I'm blessed with fantastic colleagues. It's really the only reason I'm working where I am. The staff really are fantastic.
Colleagues outside of the NHS are more variable in their competence. Some social workers are fantastic. I've a lot of time for social workers, they do a hard job with little meaningful support/team work. One disadvantage of this culture is that social workers are pretty idiosyncratic animals. They all work differently, with sometimes very different attitudes and consequently very different interventions (or lack of interventions).
This variability in social work bemused me . . . shouldn't it be a needs led service? Shouldn't what the patient (erm, client, to them) needs define what activities the social worker undertakes/the content of their care schedule? No, it all falls down to the quirks of the individual social worker (or assessment officer) in my corner, and the attitude/whim/habits they possess. Patients get very different responses and outcomes depending which area team social worker picks up their case.
What's more muddling is their response to change, including legislative changes such as the Mental Capacity Act 2005.
A social worker today said they didn't know it, she hadn't had what she thought was enough training on it, she didn't use it and it was "still new" so it didn't matter. 3 of her colleagues thought similarly. New? Still new?! It was drafted in 2005 and implemented in 2007, we've been using it for years!
Good grief.
But those individuals ignore it, don't do formal capacity assessments or Best Interest meetings/decisions or the like. Instead they refer such nonsense to their Team Leader (who has to do it all) because when she says they have to do it, and it's the law, they just tell her she's, "going off on one, again," and shrug and move on.
I'm not sure we've the ideal system, locally, for embedding current best practice within Local Authority social work teams . . .
Showing posts with label MCA 2005. Show all posts
Showing posts with label MCA 2005. Show all posts
Tuesday, 21 December 2010
Friday, 12 February 2010
Deprivation of Liberty Safeguards
The Bournewood case generated legal inconsistencies that notionally have been solved through the Deprivation of Liberty Safeguards (DOLS).
If someone's liberty is "restricted," this can lawfully happen within the Mental Capacity Act 2005 framework, if it's in the person's best interests. An example would be someone saying they wish to leave a care home and return home, but they're guided to have a cup of tea and moments later they're happy and chatting with other residents.
If the resident was hammering at the door, 'phoning for taxis to take them away all the time, sneaking out at every opportunity and adamantly refused to stay, that crosses from "restriction" to "deprivation" of liberty and the DOLS framework kicks in.
Grand. Folks get appropriate care, within a lawful framework.
On to a conversation I overheard this week :
Community mental health nurse (band 7 CPN) : "The patient's settled, the occasional comments she'd rather be at home can be managed as 'restriction' of liberty, not 'deprivation' in the care you've now structured in the detail within your care plans."
Care home manager : "Great, thank you."
CMHN : "If she progresses and makes persistent, active attempts to leave, we'll need to consider DOLS."
Manager : "Oh yes, we use doll therapy all the time to distract them."
If someone's liberty is "restricted," this can lawfully happen within the Mental Capacity Act 2005 framework, if it's in the person's best interests. An example would be someone saying they wish to leave a care home and return home, but they're guided to have a cup of tea and moments later they're happy and chatting with other residents.
If the resident was hammering at the door, 'phoning for taxis to take them away all the time, sneaking out at every opportunity and adamantly refused to stay, that crosses from "restriction" to "deprivation" of liberty and the DOLS framework kicks in.
Grand. Folks get appropriate care, within a lawful framework.
On to a conversation I overheard this week :
Community mental health nurse (band 7 CPN) : "The patient's settled, the occasional comments she'd rather be at home can be managed as 'restriction' of liberty, not 'deprivation' in the care you've now structured in the detail within your care plans."
Care home manager : "Great, thank you."
CMHN : "If she progresses and makes persistent, active attempts to leave, we'll need to consider DOLS."
Manager : "Oh yes, we use doll therapy all the time to distract them."
Monday, 12 October 2009
Legal matters
No sooner had I posted on laws on Friday, then Dr Grumble posted about legal matters on Saturday. Odd how themes pop up.
It got me thinking.
How much of my study time, over the last year, has been updates on clinical matters? Mostly I do this online and through journals, I used to do it through conferences a lot too. My external study leave (conferences, meetings, teaching away from the weekly local in-house stuff) on clinical material/updates was just 12% last year. Almost all my courses and training was legal.
The ammended Mental Health Act, the Mental Capacity Act and Deprivation of Liberty Safeguards have a lot to answer for.
It got me thinking.
How much of my study time, over the last year, has been updates on clinical matters? Mostly I do this online and through journals, I used to do it through conferences a lot too. My external study leave (conferences, meetings, teaching away from the weekly local in-house stuff) on clinical material/updates was just 12% last year. Almost all my courses and training was legal.
The ammended Mental Health Act, the Mental Capacity Act and Deprivation of Liberty Safeguards have a lot to answer for.
Thursday, 1 October 2009
Cash
I saw a lady on a medical ward. She is relatively young. She has diabetes, dementia and Down's syndrome. She was confused. She had fallen at home, her family explained that they couldn't manage her at home. Many meetings were held; she wanted to go back home.
The assessment of needs was clear. OT, social work and nursing assessments evidenced deficits that were pervasive (and progressive) throughout the 24 hours of a day, so couldn't be met through home care popping in to do specific activities. She needed ongoing care with appropriate, timely interventions to meet her needs. Her family had been doing this but were too burnt out and frazzled to sustain this, which in itself was a source of sorrow, guilt and abject misery.
The lady was an incapacitated adult, at that point in time, with respect to the specific decision on where she would reside. Best Interest meetings were held. All those involved in her care or interested in her welfare chirped up with their views. Everyone said the same thing. She now needed to be in a 24 hour care setting if her needs were to be appropriately met.
We gave our views to her medical team. She went in to permanent care.
It was a good outcome. On review she's very happy in her care home. She enjoys the company, she's warmed to several staff and really enjoys being around them, following them around and as she sees it helping in their duties (she spends ages in their laundry). Takes staff two to three times as long to get the work done with her help, but she enjoys it and it's meaningful activity for her. Staff see it as therapeutic time spent with her, not nuisance. Brilliant.
Her family visit daily and are very happy with things, too.
She didn't want to go in to care. The decision to place her in care was made within the section 4 framework of the Mental Capacity Act 2005, subsequently with necessary health and social care being delivered through section 5. There's no use of the Mental Health Act 1983. There's no free section 117 aftercare. She and her family pay for care. 10 years ago, requiring someone to reside in a care setting permanently when they didn't wish to be there, she'd have got this for free. Now she pays for it all.
A dismal consequence of the MCA 2005, methinks.
The assessment of needs was clear. OT, social work and nursing assessments evidenced deficits that were pervasive (and progressive) throughout the 24 hours of a day, so couldn't be met through home care popping in to do specific activities. She needed ongoing care with appropriate, timely interventions to meet her needs. Her family had been doing this but were too burnt out and frazzled to sustain this, which in itself was a source of sorrow, guilt and abject misery.
The lady was an incapacitated adult, at that point in time, with respect to the specific decision on where she would reside. Best Interest meetings were held. All those involved in her care or interested in her welfare chirped up with their views. Everyone said the same thing. She now needed to be in a 24 hour care setting if her needs were to be appropriately met.
We gave our views to her medical team. She went in to permanent care.
It was a good outcome. On review she's very happy in her care home. She enjoys the company, she's warmed to several staff and really enjoys being around them, following them around and as she sees it helping in their duties (she spends ages in their laundry). Takes staff two to three times as long to get the work done with her help, but she enjoys it and it's meaningful activity for her. Staff see it as therapeutic time spent with her, not nuisance. Brilliant.
Her family visit daily and are very happy with things, too.
She didn't want to go in to care. The decision to place her in care was made within the section 4 framework of the Mental Capacity Act 2005, subsequently with necessary health and social care being delivered through section 5. There's no use of the Mental Health Act 1983. There's no free section 117 aftercare. She and her family pay for care. 10 years ago, requiring someone to reside in a care setting permanently when they didn't wish to be there, she'd have got this for free. Now she pays for it all.
A dismal consequence of the MCA 2005, methinks.
Wednesday, 29 July 2009
Police
Jess raised the point of police accessing private places, to bring people to a place of safety for assessment.
In theory, this is covered under section 135 of the Mental Health Act 1983.
Someone's in a private place, refuses help, seems to need care, generates significant and risky problems (for themselves or others), what's to be done? An Approved Mental Health Professional presents their concerns to a magistrate who can then issue a warrant for police to access the person, eg forcing their way into their home, to then take them to a place of safety.
Unusually, they're then locked up in a place of safety for 72 hours, but I can't discharge them from the section 135. The police or the Approved Mental Health Professional does that.
In practice, it's hardly ever used. I've seen it used once.
If someone's in their own home or garden or other not-public area, invariably a section 2 is considered instead.
Jess is quite correct that this means someone who's presenting with a health problem, and consequent behavioural changes and evidence of ill health being manifest to one and all, then has an ambulance crew arrive who do . . . what? If detained under the MHA 1983 then they can be conveyed to hospital. If they're evidenced to be incapacitated adults (with respect to this decision) then they can be conveyed to hospital (if it's in their best interests) under the MCA 2005. Our ambulance crews need to be given completed locally agreed forms documenting this lack of capacity before they'll convey.
So locally, the use of the MHA 1983 (with sections 2 and 136) and MCA 2005 (sections 4 and 5) sort most out of hours problems where statutory powers need to be used to orchestrate care. Rarely, very rarely, section 135 is considered.
In theory, this is covered under section 135 of the Mental Health Act 1983.
Someone's in a private place, refuses help, seems to need care, generates significant and risky problems (for themselves or others), what's to be done? An Approved Mental Health Professional presents their concerns to a magistrate who can then issue a warrant for police to access the person, eg forcing their way into their home, to then take them to a place of safety.
Unusually, they're then locked up in a place of safety for 72 hours, but I can't discharge them from the section 135. The police or the Approved Mental Health Professional does that.
In practice, it's hardly ever used. I've seen it used once.
If someone's in their own home or garden or other not-public area, invariably a section 2 is considered instead.
Jess is quite correct that this means someone who's presenting with a health problem, and consequent behavioural changes and evidence of ill health being manifest to one and all, then has an ambulance crew arrive who do . . . what? If detained under the MHA 1983 then they can be conveyed to hospital. If they're evidenced to be incapacitated adults (with respect to this decision) then they can be conveyed to hospital (if it's in their best interests) under the MCA 2005. Our ambulance crews need to be given completed locally agreed forms documenting this lack of capacity before they'll convey.
So locally, the use of the MHA 1983 (with sections 2 and 136) and MCA 2005 (sections 4 and 5) sort most out of hours problems where statutory powers need to be used to orchestrate care. Rarely, very rarely, section 135 is considered.
Thursday, 23 April 2009
Sex
Can people have sex?
Well, yes. Obviously. Or we'd not be here and the world'd be an emptier place. But, if there weren't people then there wouldn't be Pot Noodle, so it wouldn't be all bad.
I chanced upon an article in Slate Magazine today, because I was looking for information on sex. It's with hindsight that it dawned on me that Googling (is that a verb?) for "sex" at work may raise a few eyebrows when the IT server guys see what I came up with. My, human creativity really does know no bounds. I'm so glad I did it all on someone else's computer.
The rationale for finding oh so many sites of oh so many obliging women? Because I don't know enough about sex and older people. Always one to value CPD and a thirst for knowledge and self directed learning, I assiduously studied all I could, online.
Better still, the whole team poured over it all. We didn't learn a lot. I did learn that some of my colleagues know far too much about obscure specialist subjects.
Back to the reason for our diligent search. Sex. Can older people do it?
Really, can they?
No no no, not in a sweaty, physical, swinging from the chandaliers sort of way. In a legal, "Are they allowed to?" sort of way. A tricky matter to disentangle. Googling found far more sites of scantily clad ladies of a certain age than it did of learned legal discourse. There were of course some sites dedicated to lusty, obliging women. And sites dedicated to lawyers. All from the same search. I guess lawyers and prostitutes have more in common than one may first imagine, seeking to use their skills to satisfy their clients for significant amounts of cash.
We've a lady in a care home. She holds hands with a man. They kiss and cuddle. They're both widowed, so single. They're both demented, and are incapacitated adults (within the meaning of the Mental Capacity Act 2005, with respect to the decision of an intimate relationship). They like to sleep together. They've sought to have a sexual relationship together.
It's a bit like this.
MCA 2005 directs what can and can't happen, about a great many things (e.g. marriage) but not specifically about sex. Neither does the European Convention of Human Rights, that we could find. Nor did any guidance we rummaged around, on such sites that weren't gloriously lurid.
So, the question remains unanswered. And care homes in my corner take very different views on it "meddling" as they feel wont to do. A definitive answer 'pon desire is desirable. Do older adults have a right to sex?
Well, yes. Obviously. Or we'd not be here and the world'd be an emptier place. But, if there weren't people then there wouldn't be Pot Noodle, so it wouldn't be all bad.
I chanced upon an article in Slate Magazine today, because I was looking for information on sex. It's with hindsight that it dawned on me that Googling (is that a verb?) for "sex" at work may raise a few eyebrows when the IT server guys see what I came up with. My, human creativity really does know no bounds. I'm so glad I did it all on someone else's computer.
The rationale for finding oh so many sites of oh so many obliging women? Because I don't know enough about sex and older people. Always one to value CPD and a thirst for knowledge and self directed learning, I assiduously studied all I could, online.
Better still, the whole team poured over it all. We didn't learn a lot. I did learn that some of my colleagues know far too much about obscure specialist subjects.
Back to the reason for our diligent search. Sex. Can older people do it?
Really, can they?
No no no, not in a sweaty, physical, swinging from the chandaliers sort of way. In a legal, "Are they allowed to?" sort of way. A tricky matter to disentangle. Googling found far more sites of scantily clad ladies of a certain age than it did of learned legal discourse. There were of course some sites dedicated to lusty, obliging women. And sites dedicated to lawyers. All from the same search. I guess lawyers and prostitutes have more in common than one may first imagine, seeking to use their skills to satisfy their clients for significant amounts of cash.
We've a lady in a care home. She holds hands with a man. They kiss and cuddle. They're both widowed, so single. They're both demented, and are incapacitated adults (within the meaning of the Mental Capacity Act 2005, with respect to the decision of an intimate relationship). They like to sleep together. They've sought to have a sexual relationship together.
It's a bit like this.
MCA 2005 directs what can and can't happen, about a great many things (e.g. marriage) but not specifically about sex. Neither does the European Convention of Human Rights, that we could find. Nor did any guidance we rummaged around, on such sites that weren't gloriously lurid.
So, the question remains unanswered. And care homes in my corner take very different views on it "meddling" as they feel wont to do. A definitive answer 'pon desire is desirable. Do older adults have a right to sex?
Tuesday, 14 April 2009
DOLS
You've perhaps read the Deprivation of Liberty Safeguards, and Code of Practice.
Because I'm a tad neurotic and obsessive 'bout these things, I've read it all rather thoroughly, more than once, and been to various awareness and training days. I feel pretty clued up about it all.
We've a lady in a care home. She has dementia. Her daughter thinks she needs to be in a care home since she can't manage on her own. Heck, she can't even walk on her own. She has no notion of what problems she has, what she can't do, what help she needs. She's evidently an incapacitated adult, within the meaning of the Mental Capacity Act 2005. She's no donee or deputy or advance decision. Management is therefore manifestly straightforward. We have a duty to provide appropriate care, within the Best Interests framework of the MCA 2005.
Care home staff reckon she's best in the care home. Her daughter thinks she's best placed in the care home. Nursing staff reckon she's best placed there. I think it's the only place for her. Best Interest meeting evidences her deficits and what needs to be put in place to address her health and social welfare needs (both optimally and at an acceptable minimum) and it's clear that 24 hour care within a care home's necessary. Everyone agrees.
She keeps saying she wants to go home.
She's no way out. She's not detained under any law or process (such as Guardianship, or SCT) that allows scrutiny or review or challenge. Technically she could go to the Court of Protection for a Declaration to determine if her placement in care's lawful or unlawful but, clearly, she's not in a position to instruct solicitors and progress such a course, even if it was reasonable to do so.
Enter the Deprivation of Liberty Safeguards (DOLS) that came in to force 14 days ago. The PCT or Council considser the issues if this deprivation of liberty is appropriate they issue "authorisation." After 6 assessments and enough paperwork to fell a small rainforest.
I speak with a social worker and we consider DOLS. I'm advised that we can document sufficient details in her care plan to "restrict" rather than "deprive" her of her liberty. Which then, under the MCA 2005, is lawful. Resitriction's fine. We can game on and place her and deliver necessary care under section 5, all's good.
Now, on the one hand this means there's no assessments and meetings and paperwork and taxpayers' expense for a DOLS authorisation. On the other hand, she's in a care home, saying she want to leave and go back to her house, and has no way to effect this.
14 days in and already DOLS ain't evidencing transparent decision making or external scrutiny to protect liberty in any kind of robust fashion, what so ever. Ho hum.
Because I'm a tad neurotic and obsessive 'bout these things, I've read it all rather thoroughly, more than once, and been to various awareness and training days. I feel pretty clued up about it all.
We've a lady in a care home. She has dementia. Her daughter thinks she needs to be in a care home since she can't manage on her own. Heck, she can't even walk on her own. She has no notion of what problems she has, what she can't do, what help she needs. She's evidently an incapacitated adult, within the meaning of the Mental Capacity Act 2005. She's no donee or deputy or advance decision. Management is therefore manifestly straightforward. We have a duty to provide appropriate care, within the Best Interests framework of the MCA 2005.
Care home staff reckon she's best in the care home. Her daughter thinks she's best placed in the care home. Nursing staff reckon she's best placed there. I think it's the only place for her. Best Interest meeting evidences her deficits and what needs to be put in place to address her health and social welfare needs (both optimally and at an acceptable minimum) and it's clear that 24 hour care within a care home's necessary. Everyone agrees.
She keeps saying she wants to go home.
She's no way out. She's not detained under any law or process (such as Guardianship, or SCT) that allows scrutiny or review or challenge. Technically she could go to the Court of Protection for a Declaration to determine if her placement in care's lawful or unlawful but, clearly, she's not in a position to instruct solicitors and progress such a course, even if it was reasonable to do so.
Enter the Deprivation of Liberty Safeguards (DOLS) that came in to force 14 days ago. The PCT or Council considser the issues if this deprivation of liberty is appropriate they issue "authorisation." After 6 assessments and enough paperwork to fell a small rainforest.
I speak with a social worker and we consider DOLS. I'm advised that we can document sufficient details in her care plan to "restrict" rather than "deprive" her of her liberty. Which then, under the MCA 2005, is lawful. Resitriction's fine. We can game on and place her and deliver necessary care under section 5, all's good.
Now, on the one hand this means there's no assessments and meetings and paperwork and taxpayers' expense for a DOLS authorisation. On the other hand, she's in a care home, saying she want to leave and go back to her house, and has no way to effect this.
14 days in and already DOLS ain't evidencing transparent decision making or external scrutiny to protect liberty in any kind of robust fashion, what so ever. Ho hum.
Monday, 30 March 2009
Laws
I met with the manager from a care home.
The manager claimed to be in a state of amazement, knowing naught of the unacceptable practice within her home. Ignorance that is impacting 'pon dozens of folks care. Not good.
We discussed care plans and implementation of care. Because they're out of hospital, local GPs will need to be involved in discussing medication protocols. This will take many months. So it goes.
Given her self confessed ignorance of malign care in her establishment, it became clear that we were correct in our assumption that she wasn't clued up on her statutory obligations to provide care under the Mental Capacity Act 2005.
In particular, she wasn't familiar with section 44 and the prospect of her, and staff, spending up to 5 years in prison.
The manager claimed to be in a state of amazement, knowing naught of the unacceptable practice within her home. Ignorance that is impacting 'pon dozens of folks care. Not good.
We discussed care plans and implementation of care. Because they're out of hospital, local GPs will need to be involved in discussing medication protocols. This will take many months. So it goes.
Given her self confessed ignorance of malign care in her establishment, it became clear that we were correct in our assumption that she wasn't clued up on her statutory obligations to provide care under the Mental Capacity Act 2005.
In particular, she wasn't familiar with section 44 and the prospect of her, and staff, spending up to 5 years in prison.
Sunday, 29 March 2009
Care
I feel vexed.
This is A Bad Thing because, although I don't get cross often, when I do I'm not always wholly reasonable. No no no, not in a "red mist" kind of way. More in a didactic, assertive, "I know best" kind of way which surprises folks 'cause it's typically alien for them to see this, coming from me. But, when vexed, I am wont to be classically Consultoid and Have Things My Way and assertively progress this state of affairs.
By chance, a social worker commented on assessing capacity. Her rather splendid blog should be known to you, if not, shame on you. Nip on over to here and rummage around.
What perturbed my calm mien was after a member of our CMHT visited a care home for a meeting around a patient's care, returned to the office and discussed things with me. Let's call the care home Limbo. Most care homes in my area were woeful, most are now decent, two are excellent (and I would happily have them care for my kith and kin). This care home she visited is a curious place. The environment is spot on. A modern, purpose built home with structure and content that's pretty much without fault. The staffing is uncertain. Really uncertain. Sometimes I speak with a nurse who's got oodles of common sense, is very patient centred and utterly devoted to those in her care. Popping in to Limbo when she's on shift is a joy. Every other RMN has less enthusiasm, motivation, common sense or interest in residents than my daughter's goldfish. This is not a slur against nurses, it's a comment on the dichotomy 'tween great nurses and those undertaking poor nursing practice.
This makes for curious states of affairs. One care home in our area that's poor (an in, CSCI are involved and they's an embargo sort of poor) had a resident moved to Limbo where care could be better. It was a transfer made from one home to another with the same registration, notionally providing the same level of care. A gentleman who wasn't being cared for by staff was moved to Limbo to receive appropriate care, which he wasn't getting in his previous placement. In Limbo he had exceptional care.
Seeing him in his old home, he was a state. Wild hair, soiled clothes, smelling rank (from not bathing for many months, from incontinence that wasn't attended to, faeces matting up in his pubic hair), he had food that had drippled on to him, his clothes, his beard, had dried and become adherent to him, his beard. Not good.
He was moved to Limbo, the next day I didn't recognise him. No, not an idle comment, I really did walk past him in the entrance foyer, failing to clock who he was. He'd been bathed, shaved, cared for. The nurse (who's exceptional) gave a rich account of how he'd been, despite only having known him for a two shifts.
She had spoken to him and his family. She knew what he liked, what irritated him, what relaxed him, what topics/hobbies interested him, she'd sought an understanding of him even down to what flavours of food he liked and didn't. Person centred care. Superb.
Limbo has other nurses and, sadly, to a one they're not as good. Not even in the same league. Their unqualified carers are, rightly, directed by the nurses. They're a mixed crowd but, typically, have time and interest and common sense in their delivery of care. But if nurses aren't directing them to undertake appropriate care, then appropriate care's not undertaken. Less superb.
Back to a different patient, stuck in Limbo, and a different experience. My CMHT colleague (a social worker) returned from Limbo where they'd had a meeting with 3 nursing staff. Three, on one shift, for one meeting?! The home's not that well staffed. Folk had axes to grind and had come in to make themselves clear. The social worker was concerned that no medication had been given for weeks. The nurses explained that the patient had declined medication offered. The social worker explained that, indeed, this was known and expected, because the patient was severely demented and didn't appreciate their illnesses, the impact of their illnesses, the consequent effects of this on their health and wellbeing, and the desire/need for medication to help manage this. My social worker described how the nurses in Limbo shook their heads and tutted a lot, saying they could only give medication to the patient, including his insulin, when he was unconscious.
This patient is an incapacitated adult, unable to either give or to withhold consent. The nurses just couldn't (or wouldn't) get that.
My social worker sadly didn't know the NMC guidance on covert medication so had to accept the 3 nurses telling him that they couldn't provide appropriate medication for the patient. He quoted the relevant bits of the Mental Capacity Act 2005 to them. They were having none of it. If that patient says no, the patient gets no treatment. All this is becoming much less than superb.
Worse, on review, the patient was in a state. Sitting in urine sodden clothes. Not moist, but apparently soaked. The social worker was astonished, since the urine was even dripping down the chair. He backed out of the room so staff could attend to the patient with dignity, undressing and attending to him without the social worker present. The staff left the room too. They left the patient. They wouldn't change him. He told them he'd not been incontinent and didn't need to change his clothes. The social worker questioned if, being diabetic, leaving him sat in urine was okay for his skin. Nurses said it was his choice. If that's how he wanted to live, they wouldn't and couldn't force anything on him.
Nothing polite can convey what I was thinking, feeling and expressing to my social worker at this point. Suffice to say, I was animated and more than a little vexed.
A nurse and I'm meeting with their manager tomorrow.
This is A Bad Thing because, although I don't get cross often, when I do I'm not always wholly reasonable. No no no, not in a "red mist" kind of way. More in a didactic, assertive, "I know best" kind of way which surprises folks 'cause it's typically alien for them to see this, coming from me. But, when vexed, I am wont to be classically Consultoid and Have Things My Way and assertively progress this state of affairs.
By chance, a social worker commented on assessing capacity. Her rather splendid blog should be known to you, if not, shame on you. Nip on over to here and rummage around.
What perturbed my calm mien was after a member of our CMHT visited a care home for a meeting around a patient's care, returned to the office and discussed things with me. Let's call the care home Limbo. Most care homes in my area were woeful, most are now decent, two are excellent (and I would happily have them care for my kith and kin). This care home she visited is a curious place. The environment is spot on. A modern, purpose built home with structure and content that's pretty much without fault. The staffing is uncertain. Really uncertain. Sometimes I speak with a nurse who's got oodles of common sense, is very patient centred and utterly devoted to those in her care. Popping in to Limbo when she's on shift is a joy. Every other RMN has less enthusiasm, motivation, common sense or interest in residents than my daughter's goldfish. This is not a slur against nurses, it's a comment on the dichotomy 'tween great nurses and those undertaking poor nursing practice.
This makes for curious states of affairs. One care home in our area that's poor (an in, CSCI are involved and they's an embargo sort of poor) had a resident moved to Limbo where care could be better. It was a transfer made from one home to another with the same registration, notionally providing the same level of care. A gentleman who wasn't being cared for by staff was moved to Limbo to receive appropriate care, which he wasn't getting in his previous placement. In Limbo he had exceptional care.
Seeing him in his old home, he was a state. Wild hair, soiled clothes, smelling rank (from not bathing for many months, from incontinence that wasn't attended to, faeces matting up in his pubic hair), he had food that had drippled on to him, his clothes, his beard, had dried and become adherent to him, his beard. Not good.
He was moved to Limbo, the next day I didn't recognise him. No, not an idle comment, I really did walk past him in the entrance foyer, failing to clock who he was. He'd been bathed, shaved, cared for. The nurse (who's exceptional) gave a rich account of how he'd been, despite only having known him for a two shifts.
She had spoken to him and his family. She knew what he liked, what irritated him, what relaxed him, what topics/hobbies interested him, she'd sought an understanding of him even down to what flavours of food he liked and didn't. Person centred care. Superb.
Limbo has other nurses and, sadly, to a one they're not as good. Not even in the same league. Their unqualified carers are, rightly, directed by the nurses. They're a mixed crowd but, typically, have time and interest and common sense in their delivery of care. But if nurses aren't directing them to undertake appropriate care, then appropriate care's not undertaken. Less superb.
Back to a different patient, stuck in Limbo, and a different experience. My CMHT colleague (a social worker) returned from Limbo where they'd had a meeting with 3 nursing staff. Three, on one shift, for one meeting?! The home's not that well staffed. Folk had axes to grind and had come in to make themselves clear. The social worker was concerned that no medication had been given for weeks. The nurses explained that the patient had declined medication offered. The social worker explained that, indeed, this was known and expected, because the patient was severely demented and didn't appreciate their illnesses, the impact of their illnesses, the consequent effects of this on their health and wellbeing, and the desire/need for medication to help manage this. My social worker described how the nurses in Limbo shook their heads and tutted a lot, saying they could only give medication to the patient, including his insulin, when he was unconscious.
This patient is an incapacitated adult, unable to either give or to withhold consent. The nurses just couldn't (or wouldn't) get that.
My social worker sadly didn't know the NMC guidance on covert medication so had to accept the 3 nurses telling him that they couldn't provide appropriate medication for the patient. He quoted the relevant bits of the Mental Capacity Act 2005 to them. They were having none of it. If that patient says no, the patient gets no treatment. All this is becoming much less than superb.
Worse, on review, the patient was in a state. Sitting in urine sodden clothes. Not moist, but apparently soaked. The social worker was astonished, since the urine was even dripping down the chair. He backed out of the room so staff could attend to the patient with dignity, undressing and attending to him without the social worker present. The staff left the room too. They left the patient. They wouldn't change him. He told them he'd not been incontinent and didn't need to change his clothes. The social worker questioned if, being diabetic, leaving him sat in urine was okay for his skin. Nurses said it was his choice. If that's how he wanted to live, they wouldn't and couldn't force anything on him.
Nothing polite can convey what I was thinking, feeling and expressing to my social worker at this point. Suffice to say, I was animated and more than a little vexed.
A nurse and I'm meeting with their manager tomorrow.
Friday, 6 February 2009
Incandescent
My normally calm and affable disposition has been perturbed. Why? Because of this (which I chance upon here).
Oh my giddy aunt, where do I begin?
I agree that elderly abuse is common, undetected and poorly addressed. We have a "new" law for this, now. The Mental Capacity Act 2005, section 44 (2), criminalises both ill treatment and willful neglect of incapacitated folk which can result in imprisonment for up to 5 years and a fine. We don't need new laws, we need CSCI and statutory organisations (in health and social care) having strength to highlight this then for it to be addressed.
I can't think of a month, through the last year, where I've not been involved in elderly abuse proceedings. It's commonly seen and flagged up in my corner. Police have a nigh on impossible task of generating evidence "beyond all reasonable doubt" when elderly incapacitated folk are involved. They're honest about this. Last time I was at a High Court for a protection case, the CPS barrister met with me and asked how sure I was about the patient's account, given he had advanced dementia. I explained that the detail could contain erroneous elements but that his account of what grossly trainspired was internally consistent, repeatedly stated with the same content, coherent, fitted with informant and corroborating history/evidence, fitted with the contusions/abrasions and injuries sustained so I saw the minor nuances of flux in his account as inconsequential and that I was 95% sure the account was valid. 95% still left 5% doubt, she said. Not good enough. She met with the judge and it never even went to trial.
Laws alone won't help. We have the laws. We need surveillance, intervention and sanctions if we're to effect change.
Picking on the issue of antipsychotics and running parallels to prescribing this in dementia care as being a criminal act, what?!
Frankly, this just really, really pissed me off. Antipsychotics shouldn't be used first line in dementia care. Or second line. But they can have a place. Babies and bathwater. We don't want to say that there's no patient with dementia who could ever benefit from an antipsychotic. Some experience psychosis. Some benefit from an antipsychotic. Antipsychotic are not placebo. They're proper drugs, with real risks and real side effects. These are serious (eg a 2% increase of a year of having a stroke). Of course, if you're psychotic and tormented and won't live a year, a 98% chance of not having a stroke but getting relief may p'raps have some appeal . . .
Every patient in care homes in my corner gets reviewed. By me. They're not my patients. Most of the time I've not started the medication. But I still believe antipsychotics are such risky drugs and dementia care needs such support that it's worth my time visiting each and every care home in my patch, going through each and every MARS sheet for every resident and ensuring there's rational prescribing for all of them. I see this as good clinical practice. My GPs see this as a useful service, meaning care home patients receive appropriate Consultant Psychiatrist input into their drug regimens without having to refer every care home resident to me. Most of the time I am stopping antipsychotics. Very rarely, I start them. Sometimes I fiddle with the dose. I try and ensure that there's appropriate patient centred care - every patient gets due consideration of the risks, benefits and appropriateness of medication for them, with their history, at that stage in their illness. I would suggest that this is one element of decent clinical care. I do not think that what I am doing is wayward, let alone criminal.
Oft times GPs are called out of hours or at weekends and the "on call" GP has to take a view on how to support a care home with an "unmanageable" patient they don't know, in a care home they don't know, managed by staff they don't know. The GP has no idea on what training the staff have and on what they should be able to manage. GPs try and be helpful. GPs hear care home staff say their resident is battering other folk and "needs medication" so often feel obliged to prescribe. It makes sense for me and my team to then review care.
I have no hospital in-patients at present. This is largely because EMI Nursing Homes accept my patients knowing that nursing staff and I support them, a lot, with frequent visits and use of Continuing Care for 1:1 care so they can adequately staff their units and that use of medication is easily and appropriately reviewed. Use of antipsychotics is a small but important part of care for some patients some of the time. I'm much in favour of acetylcholinesterase inhibitors, I use benzodiazepines, but sometimes, just sometimes, an antipsychotic is appropriate.
What's being proposed?
Patients without dementia can have antipsychotics.
Patients in their own houses can have antipsychotics.
Patients with dementia can not have antipsychotics.
Patients in care homes can not have antipsychotics.
Erm . . . isn't this blatantly flagrant prejudice?
Politicians offering either "guidance" to clinicians or criminalising clinical care is so so missing the point.
The newspaper goes on to say that the issue is of poor detection by Social Services and poor resourcing (with a predicted £6billion funding gap). Well then, there we are. Use the MCA 2005 if we need legal redress but let's crack on and look at malign care in care homes/institutions, CSCI's role (and teeth), CPS guidance on when to go to trial, training and support for care home staff. Then, critically, look at the lack of resourcing which has generated this system. I'll say it again. We don't need more laws. We need surveillance, intervention and sanctions if we're to effect change.
Oh my giddy aunt, where do I begin?
I agree that elderly abuse is common, undetected and poorly addressed. We have a "new" law for this, now. The Mental Capacity Act 2005, section 44 (2), criminalises both ill treatment and willful neglect of incapacitated folk which can result in imprisonment for up to 5 years and a fine. We don't need new laws, we need CSCI and statutory organisations (in health and social care) having strength to highlight this then for it to be addressed.
I can't think of a month, through the last year, where I've not been involved in elderly abuse proceedings. It's commonly seen and flagged up in my corner. Police have a nigh on impossible task of generating evidence "beyond all reasonable doubt" when elderly incapacitated folk are involved. They're honest about this. Last time I was at a High Court for a protection case, the CPS barrister met with me and asked how sure I was about the patient's account, given he had advanced dementia. I explained that the detail could contain erroneous elements but that his account of what grossly trainspired was internally consistent, repeatedly stated with the same content, coherent, fitted with informant and corroborating history/evidence, fitted with the contusions/abrasions and injuries sustained so I saw the minor nuances of flux in his account as inconsequential and that I was 95% sure the account was valid. 95% still left 5% doubt, she said. Not good enough. She met with the judge and it never even went to trial.
Laws alone won't help. We have the laws. We need surveillance, intervention and sanctions if we're to effect change.
Picking on the issue of antipsychotics and running parallels to prescribing this in dementia care as being a criminal act, what?!
Frankly, this just really, really pissed me off. Antipsychotics shouldn't be used first line in dementia care. Or second line. But they can have a place. Babies and bathwater. We don't want to say that there's no patient with dementia who could ever benefit from an antipsychotic. Some experience psychosis. Some benefit from an antipsychotic. Antipsychotic are not placebo. They're proper drugs, with real risks and real side effects. These are serious (eg a 2% increase of a year of having a stroke). Of course, if you're psychotic and tormented and won't live a year, a 98% chance of not having a stroke but getting relief may p'raps have some appeal . . .
Every patient in care homes in my corner gets reviewed. By me. They're not my patients. Most of the time I've not started the medication. But I still believe antipsychotics are such risky drugs and dementia care needs such support that it's worth my time visiting each and every care home in my patch, going through each and every MARS sheet for every resident and ensuring there's rational prescribing for all of them. I see this as good clinical practice. My GPs see this as a useful service, meaning care home patients receive appropriate Consultant Psychiatrist input into their drug regimens without having to refer every care home resident to me. Most of the time I am stopping antipsychotics. Very rarely, I start them. Sometimes I fiddle with the dose. I try and ensure that there's appropriate patient centred care - every patient gets due consideration of the risks, benefits and appropriateness of medication for them, with their history, at that stage in their illness. I would suggest that this is one element of decent clinical care. I do not think that what I am doing is wayward, let alone criminal.
Oft times GPs are called out of hours or at weekends and the "on call" GP has to take a view on how to support a care home with an "unmanageable" patient they don't know, in a care home they don't know, managed by staff they don't know. The GP has no idea on what training the staff have and on what they should be able to manage. GPs try and be helpful. GPs hear care home staff say their resident is battering other folk and "needs medication" so often feel obliged to prescribe. It makes sense for me and my team to then review care.
I have no hospital in-patients at present. This is largely because EMI Nursing Homes accept my patients knowing that nursing staff and I support them, a lot, with frequent visits and use of Continuing Care for 1:1 care so they can adequately staff their units and that use of medication is easily and appropriately reviewed. Use of antipsychotics is a small but important part of care for some patients some of the time. I'm much in favour of acetylcholinesterase inhibitors, I use benzodiazepines, but sometimes, just sometimes, an antipsychotic is appropriate.
What's being proposed?
Patients without dementia can have antipsychotics.
Patients in their own houses can have antipsychotics.
Patients with dementia can not have antipsychotics.
Patients in care homes can not have antipsychotics.
Erm . . . isn't this blatantly flagrant prejudice?
Politicians offering either "guidance" to clinicians or criminalising clinical care is so so missing the point.
The newspaper goes on to say that the issue is of poor detection by Social Services and poor resourcing (with a predicted £6billion funding gap). Well then, there we are. Use the MCA 2005 if we need legal redress but let's crack on and look at malign care in care homes/institutions, CSCI's role (and teeth), CPS guidance on when to go to trial, training and support for care home staff. Then, critically, look at the lack of resourcing which has generated this system. I'll say it again. We don't need more laws. We need surveillance, intervention and sanctions if we're to effect change.
Monday, 19 January 2009
Advocacy
More musing over the Mental Capacity Act 2005, I'm afraid.
Let's imagine there's a lady, living with her daughter who's got severe Down's syndrome, who's struggling to cope. When stressed and frustrated she self medicates with a bottle of whisky. Well, most of the time it's half a bottle, to be fair. On one occasion she'd gone through three bottles in three days, but that's unusual. Some days are good and she doesn't drink at all.
Her daughter sits in the house all day and does nothing unless prompted to do so. She's unable to generate much coherent speech and can't convey her views eloquently, but clearly prefers her mum being around and when her mother's been in hospital for a few days for cardiac investigations (which were normal, her chest pains being put down to "stress") the daughter was unsettled and unhappy.
Mum is now dementing. She can't appreciate what needs to be done at home. She becomes upset easily, frustrated easily, so isn't coping so well. She's thrown things at her daughter then been mortified at what she's done. Her daughter consistently says she's fine and she wants to be with mum. Safeguarding adults proceedings were split in views on how this should be managed but at the time concluded the only practicable outcome to address risk was to separate them, and this response wasn't proportionate to the risks evidenced and was contrary to the views that both mum and daughter were expressing. Time's moved on and now her dementia is causing problems in how she manages through the day, too, with it all getting a lot worse.
A nephew visits once every week or two and helps out, doing shopping and sorting mail and attending to the garden when he's time. He's flagged up that things aren't going well.
Mum can't work out what her daughter needs any more. She doesn't know when her daughter's hungry or thirsty or tired or wants conversation. Mum doesn't know details of what day it is or what health problems she has or what medication's for (so has mis-managed prn "as needed" medication spectacularly and is lucky to still be alive). She can't prepare food/cook and has accidentally started a fire in the kitchen. She's wholly unaware of her deficits and believes she's fine, her daughter's fine, she'll accept home care coming in to help with tidying up and the like but that's all.
A formal Best Interest meeting was held, with home care and the nephew and CMHT and GP all attending. It's the only time I've ever seen a GP attend a Best Interest meeting, but it's a very good GP who's interested in mental health and has been intimately involved in this family's care for a good number of years. The nephew has strong views about how the daughter's cared for and argues strongly for her care to be progressed appropriately. We were able to think through problems and risks and wishes and benefits and consequences at length. The outcome was that mum needed to be in a 24 hour care setting, propbably an EMI care home. Daughter probably could be managed at home with a robust package of care, but this would be tried then reviewed.
Daughter refuses this. Mum refuses this.
We can progress this. They're both incapacitated adults, with respect to the decision of their future residence and care. We met to assess their needs and how these could be provided for them. We considered the views of all parties. The professional team had a consistent unanimous view. She needs care, she can't make a valid decision on accepting/refusing this, so under section 5 she's given the necessary care and all's lawful.
But, what about the real implications? She's being made to leave her home. She's being forced to be separated from her daughter. She's going to have to reside in a care home against her wishes and have to pay the best bit of £400 a week for the privilege. She's no way to get out, that she can action.
I asked if an Independent Mental Capacity Act advocate (IMCA) could be involved. The reply was that because the nephew's involved and attending meetings and visiting and can advocate for her, she isn't "unbefriended" so an IMCA can't get involved.
I know what we're doing is right. I know if it went to court for a Declaration (irrespective of what ever the court determined) that we'd be able to evidence that our decision making is rational, appropriate, proportionate, considered and progressing care in the best interests of our both patient and her daughter. Although I spend a lot of time advocating for my patients, and my nusring colleagues have a professional responsibility to advocate for their patients (the NMC requires them to do so), when we're the ones determing she needs to be in care (and her cash will have to fund this) a degree of outside scrutiny would seem appropriate.
It sits somewhat uncomfortably that there's nobody clearly advocating independently for her.
Let's imagine there's a lady, living with her daughter who's got severe Down's syndrome, who's struggling to cope. When stressed and frustrated she self medicates with a bottle of whisky. Well, most of the time it's half a bottle, to be fair. On one occasion she'd gone through three bottles in three days, but that's unusual. Some days are good and she doesn't drink at all.
Her daughter sits in the house all day and does nothing unless prompted to do so. She's unable to generate much coherent speech and can't convey her views eloquently, but clearly prefers her mum being around and when her mother's been in hospital for a few days for cardiac investigations (which were normal, her chest pains being put down to "stress") the daughter was unsettled and unhappy.
Mum is now dementing. She can't appreciate what needs to be done at home. She becomes upset easily, frustrated easily, so isn't coping so well. She's thrown things at her daughter then been mortified at what she's done. Her daughter consistently says she's fine and she wants to be with mum. Safeguarding adults proceedings were split in views on how this should be managed but at the time concluded the only practicable outcome to address risk was to separate them, and this response wasn't proportionate to the risks evidenced and was contrary to the views that both mum and daughter were expressing. Time's moved on and now her dementia is causing problems in how she manages through the day, too, with it all getting a lot worse.
A nephew visits once every week or two and helps out, doing shopping and sorting mail and attending to the garden when he's time. He's flagged up that things aren't going well.
Mum can't work out what her daughter needs any more. She doesn't know when her daughter's hungry or thirsty or tired or wants conversation. Mum doesn't know details of what day it is or what health problems she has or what medication's for (so has mis-managed prn "as needed" medication spectacularly and is lucky to still be alive). She can't prepare food/cook and has accidentally started a fire in the kitchen. She's wholly unaware of her deficits and believes she's fine, her daughter's fine, she'll accept home care coming in to help with tidying up and the like but that's all.
A formal Best Interest meeting was held, with home care and the nephew and CMHT and GP all attending. It's the only time I've ever seen a GP attend a Best Interest meeting, but it's a very good GP who's interested in mental health and has been intimately involved in this family's care for a good number of years. The nephew has strong views about how the daughter's cared for and argues strongly for her care to be progressed appropriately. We were able to think through problems and risks and wishes and benefits and consequences at length. The outcome was that mum needed to be in a 24 hour care setting, propbably an EMI care home. Daughter probably could be managed at home with a robust package of care, but this would be tried then reviewed.
Daughter refuses this. Mum refuses this.
We can progress this. They're both incapacitated adults, with respect to the decision of their future residence and care. We met to assess their needs and how these could be provided for them. We considered the views of all parties. The professional team had a consistent unanimous view. She needs care, she can't make a valid decision on accepting/refusing this, so under section 5 she's given the necessary care and all's lawful.
But, what about the real implications? She's being made to leave her home. She's being forced to be separated from her daughter. She's going to have to reside in a care home against her wishes and have to pay the best bit of £400 a week for the privilege. She's no way to get out, that she can action.
I asked if an Independent Mental Capacity Act advocate (IMCA) could be involved. The reply was that because the nephew's involved and attending meetings and visiting and can advocate for her, she isn't "unbefriended" so an IMCA can't get involved.
I know what we're doing is right. I know if it went to court for a Declaration (irrespective of what ever the court determined) that we'd be able to evidence that our decision making is rational, appropriate, proportionate, considered and progressing care in the best interests of our both patient and her daughter. Although I spend a lot of time advocating for my patients, and my nusring colleagues have a professional responsibility to advocate for their patients (the NMC requires them to do so), when we're the ones determing she needs to be in care (and her cash will have to fund this) a degree of outside scrutiny would seem appropriate.
It sits somewhat uncomfortably that there's nobody clearly advocating independently for her.
Thursday, 15 January 2009
Liberty
This April, the Deprivation of Liberty Safeguards (DoLS) comes in to play. Well, it'll be May before we're using them, but there's invariably a bit of a false start with these things.
What's it mean?
If I use the Mental Health Act 1983 and someone's admitted to hospital under this Act for compulsory assessment and treatment, there're lots of safeguards. I can't detain them, for a start. I've never detained anyone in my life. All I can do is make a medical recommendation, which a social worker (all our AMHPs are social workers) then takes and if they reckon it's the right thing to do they give it to hospital managers to receipt, then the hospital managers detain the patient in their hospital. No one person makes the decision, for treatment under Part IV (i.e. compulsory treatment) there also has to be the agreement of another doctor. For some treatments the patient and another doctor have to agree. Some mental health treatments can't even be done no matter what doctors wish, if the patient has so stated. On section 3, the nearest relative can discharge the patient. If I want to place someone with dementia in a care setting under section 7, the nearest relative mustn't object. If the patient doesn't want to be detained, they can appeal to a Mental Health Review Tribunal who can discharge them. The MHRT is a powerful and scary body, they're a court, can hold doctors in Contempt and (other than additional "recommendations" they suggest which I'd duty bound to listen to but technically don't absolutely have to do) what they so goes.
With advocacy, nearest relatives, specialist (section 12 approved) doctors, a second doctor making recommendation for admission, an Approved Mental Health Professional making the decision on whether compulsory admission's right or not, limits on treatment and rights of appeal, the Mental Health Act 1983 seems to have the right balance of framework to ensure mentall unwell folk can get the treatment they need and deserve within a framework of checks and safeguards and scrutiny to protect their liberty and rights.
So far, so good.
The Mental Capacity Act 2005 is different. In many ways it's much simpler. It also has sound principles, stated explicitly right at the start in section 1. It has advocacy inherently embedded in decision making. It has collaborative involvement in decision making enshrined in section 4 (Best Interests decisions).
The difficulty is that it's so broad.
It's how the 17 year old care assistant, in a residential home, decides if Mrs Stainforthe should have a bath this morning, even though she can't say yes or no to that.
It's for non-mental health matters; it's how the solicitor decided if I was a capacitated adult when instructing them in conveyancing when I sold and moved house.
It's for health decisions. It's for financial matters. It's for social choices.
As a broad bit of legislation affecting any assessment of decision making (capacity) and subsequent health and social welfare care within someone's best interests, by anyone involved in their care, it's a massive bit of legislation.
What can you do with it? Why, anything in their best interests (that a Donee, Deputy, court or Advance Decision don't preclude). Really, pretty much anything. Choice of where they live. choice of medication. Choice of who, when and by who they're cared for. Choice of when, where and what surgery they'll have.
So if someone's an incapacitated adult (within the meaning of the Mental Capacity Act 2005) and has dementia and needs to be in a care home, is indifferent to this (and neither can give nor with hold consent, since they lack capacity, but equally they're not actively opting in to or refusing 24 hour care), they can be placed within a 24 hour care home. A best interests meeting is held, then under section 5 they receive care in a care home.
Great, despite not being able to consent, they still get the care they need. This is decided by a team, with involvement of family and all parties.
But, if they don't want to be in a care home, how do they get out? There is no tribunal or appeal process. There is no automatic review process. The family might have objected but the best interest considered then discounted their view and placed their relative in permanent care. Someone's in a locked EMI residential unit, forever, with civilains placing them there and no judicial process to get 'em out. Okay, family could go to court for a Declaration, but the confused patient who doesn't want to be in there's not going to chirp up and progress such a mechanism.
Enter the Deprivation of Liberty Safeguards. Before someone's deprived of their liberty, our Primary Care Trust will have to give Authorisation. Hurrah, libery is safeguarded. Excpet, out PCT didn't know about this, even last December when I met with them. It's a statutory obligation, they have to do it, but even now in January they've no staff and no framework for this work. Each application to the PCT will involve 6 assessments. They have no idea who or how they'll do this.
It's their duty. We don't have the resources to do this work. I don't want to do this work, through conflict of interest. "I'll bundle this old lady into a care home. what, we need to make sure it's for the right reasons and not just 'cause it's the easy option? Okay, let's get a review and scrutiny and authorisation - who'll do that - oh, I will!"
But I see the PCT being clueless in the assessment process. So, like capacity assessments, I see a whole slew of referrals to my door, "for an mental health assessment," so we can do most of the work for them. Ho hum.
What's it mean?
If I use the Mental Health Act 1983 and someone's admitted to hospital under this Act for compulsory assessment and treatment, there're lots of safeguards. I can't detain them, for a start. I've never detained anyone in my life. All I can do is make a medical recommendation, which a social worker (all our AMHPs are social workers) then takes and if they reckon it's the right thing to do they give it to hospital managers to receipt, then the hospital managers detain the patient in their hospital. No one person makes the decision, for treatment under Part IV (i.e. compulsory treatment) there also has to be the agreement of another doctor. For some treatments the patient and another doctor have to agree. Some mental health treatments can't even be done no matter what doctors wish, if the patient has so stated. On section 3, the nearest relative can discharge the patient. If I want to place someone with dementia in a care setting under section 7, the nearest relative mustn't object. If the patient doesn't want to be detained, they can appeal to a Mental Health Review Tribunal who can discharge them. The MHRT is a powerful and scary body, they're a court, can hold doctors in Contempt and (other than additional "recommendations" they suggest which I'd duty bound to listen to but technically don't absolutely have to do) what they so goes.
With advocacy, nearest relatives, specialist (section 12 approved) doctors, a second doctor making recommendation for admission, an Approved Mental Health Professional making the decision on whether compulsory admission's right or not, limits on treatment and rights of appeal, the Mental Health Act 1983 seems to have the right balance of framework to ensure mentall unwell folk can get the treatment they need and deserve within a framework of checks and safeguards and scrutiny to protect their liberty and rights.
So far, so good.
The Mental Capacity Act 2005 is different. In many ways it's much simpler. It also has sound principles, stated explicitly right at the start in section 1. It has advocacy inherently embedded in decision making. It has collaborative involvement in decision making enshrined in section 4 (Best Interests decisions).
The difficulty is that it's so broad.
It's how the 17 year old care assistant, in a residential home, decides if Mrs Stainforthe should have a bath this morning, even though she can't say yes or no to that.
It's for non-mental health matters; it's how the solicitor decided if I was a capacitated adult when instructing them in conveyancing when I sold and moved house.
It's for health decisions. It's for financial matters. It's for social choices.
As a broad bit of legislation affecting any assessment of decision making (capacity) and subsequent health and social welfare care within someone's best interests, by anyone involved in their care, it's a massive bit of legislation.
What can you do with it? Why, anything in their best interests (that a Donee, Deputy, court or Advance Decision don't preclude). Really, pretty much anything. Choice of where they live. choice of medication. Choice of who, when and by who they're cared for. Choice of when, where and what surgery they'll have.
So if someone's an incapacitated adult (within the meaning of the Mental Capacity Act 2005) and has dementia and needs to be in a care home, is indifferent to this (and neither can give nor with hold consent, since they lack capacity, but equally they're not actively opting in to or refusing 24 hour care), they can be placed within a 24 hour care home. A best interests meeting is held, then under section 5 they receive care in a care home.
Great, despite not being able to consent, they still get the care they need. This is decided by a team, with involvement of family and all parties.
But, if they don't want to be in a care home, how do they get out? There is no tribunal or appeal process. There is no automatic review process. The family might have objected but the best interest considered then discounted their view and placed their relative in permanent care. Someone's in a locked EMI residential unit, forever, with civilains placing them there and no judicial process to get 'em out. Okay, family could go to court for a Declaration, but the confused patient who doesn't want to be in there's not going to chirp up and progress such a mechanism.
Enter the Deprivation of Liberty Safeguards. Before someone's deprived of their liberty, our Primary Care Trust will have to give Authorisation. Hurrah, libery is safeguarded. Excpet, out PCT didn't know about this, even last December when I met with them. It's a statutory obligation, they have to do it, but even now in January they've no staff and no framework for this work. Each application to the PCT will involve 6 assessments. They have no idea who or how they'll do this.
It's their duty. We don't have the resources to do this work. I don't want to do this work, through conflict of interest. "I'll bundle this old lady into a care home. what, we need to make sure it's for the right reasons and not just 'cause it's the easy option? Okay, let's get a review and scrutiny and authorisation - who'll do that - oh, I will!"
But I see the PCT being clueless in the assessment process. So, like capacity assessments, I see a whole slew of referrals to my door, "for an mental health assessment," so we can do most of the work for them. Ho hum.
Thursday, 11 September 2008
Death
"Certainty? In this world nothing is certain but death and taxes."
- Benjamin Franklin
Well, he has a point.
This week's been frantic. A lot of folk have been unwell and (as is my wont) a nurse and I've been doing a large number of joint visits. One referral from A&E resulted in a section 136 assessment. What's that? It's when police arrest someone in a public place and convey them to a place of safety (erm, that'll be my hospital, then) for an assessment of mental disorder. In theory a section 136 is applied because the person presents as mentally disordered and is in immediate need of control and restraint. In practice it can be used 'cause someone is acting, "a bit odd," but the police would find it hard (and bureacratic) to arrest the man then go through their custody officer to get him into the cells. Oodles of paper work. Best just cart him off to health, then he's their problem. But on this occasion an assessment was indeed appropriate.
Thus, I was asked to see a retired gentleman who was detained because he wanted to kill himself and had flounced out of his partner's home and driven off (but was curiously found very swiftly after a number of mobile 'phone calls he made) yet notionally he wanted to be left alone and sought to kill himself. He'd injected himself with insulin. He could tell me, to the unit, how much. He had all his papers with him so he could relocate and settle in my patch. He'd brought suitcases and personal effects. But, erm, "I'm suicidal, I'm going to kill myself and going to end it all."
The approved social worker did some sleuthing. He's been assessed in 5 neighbouring hospitals with the same presentation. Euphemism : he's problems of anger management. Truth : he batters his partner and blames it on anger that doctors haven't cured. He feels no responsibility for this, he can be violent since, "It's not my fault." It's other people, "They wind me up, play head games, do my fucking head in, doc." So they deserve it? "Well no, but they're kind've askin' for it, really, aren't they? Kinda got it comin' with what they say." Who is responsible then? "Not me, it's them folk in [town blah 30 miles away] who never helped me. They know I fly off the handle dead easy, like, but don't treat me or anything. Nobody cares." Ah, my colleagues in a neighbouring county fail to control your anger, so you batter your partner, you're not responsible and they are, now I see.
Are there any delusions? No.
Are there any hallucinations? No.
Any cognitive impairement or confusion? No.
Any changes in physical health, medication, wellbeing? No.
Any obsessions, compulsions, odd thoughts? No.
Alcohol misuse, drug problems? No.
Erm, anything to affect your judgement at all? "Yes doc, it's her, she's done this to me."
Done what? "Said she can't live wi' me, asked me to go, so I have. But now I want to kill myself."
Ahhh.
He's assessed. Usually a section 136 assessment takes an hour or so. The approved social worker (ASW) wants more details so it goes on a while. He's observed by nursing staff.
Before this event he's had no tiredness, no loss of pleasure, no initial insomnia, no broken sleep, no early morning wakening, no loss of libido, no diurnal variation, no low mood, no hopelessness, no worthlessness, no guilt, no tearfulness. So, no evidence of somatic features of depression a few hours ago, but suicidal now. Crikey.
He's chatty, enjoys watching the telly, talks with patients about his favourite football team and a match he's looking forward to (and how he might drive up to watch it live). He speaks of new things he's ordered and has to collect next month. He talks of accomodation he wants and support he'd need, "I can't cook, like, so I need looking after."
He's expressive, reactive, no psychomotor retardation, no restlessness, no tearfulness, no distress. He speaks fluently, normal rate, rhythm, volume. Spontaneous with neither poverty of speech nor poverty of content. No dysprosody. Mood subjectively "I'm going to kill myself" but objectively is euthymic. Thoughts are of normal form and content. No perceptual anomalies. No cognitive impairement.
The ASW gets a colleague to see him. Then 'phones another. We talk with 3 nurses who've been with him most of the day, now. Reassauringly, everyone feels the same.
Nobody sees any symptoms of mental illness. Nobody feels he's evidence of mental disorder. Nobody feels he's detainable under the Mental Health Act 1983. Everyone sees him as a capacitated adult, able to make his own choices.
He says, "If you let me go, I'm going to kill myself. Don't you have to detain me, don't you have to stop me killing myself?"
I explain that's not the case, I really hope he won't kill himself, but that's his choice.
We arrange a range of accomodation options for him, for today, in a range of locations. We arrange mental health followup from a CPN and Consultant in his own town but he says he won't go to it. "Your choice, we've offered social support, we've offered mental health follow up, if you want to choose to do something else, we can't stop you."
We send him on his way.
I really, really am not sure he'll live. He's impulsive and reckless. The Mental Capacity Act 2005 states that adults with capacity must be allowed to make unwise choices. He's likely to take overdoses and, intentionally or accidentally, at high risk of killing himself through this.
As Mr Vonnegut would say, "So it goes."
- Benjamin Franklin
Well, he has a point.
This week's been frantic. A lot of folk have been unwell and (as is my wont) a nurse and I've been doing a large number of joint visits. One referral from A&E resulted in a section 136 assessment. What's that? It's when police arrest someone in a public place and convey them to a place of safety (erm, that'll be my hospital, then) for an assessment of mental disorder. In theory a section 136 is applied because the person presents as mentally disordered and is in immediate need of control and restraint. In practice it can be used 'cause someone is acting, "a bit odd," but the police would find it hard (and bureacratic) to arrest the man then go through their custody officer to get him into the cells. Oodles of paper work. Best just cart him off to health, then he's their problem. But on this occasion an assessment was indeed appropriate.
Thus, I was asked to see a retired gentleman who was detained because he wanted to kill himself and had flounced out of his partner's home and driven off (but was curiously found very swiftly after a number of mobile 'phone calls he made) yet notionally he wanted to be left alone and sought to kill himself. He'd injected himself with insulin. He could tell me, to the unit, how much. He had all his papers with him so he could relocate and settle in my patch. He'd brought suitcases and personal effects. But, erm, "I'm suicidal, I'm going to kill myself and going to end it all."
The approved social worker did some sleuthing. He's been assessed in 5 neighbouring hospitals with the same presentation. Euphemism : he's problems of anger management. Truth : he batters his partner and blames it on anger that doctors haven't cured. He feels no responsibility for this, he can be violent since, "It's not my fault." It's other people, "They wind me up, play head games, do my fucking head in, doc." So they deserve it? "Well no, but they're kind've askin' for it, really, aren't they? Kinda got it comin' with what they say." Who is responsible then? "Not me, it's them folk in [town blah 30 miles away] who never helped me. They know I fly off the handle dead easy, like, but don't treat me or anything. Nobody cares." Ah, my colleagues in a neighbouring county fail to control your anger, so you batter your partner, you're not responsible and they are, now I see.
Are there any delusions? No.
Are there any hallucinations? No.
Any cognitive impairement or confusion? No.
Any changes in physical health, medication, wellbeing? No.
Any obsessions, compulsions, odd thoughts? No.
Alcohol misuse, drug problems? No.
Erm, anything to affect your judgement at all? "Yes doc, it's her, she's done this to me."
Done what? "Said she can't live wi' me, asked me to go, so I have. But now I want to kill myself."
Ahhh.
He's assessed. Usually a section 136 assessment takes an hour or so. The approved social worker (ASW) wants more details so it goes on a while. He's observed by nursing staff.
Before this event he's had no tiredness, no loss of pleasure, no initial insomnia, no broken sleep, no early morning wakening, no loss of libido, no diurnal variation, no low mood, no hopelessness, no worthlessness, no guilt, no tearfulness. So, no evidence of somatic features of depression a few hours ago, but suicidal now. Crikey.
He's chatty, enjoys watching the telly, talks with patients about his favourite football team and a match he's looking forward to (and how he might drive up to watch it live). He speaks of new things he's ordered and has to collect next month. He talks of accomodation he wants and support he'd need, "I can't cook, like, so I need looking after."
He's expressive, reactive, no psychomotor retardation, no restlessness, no tearfulness, no distress. He speaks fluently, normal rate, rhythm, volume. Spontaneous with neither poverty of speech nor poverty of content. No dysprosody. Mood subjectively "I'm going to kill myself" but objectively is euthymic. Thoughts are of normal form and content. No perceptual anomalies. No cognitive impairement.
The ASW gets a colleague to see him. Then 'phones another. We talk with 3 nurses who've been with him most of the day, now. Reassauringly, everyone feels the same.
Nobody sees any symptoms of mental illness. Nobody feels he's evidence of mental disorder. Nobody feels he's detainable under the Mental Health Act 1983. Everyone sees him as a capacitated adult, able to make his own choices.
He says, "If you let me go, I'm going to kill myself. Don't you have to detain me, don't you have to stop me killing myself?"
I explain that's not the case, I really hope he won't kill himself, but that's his choice.
We arrange a range of accomodation options for him, for today, in a range of locations. We arrange mental health followup from a CPN and Consultant in his own town but he says he won't go to it. "Your choice, we've offered social support, we've offered mental health follow up, if you want to choose to do something else, we can't stop you."
We send him on his way.
I really, really am not sure he'll live. He's impulsive and reckless. The Mental Capacity Act 2005 states that adults with capacity must be allowed to make unwise choices. He's likely to take overdoses and, intentionally or accidentally, at high risk of killing himself through this.
As Mr Vonnegut would say, "So it goes."
Friday, 1 February 2008
Treatment
There's a presumption that patients have a right to treatment.
There's a duty of care that mental health folk have to patients.
There're laws passed (statutory instruments) that give us the tools to undertake this care.
All well and good, most of the time. But what if it's taken to extremes? Who should be treated, and how much, for how long? At best it's quirky and autocratic care, at it's worst it's paternalistic and tyrannical health care. Gets you thinking, this does, when patients crop up with unmet clinical needs that could be treated.
Let's take a lady and call her Alice. Alice is elderly and depressed. She's often had bouts of depression in the past so has a diagnosis of F33.2 Recurrent depressive disorder, current episode severe, without psychotic symptoms. She was unable to look after herself well, feeling weary and disinterested in "stuff to deal with" to get through a day, wasn't eating anything but gingernut biscuits and wasn't drinking much fluid at all. She smoked over 100 cigarettes in a day (usually it's less than 20) and was too demotivated to go and get more so was withdrawing from nicotine abruptly, too. Life's bleak, she'd rather go to sleep and not wake up. She's no energy, no hope, no joy, no quality sleep, no feeling refreshed, no motivation. She feels utterly worthless and a nuisance to everyone.
2 months ago she was right as rain.
In the past when this has happened she's had ECT, been cured, gone home and stayed well for between 10 to 22 months before another depressive episode occurs.
She refuses people coming in to her home to help. It's started anyway, but she doesn't let them in. She refuses hospital admission and is fading away fast. She's admitted under section 3 of the Mental Health Act 1983 for treatment of her underlying mental disorder, depression.
She refuses medication and historically has poor concordance with prescribed medication on discharge, with the only antidepressants in her flat on this occasion being 4 months out of date and untouched.
She's said in the past that she doesn't want ECT again.
Through her depression she's got marked bradyphrenia, depressive cognitions, cognitive distortions and abberant ideation. She's not frankly psychotic, but her thought process are disturbed through her depression so, within the meaning of the Mental Capacity Act 2005, she has imparied function of her mind and is an incapacitated adult (with respect to the decision to determine current treatment such as ECT).
This time, what should happen?
It's not even up for discussion as the law stands; she should have ECT :
- she has a mental disorder
- we have a duty of care
- she has been detained under the Mental Health Act 1983 for the treatment of this mental disorder
- statistically we know ECT is the treatment of choice (better outcomes than tablets, swifter resolution of symptoms, safer with half the mortality of antidepressants) and specifically we know it works very well for her, very quickly, such that's she's well and functioning independently for a year or two even off all medication. So the clinical intervention of choice, for her, at this stage, is ECT
- she refuses ECT and has, in writing, an Advance Decision refusing ECT treatment. But ECT can be given under Part IV of the Mental Health Act 1983 under section 62 then with a Second Opinion doctor agreeing under section 58, so we've a statutory instrument allowing us to deliver the care she needs.
- ECT is given, she gets better after 4 sessions (two weeks) but has 2 more sessions to consolidate the treatment course, she's regraded and discharged and is well
Outcome : a lady got the care she needed when she was unwell and vulnerable and was cured, for a while at least.
As an aside, having taken advice on this, if her Consultant Psychiatrist didn't give her ECT he'd be open to claims of medical negligence (having a duty of care, admitting her for treatment, having a statutory instrument to use to deliver the treatment but then electing not to do this and thus not providing her with the care she needs and deserves). Like it or not, that's the law as it stands today in England.
I'm totally for people with insight making rational decisions about their current and future care. Some people can very sensibly and very thoughtfully describe why they will or won't buy in to treatments offered to them and make a choice on this. Whether I agree or disagree with that choice then, generally, is irrelevant . . . I'm bound to accept their wishes.
The revisions to the Mental Health Act 1983 are making things slightly different. In the future, if you've an Advance Decision to refuse treatment (including ECT treatment) andf that Advance Decision is undertaken in accordance with the Mental Capacity Act 2005, it'll be legally binding. The Mental Health Act 1983 can't then be used to deliver ECT even if the person's incapacitated with regards to this decision.
I wonder what this will mean for Alice.
There's a duty of care that mental health folk have to patients.
There're laws passed (statutory instruments) that give us the tools to undertake this care.
All well and good, most of the time. But what if it's taken to extremes? Who should be treated, and how much, for how long? At best it's quirky and autocratic care, at it's worst it's paternalistic and tyrannical health care. Gets you thinking, this does, when patients crop up with unmet clinical needs that could be treated.
Let's take a lady and call her Alice. Alice is elderly and depressed. She's often had bouts of depression in the past so has a diagnosis of F33.2 Recurrent depressive disorder, current episode severe, without psychotic symptoms. She was unable to look after herself well, feeling weary and disinterested in "stuff to deal with" to get through a day, wasn't eating anything but gingernut biscuits and wasn't drinking much fluid at all. She smoked over 100 cigarettes in a day (usually it's less than 20) and was too demotivated to go and get more so was withdrawing from nicotine abruptly, too. Life's bleak, she'd rather go to sleep and not wake up. She's no energy, no hope, no joy, no quality sleep, no feeling refreshed, no motivation. She feels utterly worthless and a nuisance to everyone.
2 months ago she was right as rain.
In the past when this has happened she's had ECT, been cured, gone home and stayed well for between 10 to 22 months before another depressive episode occurs.
She refuses people coming in to her home to help. It's started anyway, but she doesn't let them in. She refuses hospital admission and is fading away fast. She's admitted under section 3 of the Mental Health Act 1983 for treatment of her underlying mental disorder, depression.
She refuses medication and historically has poor concordance with prescribed medication on discharge, with the only antidepressants in her flat on this occasion being 4 months out of date and untouched.
She's said in the past that she doesn't want ECT again.
Through her depression she's got marked bradyphrenia, depressive cognitions, cognitive distortions and abberant ideation. She's not frankly psychotic, but her thought process are disturbed through her depression so, within the meaning of the Mental Capacity Act 2005, she has imparied function of her mind and is an incapacitated adult (with respect to the decision to determine current treatment such as ECT).
This time, what should happen?
It's not even up for discussion as the law stands; she should have ECT :
- she has a mental disorder
- we have a duty of care
- she has been detained under the Mental Health Act 1983 for the treatment of this mental disorder
- statistically we know ECT is the treatment of choice (better outcomes than tablets, swifter resolution of symptoms, safer with half the mortality of antidepressants) and specifically we know it works very well for her, very quickly, such that's she's well and functioning independently for a year or two even off all medication. So the clinical intervention of choice, for her, at this stage, is ECT
- she refuses ECT and has, in writing, an Advance Decision refusing ECT treatment. But ECT can be given under Part IV of the Mental Health Act 1983 under section 62 then with a Second Opinion doctor agreeing under section 58, so we've a statutory instrument allowing us to deliver the care she needs.
- ECT is given, she gets better after 4 sessions (two weeks) but has 2 more sessions to consolidate the treatment course, she's regraded and discharged and is well
Outcome : a lady got the care she needed when she was unwell and vulnerable and was cured, for a while at least.
As an aside, having taken advice on this, if her Consultant Psychiatrist didn't give her ECT he'd be open to claims of medical negligence (having a duty of care, admitting her for treatment, having a statutory instrument to use to deliver the treatment but then electing not to do this and thus not providing her with the care she needs and deserves). Like it or not, that's the law as it stands today in England.
I'm totally for people with insight making rational decisions about their current and future care. Some people can very sensibly and very thoughtfully describe why they will or won't buy in to treatments offered to them and make a choice on this. Whether I agree or disagree with that choice then, generally, is irrelevant . . . I'm bound to accept their wishes.
The revisions to the Mental Health Act 1983 are making things slightly different. In the future, if you've an Advance Decision to refuse treatment (including ECT treatment) andf that Advance Decision is undertaken in accordance with the Mental Capacity Act 2005, it'll be legally binding. The Mental Health Act 1983 can't then be used to deliver ECT even if the person's incapacitated with regards to this decision.
I wonder what this will mean for Alice.
Sunday, 7 October 2007
Sections
The Mental Health Act 1983 is, obviously, the law. It's a "statutory instrument" that contains provision to detain people with mental health problems and unmet needs in hospital (even though they don't wish to be there). There's a Code of Practice that tells us how we're to use the MHA 1983.
A couple points are worthy of mention.
"Sectioning"
When I was a trainee doctor, we'd get shredded for talking of "sectioning" someone. We were instead to speak of "detaining someone under section blah" which at the time seemed pedantic thought control. One Royal College examiner said he'd failed a candidate for such talk. With hindsight it's sitting increasingly well with me, but p'raps I'm simply becoming more pedantic as time marches on. Being less glib and more professional is important, though.
Being detained
I've never detained anyone. Well, technically not. I've made medical recommendations. Approved Social Workers have made applications to hospital managers for a patient to be detained. Hospital Managers have agreed to detain the patient in their hospital.
Sophistry?
It shouldn't be.
Nurses have to be the patient's advocate, the NMC says so. Curiously, the GMC doesn't have anything like that directing doctors but most of us do feel we have such a role. As such, when we're advocating that a patient has a right to get the help they need and deserve it's useful to be part of the decision making process rather than be painted wholly as the prison warden. We don't detain people, we make recommendations for their care then social workers and hospital managers detain them if that's necessary. As such we can continue to focus on their care. A seemingly tiny point, but such things shift the culture and philosophy of mental health units from paternalistic/abusive to collaborative/clinically driven.
Anyway, I'm a civilian. Should I be locking people up?
Least restrictive setting
We've got to manage patients in the least restrictive setting. Hospital in-patient care should be for folk who have needs that can only be addressed through hospital care and increasingly these are far and few between . . . what can be done in a hospital that teams can't do in the community? There are assessments and interventions, of course. But typically it's rare that there's specific work that a hospital admission does that couldn't be done in the community (which is self evident, given that 1/4 of the population will at some point in their lives experience mental illness, but so few reach Secondary Care services let alone in-patient admission).
Hands up who thinks detaining people is just about hospitals? A not uncommon scenario for me is of someone with dementia who's been diagnosed and treatment's been optomised but they can't manage in the community despite having lots of support. One elderly lady this Summer became more confused at night, thinking since it was light that 9.00pm was 9.00am. She was helped to bed at 8.00pm by home care and would then rise to wander around the street through the night - living on a busy main road made this particularly unsafe. She'd been active at night for many months, it got worse, what were we to do? She was adamant that she wanted to stay at home.
Section 7 of the MHA 1983 lets the local Social Services authority force someone to reside at a specific address (e.g. you now live at Care Home X). As this is then the law, if they leave police are obliged to return them to this property. They're also compelled to attend out-patient clinics, any medical reviews and even non-medical meetings such as job centre attendance, going to a specific place of work, or having to attend specific evening classes as well as having no choice where they live.
All this seems pretty heavy, doesn't it? What I find more perturbing is that the protection patients have within the MHA 1983 are pretty good. The Mental Capacity Act 2005 is far more widely reaching (e.g. allowing community treatment orders against the patient's wishes) but has none of the scrutiny, no need for 2 doctors/doctors with specialist training and experience, no rights of appeal to hospital managers and a Mental Health Review Tribunal and no review dates. Scary.
A couple points are worthy of mention.
"Sectioning"
When I was a trainee doctor, we'd get shredded for talking of "sectioning" someone. We were instead to speak of "detaining someone under section blah" which at the time seemed pedantic thought control. One Royal College examiner said he'd failed a candidate for such talk. With hindsight it's sitting increasingly well with me, but p'raps I'm simply becoming more pedantic as time marches on. Being less glib and more professional is important, though.
Being detained
I've never detained anyone. Well, technically not. I've made medical recommendations. Approved Social Workers have made applications to hospital managers for a patient to be detained. Hospital Managers have agreed to detain the patient in their hospital.
Sophistry?
It shouldn't be.
Nurses have to be the patient's advocate, the NMC says so. Curiously, the GMC doesn't have anything like that directing doctors but most of us do feel we have such a role. As such, when we're advocating that a patient has a right to get the help they need and deserve it's useful to be part of the decision making process rather than be painted wholly as the prison warden. We don't detain people, we make recommendations for their care then social workers and hospital managers detain them if that's necessary. As such we can continue to focus on their care. A seemingly tiny point, but such things shift the culture and philosophy of mental health units from paternalistic/abusive to collaborative/clinically driven.
Anyway, I'm a civilian. Should I be locking people up?
Least restrictive setting
We've got to manage patients in the least restrictive setting. Hospital in-patient care should be for folk who have needs that can only be addressed through hospital care and increasingly these are far and few between . . . what can be done in a hospital that teams can't do in the community? There are assessments and interventions, of course. But typically it's rare that there's specific work that a hospital admission does that couldn't be done in the community (which is self evident, given that 1/4 of the population will at some point in their lives experience mental illness, but so few reach Secondary Care services let alone in-patient admission).
Hands up who thinks detaining people is just about hospitals? A not uncommon scenario for me is of someone with dementia who's been diagnosed and treatment's been optomised but they can't manage in the community despite having lots of support. One elderly lady this Summer became more confused at night, thinking since it was light that 9.00pm was 9.00am. She was helped to bed at 8.00pm by home care and would then rise to wander around the street through the night - living on a busy main road made this particularly unsafe. She'd been active at night for many months, it got worse, what were we to do? She was adamant that she wanted to stay at home.
Section 7 of the MHA 1983 lets the local Social Services authority force someone to reside at a specific address (e.g. you now live at Care Home X). As this is then the law, if they leave police are obliged to return them to this property. They're also compelled to attend out-patient clinics, any medical reviews and even non-medical meetings such as job centre attendance, going to a specific place of work, or having to attend specific evening classes as well as having no choice where they live.
All this seems pretty heavy, doesn't it? What I find more perturbing is that the protection patients have within the MHA 1983 are pretty good. The Mental Capacity Act 2005 is far more widely reaching (e.g. allowing community treatment orders against the patient's wishes) but has none of the scrutiny, no need for 2 doctors/doctors with specialist training and experience, no rights of appeal to hospital managers and a Mental Health Review Tribunal and no review dates. Scary.
Friday, 27 July 2007
Mental Capacity Act 2005
There's been a bit of sneaky legislation.
The Mental Capacity Act 2005
Have you had a rummage around through The Mental Capacity Act 2005 (MCA 2005) yet?
I've read it from cover to cover a couple times now, since it's highly relevant to my work, but even so it was only when a number of lawyers have explained some of it to me that the implications are becoming clear. And scary.
The legislation is broad. It doesn't apply just to mental health, or just to health in fact.
Question : When a social worker determines if a person can make decisions about going in to care, solicitor determines if I have capacity to instruct them on the conveyancing to buy a new house, when a bank clerk determines if someone's capable of managing their finances, whether a frail old lady in a care home can refuse a bath, what test is used in any and all circumstances to decide if I, or whoever, does have capacity to do these things?
Answer : The Mental Capacity Act 2005. It has within it the test that is used to assess capacity. Any capacity. In any situation. For anything. By anyone. So, a pretty big bit of legislation, then.
Good bits
No longer will social workers routinely be able to ask me if a patient on a medical or surgical ward, or in their own home, has capacity to make choices about going in to a care home. The social worker will have to determine that for themselves. It is not a delegable duty. Professionals taking responsiblity for their professional decisions, this is a good thing. Specialists still can give a view in complex cases but that doesn't over ride the decision any other individual makes on their own assessment of capacity.
Worrying bits
Let's assume that I've a patient who lacks capacity to make decisions about their future treatment. Maybe they're too depressed and thought disordered to weigh up choices, benefits, risks, consequences and outcomes of various alternatives. Maybe they're dementing through Alzheimer's disease. Within the meaning of the MCA 2005 this makes them an "incapacitated adult" with respect to this decision on treatment.
Section 5 lets us treat an incapacitated adult.
Positively, it means nurses and carers can deliver care lawfully. The patient needs dressing in a morning, may need help bathing, may need help dressing in nightwear on an evening. Section 5 lets them deliver this hands on care without this undressing of a patient without their consent constituting trespass against the person and criminal assault. Which is a good thing, carers are empowered to deliver care.
Worryingly, it means I can give any care on the understanding, ". . . that it will be in [the patient's] best interests for the act to be done."
The MCA 2005 covers personal welfare (health and social welfare) decisions.
If a muddled patient needs care (medical, nursing or social) such as, say, an injection, it could be given to the adult under the MCA 2005. In fact, ECT or any other treatment can be. Antibiotics, amputation, arthoplasty, whatever is needed and the patient's doesn't have capacity to consent to (but otherwise could consent to).
This effectively obliges us to use community treatment orders. When the MCA 2005 comes fully in to force this Autumn a psychotic patient who doesn't appreciate the role of medication can then have depot antipsychotic medication injected in to them in their own home without their consent.
The safeguards
They're not detained under the Mental Health Act 1983 (MHA 1983), they have none of the protections of the MHA 1983 and no scrutiny or review that the MHA 1983 requires.
An independent MCA advocate (IMCA) can give an opinion and a court appointed deputy can give a direction. If you've made a Lasting Power of Attorney (LPA) then your Donee can give or refuse consent for health and social welfare decisions, if you have empowered them to do so in the LPA. Nobody else can. In all other circumstances then other folks views are taken in to account but the only ones truly empowered and determining what is is the patient's best interests is the multi-disciplinary team.
So if I'm knocking on someone's door with a nurse to inject them in their own home, how can they appeal against this decision? No Mental Health Act Commission review. No second doctor needing another medical recommendation. No Second Opinion Act Doctor (SOAD) approving medication, ECT and so on. No right to appeal (to managers or to a Mental Health Act Commission tribunal). No right of relatives to discharge.
Hmmm, not many safeguards or rights at all, in fact . . .
A thought
1 in 4 of us will experience mental illness at some point in our lives.
Lest, in a moment of lost capacity, malign or unwanted care is benevolently foisted 'pon us, I reckon it's time for us to see our solicitors and sort out Advance Decisions and two Lasting Power of Attorneys (one for Personal Welfare and one for Property and Affairs).
Who's going to win here, then?
Solicitors must be ecstatic with glee.
The Mental Capacity Act 2005
Have you had a rummage around through The Mental Capacity Act 2005 (MCA 2005) yet?
I've read it from cover to cover a couple times now, since it's highly relevant to my work, but even so it was only when a number of lawyers have explained some of it to me that the implications are becoming clear. And scary.
The legislation is broad. It doesn't apply just to mental health, or just to health in fact.
Question : When a social worker determines if a person can make decisions about going in to care, solicitor determines if I have capacity to instruct them on the conveyancing to buy a new house, when a bank clerk determines if someone's capable of managing their finances, whether a frail old lady in a care home can refuse a bath, what test is used in any and all circumstances to decide if I, or whoever, does have capacity to do these things?
Answer : The Mental Capacity Act 2005. It has within it the test that is used to assess capacity. Any capacity. In any situation. For anything. By anyone. So, a pretty big bit of legislation, then.
Good bits
No longer will social workers routinely be able to ask me if a patient on a medical or surgical ward, or in their own home, has capacity to make choices about going in to a care home. The social worker will have to determine that for themselves. It is not a delegable duty. Professionals taking responsiblity for their professional decisions, this is a good thing. Specialists still can give a view in complex cases but that doesn't over ride the decision any other individual makes on their own assessment of capacity.
Worrying bits
Let's assume that I've a patient who lacks capacity to make decisions about their future treatment. Maybe they're too depressed and thought disordered to weigh up choices, benefits, risks, consequences and outcomes of various alternatives. Maybe they're dementing through Alzheimer's disease. Within the meaning of the MCA 2005 this makes them an "incapacitated adult" with respect to this decision on treatment.
Section 5 lets us treat an incapacitated adult.
Positively, it means nurses and carers can deliver care lawfully. The patient needs dressing in a morning, may need help bathing, may need help dressing in nightwear on an evening. Section 5 lets them deliver this hands on care without this undressing of a patient without their consent constituting trespass against the person and criminal assault. Which is a good thing, carers are empowered to deliver care.
Worryingly, it means I can give any care on the understanding, ". . . that it will be in [the patient's] best interests for the act to be done."
The MCA 2005 covers personal welfare (health and social welfare) decisions.
If a muddled patient needs care (medical, nursing or social) such as, say, an injection, it could be given to the adult under the MCA 2005. In fact, ECT or any other treatment can be. Antibiotics, amputation, arthoplasty, whatever is needed and the patient's doesn't have capacity to consent to (but otherwise could consent to).
This effectively obliges us to use community treatment orders. When the MCA 2005 comes fully in to force this Autumn a psychotic patient who doesn't appreciate the role of medication can then have depot antipsychotic medication injected in to them in their own home without their consent.
The safeguards
They're not detained under the Mental Health Act 1983 (MHA 1983), they have none of the protections of the MHA 1983 and no scrutiny or review that the MHA 1983 requires.
An independent MCA advocate (IMCA) can give an opinion and a court appointed deputy can give a direction. If you've made a Lasting Power of Attorney (LPA) then your Donee can give or refuse consent for health and social welfare decisions, if you have empowered them to do so in the LPA. Nobody else can. In all other circumstances then other folks views are taken in to account but the only ones truly empowered and determining what is is the patient's best interests is the multi-disciplinary team.
So if I'm knocking on someone's door with a nurse to inject them in their own home, how can they appeal against this decision? No Mental Health Act Commission review. No second doctor needing another medical recommendation. No Second Opinion Act Doctor (SOAD) approving medication, ECT and so on. No right to appeal (to managers or to a Mental Health Act Commission tribunal). No right of relatives to discharge.
Hmmm, not many safeguards or rights at all, in fact . . .
A thought
1 in 4 of us will experience mental illness at some point in our lives.
Lest, in a moment of lost capacity, malign or unwanted care is benevolently foisted 'pon us, I reckon it's time for us to see our solicitors and sort out Advance Decisions and two Lasting Power of Attorneys (one for Personal Welfare and one for Property and Affairs).
Who's going to win here, then?
Solicitors must be ecstatic with glee.
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