What does it mean when somebody says “He/She has no capacity”
Mental Capacity Act ensures rights of those being cared for in the hospital. It protects and empowers patients who may lack the mental capacity to make specific decisions surrounding their health and wellbeing. It also creates responsibilities to those providing care and in doing so, prevents the vulnerable from being neglected, abused or ill-treated.
There are clinical conditions in which one’s capacity to make decisions may be compromised. For example Dementia, Mental Health Illness, Brain injury or a learning disability, however the capacity to make decisions may vary depending on what the decisions is for. An individual may have the capacity to decide on their financial affairs but they may lack the capacity to make decisions on their discharge from hospital or their treatment.
Hence why, Mental Capacity Act exists to ensure patients are protected.
Mental Capacity Act
delineates these 5 principles
1. Assume A Person Has The Capacity To Make A Decision Themselves, Unless It's Proved Otherwise
82 year old male admitted with a fall or 62 year old female admitted with chest infection – you will need to assume that they have the capacity to make decisions relating to their care unless if they have other co-morbidities or their current unwell state is rendering them to have no capacity.
2. Wherever Possible, Help People To Make Their Own Decisions
Provide as much relevant information as possible, give them alternatives, the risks and benefits of a particular decision, utilise different means of communication, identify the best time of the day to assess their capacity
3. Do Not Treat A Person As Lacking The Capacity To Make A Decision Just Because They Make An Unwise Decision
76 year old gentleman admitted with a fall, deconditioned due to lack of mobility, now has developed moderate oropharyngeal dysphagia and is at risk of aspiration if he drinks normal fluids. He has been advised to drink thickened fluids. Upon assessing his capacity, he understands the information given to him, the risks and the benefits, alternatives etc, however he still decides to go against this advice because he reports
“thickened fluids are unnatural” – he may have the capacity but he would be making an unwise decision.
4. If You Make A Decision For Someone Who Does Not Have Capacity, It Must Be In Their Best Interests
You should include whatever information/people is necessary to ensure the decision is in their best interest, i.e., when deciding where would be the best place for the patient to be discharged to.
5. Treatment And Care Provided To Someone Who Lacks Capacity Should Be The Least Restrictive Of Their Basic Rights And Freedoms
Considering discharging a patient home with a package of care in place as opposed to a Nursing/Care Home as it is the least restrictive but safest option for them.
How To Assess For Mental Capacity?
When assessing for mental capacity, you need to follow these steps:
- Provide information surrounding the decisions they need to make
- Provide risks and benefits
- Ask them to re-iterate what is it that they understood from your conversation
- Assess whether or not they can relay the information back to you
- Ask what their opinion/decision of the matter is?
A person is said to have NO CAPACITY (unable to make a decision) if they:
- Cannot understand the information relevant to the decision
- Cannot retain that information
- Cannot use or weigh up that information as part of the process of making the decision
- Cannot communicate the information back to you
Deprivation Of Liberty Safeguards
Deprivation of Liberty Safeguards or “DOLS” is a part of the MCA. On occasions, you may encounter a patient who may lack capacity and there may be a situation when it is necessary to deprive a person of their liberty as long as it is in their best interest. This may include restriction and restraint to prevent harm, however this DOLS needs to be authorised by the local authority upon assessment.
Doctors should fill in a form. Each DOLS last for 7 days and it must be reviewed.
Lasting Power Of Attorneys (LPA)
To summarise, patients may have LPAs for various things, e.g. LPA for finance, LPA for health and wellbeing, or LPA for both. This means that the person is hospital has nominated one of his relatives to make decisions about their health and welfare. As doctors, we are more interested in LPA for health and wellbeing as this means that we have to involve this individual in all clinical decisions.
Independent Mental Capacity Advocate (LMCA)
These are independent individuals who step in, in the decision-making process for the patient who lacks capacity and who has nobody to support and represent them.