The Mental Capacity Act 2005 (England and Wales) is a framework to empower and protect people who through established lack of mental capacity are unable at times, to make some decisions about themselves.
In this post I will consider major decisions relating to health care treatment.
I would recommend you visit http://www.publicguardian.gov.uk/mca/mca.htm which provides a comprehensive, easily read and understood view of the act.
All the residents in my workplace have care plans covering The Mental Capacity Act and where needed, care plans covering Best Interests. These are evaluated monthly and reviewed half yearly,
However, we have been requested by our local PCT to assess the residents again, its purpose purely that of Anticipatory Care Planning and - as it appears to us - its desired goal that every resident will have an Advance Decision to Refuse Treatment in place.
The following principles are covered in The Mental Capacity Act 2005:
- 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 him do so have been taken without success.
- A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
- An act done, or the decision is made, under the Act on or behalf of a person who lacks capacity must be done, or made, in his best interests.
- Before the act is done, or the decision is made, regard must be had as to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action.
The test of capacity looks at whether the person has an impairment of the mind or brain, or if there is some sort of disturbance affecting the way their mind or brain works. Whether this impairment of disturbance is temporary or permanent does not matter. It is whether the impairment of mind or brain means that the person is unable to make the decision in question at the time it needs to be made.
The functional test looks at whether the resident can:
- Understand information about the decision to be made.
- Retain the information in their mind,
- Use or weigh that information as part of their decision-making process.
- Communicate their decision (by talking, using sign language or any other means.
I work in a mental health environment, so do not pretend to understand how Anticipatory Care Planning is viewed in a general nursing setting. I can only express views on what I know.
Our residents are a mix of age related dementia's, alcohol related dementia's, acquired brain injuries, organic brain syndromes and enduring mental health problems. The ages of some of our residents would frighten you! You do not have to be old to live in nursing/residential care!
I worry that these vulnerable folk are being gently pushed into making a decision that may result in an untimely death and that it is purely a cost saving/hospital bed freeing exercise.
Consider (3) of the principles of the MCA - a person is not to be treated as unable to make a decision merely because he makes an unwise decision. If a decision can only be one of "Yes, I will sign up to a ADRT" or "No! I won't!" - which is the unwise decision?
Consider sweet little Ethel who happily signs her own death warrant - just to please! She has not considered death, but has succumbed to suggestions that she does not want to die in pain or become a burden on her family; but she really doesn't want to die and has no idea of the ramifications of the document she has just signed.
Consider Fred who has an acquired brain injury with resulting dysthymia. Fred often states that he wishes he was dead - but there is no suicidal ideation. On the day he signs up to an ADRT he certainly does have mental capacity - but he is depressed; due to his depression we come back to principle (3) - is it a wise or unwise decision. Would he make the same decision tomorrow if he is not depressed?
The permutations of why decision making is wrong - if making a decision in a vacuum - are endless!
The Mental Capacity Act came into force to protect the vulnerable - not to be used as a tool to engage the vulnerable into signing their own death warrants!
The next post will look at the Liverpool Care Pathway.