Friday 23 July 2010

The Mental Capacity Act 2005 and Best Interests

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 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:

  1. A person must be assumed to have capacity unless it is established that they lack capacity.
  2. 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.
  3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
  4. 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.
  5. 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:

  1. Understand information about the decision to be made.
  2. Retain the information in their mind,
  3. Use or weigh that information as part of their decision-making process.
  4. 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.

Anna G.

Saturday 10 July 2010


'How people die remains in the memory of those who live on.'
Dame Cicely Saunders, founder of the Modern Hospice Movement.

Part two considers aspects of the content of The Department of Healths End of Life Care Strategy. It is far too lengthy a document to condense down all the information in it, therefore I have selected points which I consider salient.

I would recommend you read it in its entirety and you will need to download End of Life Care Strategy (PDF, 781K) at

Personal observations are written in red.

End of Life Care Strategy.

Chapter 1: The challenge of end of life care.

1.29 The main aims of the NHS End of Life Care Programme were:

  • To encourage local adoption and development of end of life care models to address the needs of the local population, in particularly the Gold Standard Framework (GSF), Liverpool Care Pathway for the Dying Patient (LCP) and Preferred Priorities for Care (PPC) see chapters 3 and 4; and
  • To encourage Care Homes in improving end of life care. though adaptions of these models (see chapter4).
The NHS End of Life Care Programme has exceeded its aims in every setting. However coverage levels for January 2008 shows much more needs to be done.

The above it itself appears laudable; an opportunity to plan future care at end of life - but it worries the hell out of me and why will become clear in this and future posts.

Chapter 3: The end of life care pathway.

Trajectories of decline at the end of life.


  • Some people with long term health conditions remain in reasonably good health until shortly before their death, with a steep decline in the last few weeks or months of life. Others will experience a more gradual decline, interspersed with episode of acute ill health from which they may, or may not recover. A third group are very frail for months or years before death, with a steady progressive decline.
  • These three patterns or trajectories are illustrated in Figure 1. Some authors have suggested that the first pattern may be typical of cancer, the second may be typical for people with organ failure (e.g. those with heart failure or chronic obstructive pulmonary disease), and the third may be typical for people with dementia.
Now this is where I become more worried. I am thinking especially of groups two and three who have an ADRT in place.
Group two who experience 'episodes of acute ill health from which they may, or may not recover.' This statement implies that life or death outcomes may be very much dependent on severity and treatment. ADRT in place - no treatment = death! No chance to recover!
Group three: little gran with a RTI and in difficulty, but could recover. ADRT in place - no treatment = death! Dementia comes in many forms and consider X who is forty-nine and has pre-senile dementia. Consider Y who has another form of dementia and is thirty-six, and whose condition will remain stable for the rest of his/her natural lifespan. Both have a moderate amount of memory loss and associated apathy - but continue to operate at a level where their life still has obvious quality. Whatever condition they may present with in the future - I am not talking end-stage illness here - requiring treatment to sustain life; they will be denied it if an ADRT is in place. They will have signed their own death warrants.
Rant over! I did intend to write more - but I think this is enough.
Part three will cover Mental Capacity and the Mental Capacity Act 2005.
Anna G.

Thursday 8 July 2010

Just to let you know!

I think that before I continue with my posts re Anticipatory Care Planning, I should declare that I am not anti-GP/doctor, as it might appear at times that I am.

Care homes receive a bad press and according to the CQC, this is well deserved in an estimated twenty-five percent of all homes. This figure is of course shocking! I would urge any GP who has concerns re the care in care homes to first approach the manager and discuss their fears, and if they feel this has had no effect, to report concerns to the CQC.

The only way we can effect change is to speak out!

Possibly, because all care homes appear to be regarded as profit led hell-holes where the elderly are left to stew in their own body fluids, many GPs take a dim view of us and present with an antagonistic approach to staff.

I also believe that some GPs do not really understand the reality of living with dementia, and how it affects the sufferer and those around them. Twenty-fours hours is a big difference from a practice consultation or a home visit. Care homes have many residents, all with their own idiosyncratic presentations. I am sure at times that even in excellent homes - when conflict occurs between residents (which sometimes happens), visitors may perceive this as lack of care.
The only way to prevent this is to drug the residents up to the eye-balls or somehow restrain them in a chair!

My home is served by several GP practices. Most regard us with disdain and a few of these GPs are so skilled they can diagnose from a doorway! See a patient with 'management problems' - doorway diagnosis! The other GPs are excellent and we work together for the benefit of the resident. If we lack knowledge of a particular condition - we can ask for information without embarrassment, and they will kindly educate us.

The OOH GPs are to be commended for their approach to the the residents and their willingness to listen to staff. No complaints here, but this has not always been the case. This change may be due to the unfortunate incident re Dr. Ubani - but I do not know for certain.

Please GPs, realise that care homes do not have an in-house doctor; nor do we nurses profess to have a doctors knowledge base. We need your help, and more importantly, so do our residents.

It is sadly the case in some instances, that nurses are regarded as non-entities by some GPs. A doctor friend once said to me: "Anyone on a pedestal in medicine shouldn't be in medicine, and I think we need to get back to appreciating one another and enjoying our interaction with patients."

Nothing more need be said!


Sunday 4 July 2010



At the beginning of the twentieth century, the period of life expectancy at birth was around 48.5 for males and 50.4 for females.

The period of life expectancy at birth in the United Kingdom, as per the United Nations (2005-2010) is now 77.2 years for males and 81.6 years for females.

With advances in medicine and a resulting reduction in infant mortality; availability of treatment; better diets and decreased poverty - people are living longer.

According to there were 20 million people aged fifty and over in the UK in 2003. This was a 45% increase from 13.8 million in 1951. The projected increase by 2031 is a further 36%, with an estimated 27.2 million aged fifty and over.

An aging population equals a higher propensity to long term medical conditions - many of whom don't realise that some of these conditions are terminal. However - again according to government statistics - consider themselves to be in good health, even if they have a long term illness that restricts their daily activities.

Unfortunately, an aging population is regarded as a burden on the state. Despite the fact that they contributed to the system - they were not expected to live so long, and therefore - to take so much out of it.

It has therefore become necessary to initiate culling strategies. First there came the Liverpool Care Pathway (LCP) - which I am sure was formulated with the best on intentions (and I will blog about it on a later date) - and now there is the push towards Advance Decisions to Refuse Treatment (ADRT). As stated - both devised with the best of intentions - but both are wide open to abuse.

A number of my colleagues recently attended a PCT meeting re Care Planning at the End of Life. Its secondary title was "Anticipatory Care Planning in Care Homes." Its prime aim is to enforce as a requirement, the implementation of ADRT.

" ************* Care Homes Project.

The project has three main strands:
  1. Link GPs - the development of a Link GP role whereby a dedicated GP is contracted to work with each participating care home. The role is to support the care home in the implementation of clinical policies and procedures and to support and encourage the home to adopt clinical guidelines that are discussed during educational sessions
  2. Educational Programme - eight sessions over the course of twelve months, designed for care home staff and the Link GPs. The meetings will include anticipatory care planning, end of life care, falls and osteoporosis, COPD, chest infections, UTIs, nutrition and wound care.
  3. Anticipatory Care Planning - Link GPs will work with patients in care homes to develop anticipatory care plans in association with their families and care home staff."
The above may appear quite a breakthrough - GPs actually wanting to work with care homes (!) - but it is not!

The whole affair is quite scary and we fear that it is a further nail in the coffins of the elderly. When we first had experience of the LCP - we thought it a wonderful, caring thing that enabled the dying a pain free release. Now we can state (with an almost 95% degree of certainty) which residents admitted to hospital (GP initiation) with a RTI, will return home to us and who will be placed on the LCP! This knowledge is not based on the fact that we know that resident A is sicker than resident B; it is dependant on the support system of their NOK primarily and other known factors.

More to follow.......

Anna G.

Friday 2 July 2010


The Telegraph on line reports that Wythenshawe Hospital in Manchester is to put doctors and nurses in charge of running the hospital!

The twenty-six departments are to be replaced by nine new ones. All new departments will have a medical consultant at the helm, supported by a nurse and a manager. The consultants will spend 80% of their time on medical duties and the remaining 20% running the department.

The University Hospital of South Manchester Trust has agreed a contract with Manchester Business School to provide the necessary management training for the docs.

Brilliant news and it appears that our coalition government are living up to their promises in "empowering professionals to deliver better outcomes for patients."

For the full story see

Anna G.