using the mental capacity act
DESCRIPTION
The Mental Capacity Act and using it for assessment in a homelessness context. as delivered on April 4th at the LNNM homelessness conference by Paul Emerson, ex-START team and Maxine Radcliffe, Nurse Practitioner at Great Chapel Street Medical CentreTRANSCRIPT
Housing officers Benefits advice
Drug and Alcohol
Services
Day centre teams:
Passage, WLDC CSTM
Social Services, Specialist Midwives
Voluntary sector Night Shelters: SFTS Churches
Other Specialist hospital services
Other Primary
care outside
our clinic
Outreach teams:
CSTM, St Mungos, Compass
JHT
A+E teams/LAS crews
Outreach Nurse/ Case
Manager
My role at Great Chapel Street
Nicholson. T , Cutter. W Hotopf. M (2008)
BMJ Capacity Assessment Flowchart 1
Nicholson. T , Cutter. W Hotopf. M (2008)
BMJ Capacity Assessment Flowchart 2
Why this is important for nurses: My experience
I’ve personally successfully admitted 3 patients from outreach using the capacity act in the last 18 months.
In all three cases the individuals were in ICU/HDU for at least 2 weeks initially and had extended hospital stays.
In each case LAS had already attended multiple times and there had been a lengthy ongoing process of concerns being raised.
In each case I wrote a lengthy letter outlining concerns. I divided them into physical health, mental health social clear bullet point lists.
I also explicitly clarified why I felt they did not have capacity. Eg Mr PC in my opinion is unable currently to weight this decision as when we discussed x he said y..
Practical considerations when admitting under MCA Admitting someone under the capacity act is a logistical challenge.
It requires Ambulance support and (usually) Police. This is not always available concurrently and is often why attempts fail
Liaise with services ahead of time: Police/Ambulance/Admitting hospital/ Outreach. Things will run more smoothly.
Accept that you may need to make several attempts. Even if you are sure that the person doesn’t have capacity to make decisions around their health on an ongoing basis
Have as much supporting documentation ready as you can. Do a letter outlining issues and any assessment. It may be an idea to leave a copy of this with the person if they will accept it, if you are unable to admit them. They may be picked up by another team.
Discuss with your team. A common theme with these patients is that they split teams, with different practitioners having different perspectives. Get feedback, but if you are the primary caregiver trust your judgement.
Case 1: The Behavioural Medical Nightmare
Mr PC 44yr old Irish man Hostel housing Substance misuse (Crack, Heroin) Alcohol misuse Oedema (nephrotic syndrome) Amyloidosis Osteomyelitis Difficult personality
Case 1: Mr PC
Presented to us September 2012. Previously known in 2006
On methadone IVDU incl large veins, crack, benzos Alcohol dependence History of drug-induced psychosis DVT, anaemia, peripheral oedema Loud, demanding, rude, abusive. Banned from local
chemists. Multiple A&E attendances
Case 1: Mr PC
ChallengesAddressing physical health concerns Concordance with medications Leg ulceration and worsening oedema Concerns over mental state / capacity / memory Needed Admission but was more focused on
getting next giro. Conflicts of agendas between healthcare
practitioners and patient
Fluctuating Capacity
Capacity varies – can be more or less intoxicated etc.
Important to remember that unwise decisions do not equal No Capacity
References
Nicholson. T , Cutter. W Hotopf. M (2008) Assessing mental capacity: the Mental Capacity Act BMJ. 336(7639): 322–325