nhs, Uncategorized

Everybody’s Talking (at me…)

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I’m stuck. How to I get people to assess and document mental capacity?

This is something I have been struggling with for a few years now.  I know I’m not alone either.

In last weeks blog I alluded to the fact that part of the Older People in Acute Care inspection focused on mental capacity documentation.  I also spoke about how nursing staff were being held to account for it when it is medical staff who are responsible.

I also came across this tweet by the British Geriatrics Society (@GeriSoc):

‘Some pts in hospital for ages, have multiple procedures, before capacity finally questioned only because they want to go home! #bgsconf‘ 

This is a situation I have been witness to repeatedly.

How can we be striving for person centred care and yet the most fundamental aspect of this is not addressed?

It was therefore fortuitous that I was asked to present to our Clinical Governance Board on this topic.  So with the question twirling in my brain of how to improve it I started with some basic education.

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Does this person have capacity?  What about the others….?

Now the first thing I had to do was make an assumption that the people sat in the room had capacity.  That’s how we should approach the assessment of anyone we see in hospital, clinic or at home.  They should have a broad understanding of what is wrong with them, the treatment offered and what would happen if they refused treatment.  They also have to be able to communicate this decision and we should help facilitate this if they are unable.

I quickly ascertained that my audience was full of mentally competent people who were keen to hear what I had to say.

I moved onto what is meant by mental capacity.

Just because you can make bad choices it does not mean you lack mental capacity.  You just have to explore the reasoning behind why they believe what they do.

Mental capacity can also be fluid.  This is true in the case of the person with delirium. As the condition fluctuates there can be times when the person is lucid but at other times they can be confused and/or hallucinating.

Finally mental capacity is task specific.  This is of particular importance in the person with dementia.  They may be able to understand the need for treatment for a chest infection but lack insight regards their own safety at home.

So how can we maximise the decision making ability of the person?  Well first you have to have enough time to go through things, including time to re-assess where necessary.  You need peace and quiet.  The person should have every possible chance to use what capacity they do have. That means put their glasses on, check that hearing aids work, have written information available and allow family members or carers to be present.

Lastly I have spoken about mental capacity in relation to medical treatment.  There is a whole other aspect to it that encompasses decisions pertaining to financial and welfare matters.

With all this to consider is it any wonder that mental capacity is a complex and time consuming process?

So back to my question – how to engage people with it?  I personally think we need a much broader range of people trained in the assessment of mental capacity.  I think our nursing staff have much to offer in this area and I would welcome any thoughts or comments around this.

I also think we need to ensure that medical staff are properly educated.  It is a daunting topic but one that is relatively straight forward to understand if taught well.

Meantime I draw parallels with DNACPR discussions and documentation in terms of importance and the legal aspect.  We would not dream of having a conversation around treatment escalation/resuscitation and not document it.  Why do we not apply the same level of importance to a person’s mental capacity?

It makes no sense….!

3 thoughts on “Everybody’s Talking (at me…)”

  1. Of all the professions it’s actually nurses that need capacity assessed most e.g. to give medication, to catheterise someone, to put up a drip etc

    Traditionally it’s been the medic who has competed the assessment, which leaves some staff saying it’s a doctors job and we’re too busy. The lack of understanding of whose job it is is rooted in what has gone before.

    However, of nurses do take on this additional role where will he capacity to assess capacity come from – as you’ve said, it’s a time consuming process to be done properly and time doesn’t grow on trees!

    Keep asking the questions.

    DTB

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    1. Thanks for this. I agree regards the nurses having the biggest need for capacity assessment. The entire NHS would grind to a halt if ‘fundamental needs’ were unable to be carried out if no assessment has been done (not that I’m suggesting this).
      More people trained/allowed to do this I think is key.

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  2. I agree that the mix of assessment of cognitive function and capacity are usually oversimplified into a single point process, rather than being more continuous and nuanced. Add assessment of delirium into the mix of cognitive function and capacity and the situation starts to cause a headache to many practitioners including me.

    I I love using this paper by Donald Lyons, it’s a bit old now, but still good, and has some great cases examples. It’s great for ‘teaching’ staff and even patients and relatives.

    https://www.rcpe.ac.uk/sites/default/files/lyons.pdf

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