responsibility of the person closest to the decision being made to carry out the assessment. The aim was to examine the factors that influence mental capacity assessments in home health care settings and identify the facilitators and inhibitors to the conduct and process of assessments as perceived and experienced by non-medical health practitioners providing generalist community services. Semi-structured interviews with a purposive sample of community nurses, community physiotherapists and community occupational therapists in one NHS Trust in London. Data were analysed thematically. The main themes were issues relating to: intrinsic patient factors and behaviours; recognising, managing and utilising the influence of the family; practitioner motivation and competence; working together as a team to optimise shared decision making, and; the importance of place. While some issues appear germane to both hospital and home health care settings, others are unique to - or manifest very differently in - home health care settings. The findings suggest that the influence of family members, long-term practitioner-patient relationships and physical distance from co-workers make the conduct and process of mental capacity assessments in home health care settings an inherently complex endeavour.

Health and social care practitioners’ experiences of assessing mental capacity in a community learning disability team

Accessible summary The Mental Capacity Act says when and how to assess someone's ability to make a decision and how best to support them to do this. Eight workers in community learning disability teams were interviewed about their experiences of assessing people's ability to make decisions. The workers said that there were a number of areas that they felt were important and which helped them to do good assessments. They also said there were some things that they found difficult. We suggest some changes that could be made to help workers when assessing people's ability to make decisions. It is important to help people make decisions for themselves where they can and to help them when they cannot. AbstractBackground: The study explored experiences of health and social care practitioners within a community learning disability team in undertaking mental capacity assessments with people with learning disabilities.Materials and Methods: Eight practitioners were interviewed using a semi‐structured interview schedule.Results: The information gained was analysed using thematic network analysis. Twelve basic themes emerged which fit into five organising themes labelled: ‘systemic barriers to assessment’; ‘capacity assessing as a process’; ‘person‐specific challenges’; ‘protective practices’; and ‘protection of a fundamental human right’. A global theme, ‘freedom of action versus restrictions on action’, was identified.Conclusions: The themes highlighted that there were a range of organisational, systemic and person‐specific factors that impacted on the perceived quality of and assessors’ confidence in their assessments of mental capacity. Furthermore, these factors appeared to create a range of tensions for assessors increasing the likelihood of cognitive dissonance. Practice implications surround maintaining knowledge, ensuring adequate skills in the practical application of knowledge and reducing organisational barriers.

Negotiating the domain of mental capacity

‘The decision on capacity is one for the judge to make’. 1 Deciding whose voices matter in the assessment of someone’s decision-making capacity raises issues of social and legal policy. Despite legal judgments explicitly asserting that the law has the upper hand in mental capacity assessment, both statute and judgments from the Court of Protection (CoP) have to some extent endorsed capacity as largely the domain of medical expertise. Academics have claimed that the courts have historically adopted a ‘deferential’ or even ‘medicalized’ approach to expert evidence on this issue. Yet, it is vital that the CoP exercises rigorous scrutiny of capacity assessment, for while human rights discourse constructs ‘objective medical expertise’ as a safeguard against the arbitrary forfeiture of decision-making power, excessive deference can transform medical opinion from safeguard to a form of arbitrariness in its own right. This short sociolegal study combines quantitative and qualitative approaches to probe this suggestion of deference, drawing from a sample of over 60 CoP judgments where the issue of capacity was examined in some detail. In the course of undertaking this task, the article interrogates the notions of ‘deference’ and ‘medicalization’ to explore the intertwining of medical and legal domains on the issue of mental capacity.

Dangerous Liaisons? Psychiatry and Law in the Court of Protection-Expert Discourses of 'Insight' (and 'Compliance').

A finding that ‘P’ (as the person who is subject to Court of Protection proceedings is known) lacks mental capacity is the trigger for exposing them to decision-making by others and the powers of the Court of Protection (CoP) which, in the words of Justice Hedley, can be ‘invasive and draconian’ (Hedley J in PC v City of York Council cited in [2013] EWCA Civ 478 [13]). Whilst the law asserts the upper hand in the assessment of mental capacity for persons who come before the CoP, it is the discipline of psychiatry, which dominates expert witness testimony in these proceedings. There are a number of implications of allowing psychiatry to dominate this terrain, not least that, as will be argued in this article, clinical discourse, which makes reference to non-statutory terminology such as ‘lack of insight’ and ‘non-compliance’ are imported into the business of capacity assessment. This terminology, if used lazily and without clear reference to the statutory criteria, has the potential to muddy the waters of assessing P’s capacity. At its worst, it can mask value judgements, which threaten to undermine the law’s ‘autonomy promoting’ provisions set out in the Mental Capacity Act 2005. Whilst it is not intended to discredit ‘insight’ as a concept in psychiatry, this article concludes that it has a proper context and that in the mental capacity context, decision-makers, lawyers, and advocates should exercise careful scrutiny of its use, and CoP judgments should carefully interrogate the language imported by expert witnesses.

Assessment of mental capacity: a practical guide for doctors and lawyers (4th edition)

Assessment of mental capacity: a practical guide for doctors and lawyers (4th edition)

Mental Capacity Assessments Among Inpatients Referred to the Consultation-Liaison Psychiatry Unit at a University Hospital in Bangkok, Thailand.

Clinicians routinely assess patients' mental capacity on a daily basis, but a more thorough assessment may be needed in complex cases. We aimed to identify the characteristics of inpatients in a general hospital, who were referred to a liaison psychiatry service for mental capacity assessment, reasons for the referrals, and the factors associated with their mental capacity. A 6-year retrospective study (2008-2013) was conducted using data collected routinely (e.g., age, gender, diagnosis, Thai Mental State Examination score, reasons for the referral, and the outcome of capacity assessment) on referrals for mental capacity assessment to a Consultation-liaison Psychiatry Unit at a university hospital in Thailand. Among 6194 consecutive referrals to the liaison-psychiatry services, only 0.6% [n=37, mean age (SD), 59.83 (20.42)] were referred for capacity assessment, 43.24% of which lacked mental capacity. The most common requests from referring physicians were for assessment of testamentary capacity (15 assessed, 53.33% lacking capacity), financial management capacity (14 assessed, 50% lacking capacity), and capacity to consent to treatment (9 assessed, 22.22% lacking capacity). Delirium, rather than dementia or other mental disorders, was associated with mental incapacity (p<0.001) and being more dependent during the admission (p=0.048). There were no significant differences for mean age (p=0.257) or Thai Mental State Examination score (p=0.206). The main request from referring clinicians was to assess testamentary capacity. Delirium and being more dependent during the admission were associated with lack of mental capacity, whereas age and dementia were not.