We had a letter about a patient.
Nothing too unusual about that.
The patient was on a ward, having been there for a goodly length of time, detained under the Mental Health Act 1983 for treatment of delusions and hallucinations and passivity. It was the patient's first psychotic episode, the delusions had been managed in the community with the patient's family providing rich support, but the effects on work and relationships and health and risk to self resulted in police bringing him to hospital for assessment and care.
The patient felt that a secret military experiment with satellites was affecting her. She wrote to civil servants, her Member of Parliament and the Prime Minister. She was convinced that her experiences were through technological processes the military were developing and she wanted the experiment on her to stop.
We had a letter from FTAC.
Have you heard of them? I hadn't. The Fixated Threat Assessment Centre (FTAC) was apparently set up in October 2006, according to The Times, and consists of police and mental health workers who "identify suspects." Our patient came to light from their 2 or 3 letters to politicians.
Did you know police screened mail to "identify suspects" and then direct mental health services to intervene? Parliamentary questions have been posed, apparently Mr McNulty had "security, counter terrorism and police" within his portfolio, yet he was the chap explaining FTAC to parliament.
Hmmm. It seems that Big Brother is indeed watching us. And Big Brother's mate is a mental health worker . . .
Showing posts with label liberty. Show all posts
Showing posts with label liberty. Show all posts
Wednesday, 14 October 2009
Friday, 31 July 2009
Work
The Girl asked about managing someone with suicidal risk.
It's a contentious area because how ever you deliver care for these patients, you get it wrong.
If you want no risk, you're overly draconian and coercive and admit everyone. To assess if there's mental disorder and risk to self, you recommend they're admitted under a section of the Mental Health Act 1983 for assessment, if they decline. Why not? A few days assessment to save lives, a fair price to pay, no?
If you want to preserve patient liberty, autonomy and their ownership/control of their problems, choice, collaborative therapeuric working then you'd not detain or admit many at all. So some folk would be suicidal out in the community, with some going on to completed suicide. Whether in-patient care would prevent all that is another issue.
So you admit everyone, thus notionally reducing suicidal risk. Or you don't admit everyone, thus accepting patients (and not Secondary Care) are managing a lot of the risk themselves.
Clearly, not everyone's going to be happy all the time.
It's telling that the first theme that came to me on this issue is risk managament. That's how management of suicidality is taught, reported, framed, documented, written about. The Department of Health and Royal College aren't in the habit of sending me helpful letters about clinical elements and therapeutic elements of care, it's invariably about risk. The Trust doesn't look at quality of care or constituents of care of patient pathways, it looks principally at governance and risk.
I can see that risk management is part of the equation because if the decision's wrong then someone could die. Unlike other areas of medicine, in psychiatry this patient death often could be seen as preventable. Getting the risk management right is therefore vital (in the true sense of the word) since it's about a life.
My first evening on call as an SHO involved section 136 assessments (it was in an age when the SHO did them . . . now I'm a Consultant it's Consultants who do them) and liaison assessments in A&E (again, SHO's did those, now it's not something junior doctors are allowed to do, so it's Consultant work) and GP referrals for assessment (again, this now falls to Consultants). I'd trained as a GP before going in to psychiatry, so prior work in A&E then in GP gave me some confidence in triage, risk management and safety netting, but not the clinical competence to manage acute mental health presentations.
My first night on call involved assessing a lady in her 20's who cut herself. I took took a psychiatric history, went through mental state examination, checked we had a bed for her, 'phoned the on-call Consultant to be told to send her home. I couldn't quite get it. Her self injurious behaviour was seen by the Consultant as a sign of distress, of not being well, of poorly coping, but guessed it was part of her way of coping. I was told to send her home and arrange for her team to see her in the morning.
As time moved on this started to make more sense because what the Consultant had been sifting through was information to suggest whether there was evidence of acute psychiatric illness (necessitating acute care) or whether it was more of a psychological problem (which psychiatry couldn't fix by acute admission).
That really is what an assessment of someone feeling suicidal should be about. It should be about a clinical assessment (rather than an assessment skewed by political drivers) to look at patient need, then consequent care necessary to address that need.
Taken back to basics, this makes assessment of a suicidal patient no more fraught than assessments of someone with a chest infection.
Free will. People have free will. If someone's wishing to hurt or kill themselves and have capacity to make that decision, support can be offered but ultimately it's their choice. We can't use the Mental Health Act 1983 or Mental Capacity Act 2005 if someone's capacitated, with no mental disorder. The harsh reality is therefore that it's likely that someone could elect to kill themselves after being assessed. But if they weren't mentally ill and were offered appropriate support, surely mental health services have done their job.
Believing this has resulted in significant positive risk taking, including sending a gentleman on his way with police who was covered in petrol and threatening to immolate himself. But he wasn't mentally ill.
That's how I personally manage the assessment of suicidality without finding it too scary and being risk averse, I pull back to look at the clinical presentation and consequent need, then simply go from there . . .
It's a contentious area because how ever you deliver care for these patients, you get it wrong.
If you want no risk, you're overly draconian and coercive and admit everyone. To assess if there's mental disorder and risk to self, you recommend they're admitted under a section of the Mental Health Act 1983 for assessment, if they decline. Why not? A few days assessment to save lives, a fair price to pay, no?
If you want to preserve patient liberty, autonomy and their ownership/control of their problems, choice, collaborative therapeuric working then you'd not detain or admit many at all. So some folk would be suicidal out in the community, with some going on to completed suicide. Whether in-patient care would prevent all that is another issue.
So you admit everyone, thus notionally reducing suicidal risk. Or you don't admit everyone, thus accepting patients (and not Secondary Care) are managing a lot of the risk themselves.
Clearly, not everyone's going to be happy all the time.
It's telling that the first theme that came to me on this issue is risk managament. That's how management of suicidality is taught, reported, framed, documented, written about. The Department of Health and Royal College aren't in the habit of sending me helpful letters about clinical elements and therapeutic elements of care, it's invariably about risk. The Trust doesn't look at quality of care or constituents of care of patient pathways, it looks principally at governance and risk.
I can see that risk management is part of the equation because if the decision's wrong then someone could die. Unlike other areas of medicine, in psychiatry this patient death often could be seen as preventable. Getting the risk management right is therefore vital (in the true sense of the word) since it's about a life.
My first evening on call as an SHO involved section 136 assessments (it was in an age when the SHO did them . . . now I'm a Consultant it's Consultants who do them) and liaison assessments in A&E (again, SHO's did those, now it's not something junior doctors are allowed to do, so it's Consultant work) and GP referrals for assessment (again, this now falls to Consultants). I'd trained as a GP before going in to psychiatry, so prior work in A&E then in GP gave me some confidence in triage, risk management and safety netting, but not the clinical competence to manage acute mental health presentations.
My first night on call involved assessing a lady in her 20's who cut herself. I took took a psychiatric history, went through mental state examination, checked we had a bed for her, 'phoned the on-call Consultant to be told to send her home. I couldn't quite get it. Her self injurious behaviour was seen by the Consultant as a sign of distress, of not being well, of poorly coping, but guessed it was part of her way of coping. I was told to send her home and arrange for her team to see her in the morning.
As time moved on this started to make more sense because what the Consultant had been sifting through was information to suggest whether there was evidence of acute psychiatric illness (necessitating acute care) or whether it was more of a psychological problem (which psychiatry couldn't fix by acute admission).
That really is what an assessment of someone feeling suicidal should be about. It should be about a clinical assessment (rather than an assessment skewed by political drivers) to look at patient need, then consequent care necessary to address that need.
Taken back to basics, this makes assessment of a suicidal patient no more fraught than assessments of someone with a chest infection.
Free will. People have free will. If someone's wishing to hurt or kill themselves and have capacity to make that decision, support can be offered but ultimately it's their choice. We can't use the Mental Health Act 1983 or Mental Capacity Act 2005 if someone's capacitated, with no mental disorder. The harsh reality is therefore that it's likely that someone could elect to kill themselves after being assessed. But if they weren't mentally ill and were offered appropriate support, surely mental health services have done their job.
Believing this has resulted in significant positive risk taking, including sending a gentleman on his way with police who was covered in petrol and threatening to immolate himself. But he wasn't mentally ill.
That's how I personally manage the assessment of suicidality without finding it too scary and being risk averse, I pull back to look at the clinical presentation and consequent need, then simply go from there . . .
Thursday, 30 July 2009
Shotguns
To get a shotgun in my corner (I don't know if it's a national requirement), a doctor's statement is needed.
This asserts that the person's sane and isn't going to go around killing lots of people.
Tricky one, that.
How can such an assessment of future risks be undertaken robustly? Locally, one GP practice solves this with a simple question to anyone asking for a shotgun. "Do you want a gun?" Anyone saying, "Yes!" doesn't get one. Most people don't want more guns in our society and think they're scary, so they'll assume that anyone who asks for one shouldn't have one. Their take is that they never offer a statement of support.
It's not NHS work, so my Trust obviously won't suffer me seeing folks in clinics or using patients' NHS time for private fee paying work, so it ain't something I do.
But as someone aligned to more libertarian views, it doesn't sit wholly comfortably with me. Shouldn't folk be able to have latitude to do what they want to do, but with that freedom accept the responsibility of consequences? Yet, with guns and the heightened risks to others this generates, it somehow has a different complexion to debates on drugs or other issues.
This asserts that the person's sane and isn't going to go around killing lots of people.
Tricky one, that.
How can such an assessment of future risks be undertaken robustly? Locally, one GP practice solves this with a simple question to anyone asking for a shotgun. "Do you want a gun?" Anyone saying, "Yes!" doesn't get one. Most people don't want more guns in our society and think they're scary, so they'll assume that anyone who asks for one shouldn't have one. Their take is that they never offer a statement of support.
It's not NHS work, so my Trust obviously won't suffer me seeing folks in clinics or using patients' NHS time for private fee paying work, so it ain't something I do.
But as someone aligned to more libertarian views, it doesn't sit wholly comfortably with me. Shouldn't folk be able to have latitude to do what they want to do, but with that freedom accept the responsibility of consequences? Yet, with guns and the heightened risks to others this generates, it somehow has a different complexion to debates on drugs or other issues.
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, 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.
Wednesday, 6 August 2008
Meddling
When to meddle?
I've a lady who's not coping perfectly well (past diagnoses include panic disorder (moderate), major depressive disorder, emotionally unstable personality disorder (impulsive type), PTSD) but manages. She's been managing for a few years, now. I know this because I've been seeing her at home at frequent intervals over the last couple years. She's making errors (unable to recall recent events accurately, unable to appreciate the value of assetts, unable to understand meaning behind interactions). She has been prompted to do activities of daily living for years, so cues in to meal times, bed time, time to bathe, when to change clothes according to when she's directed to do so. She only takes medication when prompted to do so.
She lives with her husband. He has mild dementia. He has coped with her mental health problems and his role as carer through self medicating with half a bottle of spirits a day, every day, for years. He doesn't act on things adeptly but in fairness this is longstanding and hasn't changed (e.g. every time I go I end up throwing out mouldy rotten food from their fridge). Sometimes he drinks more, gets drunk and falls over. Every couple months an ambulance crew attend.
Social services have offered support which has been accepted then after a short time refused. They don't want folk in their home, meddling.
He prompts her to take medication. He does this suboptimally. She has arthritic pains and dyspepsia. He gives her over the counter medication including paracetamol, ibuprofen and aspirin. The NSAIDs will probably be making her dyspepsia worse but since they're pain killers and she has mediastinal/stomach pains, they use more of them. Ho hum.
It's not a great situation, is it? But, somehow, they've managed for a year or so, limping along together. No serious harm has befallen them. They're living as they wish to, together, in their own home. On deciding future care and where to reside, both are incapacitated adults, within the meaning of the Mental Capacity Act 2005.
They're refusing practical support. There's no medication that can improve their experiences or mitigate risks. The choices are therefore quite stark. Do we leave them to limp along, or are they placed in 24 hour care?
I've a lady who's not coping perfectly well (past diagnoses include panic disorder (moderate), major depressive disorder, emotionally unstable personality disorder (impulsive type), PTSD) but manages. She's been managing for a few years, now. I know this because I've been seeing her at home at frequent intervals over the last couple years. She's making errors (unable to recall recent events accurately, unable to appreciate the value of assetts, unable to understand meaning behind interactions). She has been prompted to do activities of daily living for years, so cues in to meal times, bed time, time to bathe, when to change clothes according to when she's directed to do so. She only takes medication when prompted to do so.
She lives with her husband. He has mild dementia. He has coped with her mental health problems and his role as carer through self medicating with half a bottle of spirits a day, every day, for years. He doesn't act on things adeptly but in fairness this is longstanding and hasn't changed (e.g. every time I go I end up throwing out mouldy rotten food from their fridge). Sometimes he drinks more, gets drunk and falls over. Every couple months an ambulance crew attend.
Social services have offered support which has been accepted then after a short time refused. They don't want folk in their home, meddling.
He prompts her to take medication. He does this suboptimally. She has arthritic pains and dyspepsia. He gives her over the counter medication including paracetamol, ibuprofen and aspirin. The NSAIDs will probably be making her dyspepsia worse but since they're pain killers and she has mediastinal/stomach pains, they use more of them. Ho hum.
It's not a great situation, is it? But, somehow, they've managed for a year or so, limping along together. No serious harm has befallen them. They're living as they wish to, together, in their own home. On deciding future care and where to reside, both are incapacitated adults, within the meaning of the Mental Capacity Act 2005.
They're refusing practical support. There's no medication that can improve their experiences or mitigate risks. The choices are therefore quite stark. Do we leave them to limp along, or are they placed in 24 hour care?
Thursday, 3 January 2008
Free Care
The NHS, notionally, is free at the point of contact.
Okay, we pay for prescriptions and eye tests and dental work but, for the most part, it's true that most of the NHS is free at the point of delivery.
Excellent.
Health care is delivered without charge.
But, the huge grey cloud dominating the faint silver lining is that social care is not free. We pay a lot in to social care as taxpayers (over twice what we pay in to health) and then the recipients of social care (when patients) invariably pay for it, too.
If I've a patient who's not coping awfully well at home but can manage with support, they're helped and usually manage in their own home for a goodly length of time, sometimes indefinately. Get a cleaner to do the housework, Social Services to arrange 4 social care visits a day to help with personal care, prompting with medication, checking they're alright (although officially that can't be the reason for their visit), helping heat up a meal for them and acting a resource to sort out problems (letters they don't understand, or whatever). Their loneliness and weary days can be addressed in part through social day care where they've more vibrant company with local folk and ongoing support.
But none of this is NHS work, none of it is free. They pay for their cleaner, they pay for each home care visit, they pay for their meals delivering, they pay for their day care.
The exception . . . if you're detained under section 3 of the Mental Health Act 1983 then you're entitled to section 117 aftercare. The Code of Practice states that this, ". . . require health and local authorities . . . to provide after-care for patients who have been detained under the longer-term provisions of the Act . . . until they are satisfied that is is no longer necessary . . . section 117 obligations have statutory force."
This means if I'm involved in a detained patient's care and consider a care package such as social care visits would be useful, we can't force the patient to spend their money on this (but they have no choice but to be in hospital and have treatment) so any social care is paid for by the local authority (i.e. Social Services). On leaving hospital, both health care and social care is free.
Bit of a puzzle, this. If we manage folk as we do, keeping them in their own homes where they wish to be for as long as possible then their family and they choose a 24 hour care home if things progress and it's necessary, they're enjoying time in their own home (i.e. in the least restrictive setting) and all is well. If we drag them kicking and screaming in to hospital under section 3, when they leave hospital everything's free.
The General Medical Council document from 2006, "Good Medical Practice", states the duties of a doctor registered with the GMC with the first and foremost requirement being, "Make the care of your patient your first concern."
Care, not health. Hmmm. Should we be detaining everyone, so their social care is free?
Okay, we pay for prescriptions and eye tests and dental work but, for the most part, it's true that most of the NHS is free at the point of delivery.
Excellent.
Health care is delivered without charge.
But, the huge grey cloud dominating the faint silver lining is that social care is not free. We pay a lot in to social care as taxpayers (over twice what we pay in to health) and then the recipients of social care (when patients) invariably pay for it, too.
If I've a patient who's not coping awfully well at home but can manage with support, they're helped and usually manage in their own home for a goodly length of time, sometimes indefinately. Get a cleaner to do the housework, Social Services to arrange 4 social care visits a day to help with personal care, prompting with medication, checking they're alright (although officially that can't be the reason for their visit), helping heat up a meal for them and acting a resource to sort out problems (letters they don't understand, or whatever). Their loneliness and weary days can be addressed in part through social day care where they've more vibrant company with local folk and ongoing support.
But none of this is NHS work, none of it is free. They pay for their cleaner, they pay for each home care visit, they pay for their meals delivering, they pay for their day care.
The exception . . . if you're detained under section 3 of the Mental Health Act 1983 then you're entitled to section 117 aftercare. The Code of Practice states that this, ". . . require health and local authorities . . . to provide after-care for patients who have been detained under the longer-term provisions of the Act . . . until they are satisfied that is is no longer necessary . . . section 117 obligations have statutory force."
This means if I'm involved in a detained patient's care and consider a care package such as social care visits would be useful, we can't force the patient to spend their money on this (but they have no choice but to be in hospital and have treatment) so any social care is paid for by the local authority (i.e. Social Services). On leaving hospital, both health care and social care is free.
Bit of a puzzle, this. If we manage folk as we do, keeping them in their own homes where they wish to be for as long as possible then their family and they choose a 24 hour care home if things progress and it's necessary, they're enjoying time in their own home (i.e. in the least restrictive setting) and all is well. If we drag them kicking and screaming in to hospital under section 3, when they leave hospital everything's free.
The General Medical Council document from 2006, "Good Medical Practice", states the duties of a doctor registered with the GMC with the first and foremost requirement being, "Make the care of your patient your first concern."
Care, not health. Hmmm. Should we be detaining everyone, so their social care is free?
Thursday, 13 December 2007
Social Care
It's not often that I recommend that a patient is detained under the Mental Health Act 1983, but this week I had cause to do just that. That makes 3 patients detained this year, not bad for a full time Consultant Psychiatrist and less than my colleagues, but I'm still conscious that it's loss of liberty and choice for 3 people at a distressing time in their lives.
This week it was a gentleman who's thoroughly confused but has never been seen by mental health services. He's been living in squalour for months. Social services visited him, he declined help, they left him. This seems frankly criminal, given the state he was in. His fridge didn't work and had only rotten food that was composting down in it. Milk bottles were full of solid milk. Items on the floor were shredded by rodents. Dead mice and mice droppings littered the rooms and stairs. Urine and faeces was soaked in to him, his clothes, his furniture. He was unkempt, unwashed for months, had debris stuck to him and his clothing and smelt of the urine and faeces that he'd been generating and sitting in for months. Broken glass was on his lawn, porch and stairs. He had no heating and we discovered the reason his fridge wasn't working and he was sitting in gloom was because he had no electricity. Now I know I'm just a medic and not a trained Social Worker, but this does seem a curiously suboptimal state of social wellbeing to leave a chap in.
I've no idea if he's toxic through infection or if he's cancer that's metastasised to his brain (he's had cancer in the past that was cut out but he never attended follow up), if he's nutritional deficits (I can't imagine he hasn't, though) or if he's dementing. So he's now on my ward, detained under section 2, a month after social services visited his home then left him in this state.
I don't believe a Social Worker could necessarily have prevented his confusion but they could have organised the social care he needed and deserved.
Much badness.
This week it was a gentleman who's thoroughly confused but has never been seen by mental health services. He's been living in squalour for months. Social services visited him, he declined help, they left him. This seems frankly criminal, given the state he was in. His fridge didn't work and had only rotten food that was composting down in it. Milk bottles were full of solid milk. Items on the floor were shredded by rodents. Dead mice and mice droppings littered the rooms and stairs. Urine and faeces was soaked in to him, his clothes, his furniture. He was unkempt, unwashed for months, had debris stuck to him and his clothing and smelt of the urine and faeces that he'd been generating and sitting in for months. Broken glass was on his lawn, porch and stairs. He had no heating and we discovered the reason his fridge wasn't working and he was sitting in gloom was because he had no electricity. Now I know I'm just a medic and not a trained Social Worker, but this does seem a curiously suboptimal state of social wellbeing to leave a chap in.
I've no idea if he's toxic through infection or if he's cancer that's metastasised to his brain (he's had cancer in the past that was cut out but he never attended follow up), if he's nutritional deficits (I can't imagine he hasn't, though) or if he's dementing. So he's now on my ward, detained under section 2, a month after social services visited his home then left him in this state.
I don't believe a Social Worker could necessarily have prevented his confusion but they could have organised the social care he needed and deserved.
Much badness.
Saturday, 10 November 2007
Text Messages
A chap broke up with his partner of 3 to 4 months.
They started sending increasingly acrimonious text messages to one another.
Laughing with his brother he said, "this'll wind her up!" and texted her saying he'd go to the woods and kill himself.
She 'phones the police saying she's had 40 texts from him that day and he was suicidal. Police find him late afternoon and detain him under section 136 of the Mental Health Act 1983 and drag him to my hospital. Where he's laughing and smiling and well. Obviously so.
It's hours before an Approved Social Worker (ASW) could visit since they were busy with other distraught folk.
At almost midnight, the ASW arrives so she and I assess him. After a few minutes it's clear he's neither suicidal nor ill. Being zealous I spend an hour and check everything and find him to be absolutely fine and well, far better than most folk are, in truth! Cheerful, happy with his life (and new partner), no stresses, physically well, great relationships with family, no worries about anything and looking incredibly well.
The moral of the tale : Don't text folk saying you're suicidal as a joke, or police will detain you for an evening/night (with risks of it all going pear shaped after that "just in case"). Even after break ups, play nice :-)
They started sending increasingly acrimonious text messages to one another.
Laughing with his brother he said, "this'll wind her up!" and texted her saying he'd go to the woods and kill himself.
She 'phones the police saying she's had 40 texts from him that day and he was suicidal. Police find him late afternoon and detain him under section 136 of the Mental Health Act 1983 and drag him to my hospital. Where he's laughing and smiling and well. Obviously so.
It's hours before an Approved Social Worker (ASW) could visit since they were busy with other distraught folk.
At almost midnight, the ASW arrives so she and I assess him. After a few minutes it's clear he's neither suicidal nor ill. Being zealous I spend an hour and check everything and find him to be absolutely fine and well, far better than most folk are, in truth! Cheerful, happy with his life (and new partner), no stresses, physically well, great relationships with family, no worries about anything and looking incredibly well.
The moral of the tale : Don't text folk saying you're suicidal as a joke, or police will detain you for an evening/night (with risks of it all going pear shaped after that "just in case"). Even after break ups, play nice :-)
Thursday, 8 November 2007
Family
I've a gentleman with dementia. Properly, he's got ICD-10 F00.12 Alzheimer's disease, late onset, severe.
He couldn't manage at home, had support, progressed, had respite care and now is in permanent care within an EMI Residential Home.
He is happy.
Within the meaning of the Mental Capacity Act 2005, with regard to decisions on his placement and future care, he's an incapacitated adult.
I have seen him many times at this care home, he always has been settled, cared for and content. My nursing colleagues see him and find him equally well. An Occupational Therapist assessed him. A Physiotherapist has looked at his mobility of late, as it's deteriorated. A Dietician saw him 2 weeks ago to give advice on dietetic input. A Modern Matron from the PCT saw him recently to look at pressure care and prevention of sacral sores (which he's never had, but he's increasingly sedentary). His GP reviews him episodically to consider physical health concerns (episodic joint pain and cramps, mostly). An external Independent Mental Capacity Advocate (IMCA) reviewed care and felt it would be in his best interests to remain in that care home receiving the care he was receiving.
His mental health has been stable, he's on no medication at all and hasn't needed any.
The EMI Residential care home has had two unannounced visits from the regulatory body CSCI this year and found to be absolutely fine. With so many professionals going in, often unannounced when we're in the area, we've also found everything to be fine. Scrutiny of the care plans show care to be fine. No families or residents have complaints/issues.
So, my patient's in a good care home receiving good care that oodles of professionals over a many months consistently see to be the case.
The home feels they may have to serve notice on him. They do not want to, they feel great warmth for him and enjoy caring for him (which they do well). They're very patient centred, if he has sleep disruption (as he does) and wants a bath at 2.00am (as he did) then he has one. When he was offered food at meal times but declined then was hungry later on he ate pizza just before midnight. They're sensitive to his care and are very accomodating.
My patient has 2 daughters. One thinks he's getting great care. She told me today that every time she visits dad,"He's happy, and that's the most important thing." She thinks he's well cared for. She wants him to stay there.
Another daughter wants him moved. She has no formal mental illness diagnosed but in the couple years I've (endlessly) seen her I'd wager good coin she's got a personality disorder. Maybe this is kinder than her sister who says she's a "vile woman" who's been "thinking of herself all her life" and "is wicked."
This daughter concedes that all major care is delivered (he is fed, washed, toileted, mobilised and so on) but that the quality of care falls short of what she wants. So she harasses staff. Daily. And generates prolific pages of complaints. Endlessly.
Protection of Vulnerable Adults (POVA) was initiated but hasn't had helpful outcomes since the daughter's malign influence hasn't been sufficient to enable police or agencies to be involved. The POVA meeting recognised she lied and mislead people and misrepresented people's views.
My patient's happy. He's happy to stay there. The care home want him to stay there. The professionals feel he's best placed there. The independent IMCA feels he should stay there. One daughter wants him to stay there. The other daughter (who's the nearest relative) makes it untenable for the staff to look after him (and has moved him 3 times already).
The evidence base is that if he were to move at this stage in his illness he'll be dead within 12 months.
Is there any lawful way we can prevent the nearest relative from visiting her father when she's impacting so negatively on the home that her father's best interests are not being served?
He couldn't manage at home, had support, progressed, had respite care and now is in permanent care within an EMI Residential Home.
He is happy.
Within the meaning of the Mental Capacity Act 2005, with regard to decisions on his placement and future care, he's an incapacitated adult.
I have seen him many times at this care home, he always has been settled, cared for and content. My nursing colleagues see him and find him equally well. An Occupational Therapist assessed him. A Physiotherapist has looked at his mobility of late, as it's deteriorated. A Dietician saw him 2 weeks ago to give advice on dietetic input. A Modern Matron from the PCT saw him recently to look at pressure care and prevention of sacral sores (which he's never had, but he's increasingly sedentary). His GP reviews him episodically to consider physical health concerns (episodic joint pain and cramps, mostly). An external Independent Mental Capacity Advocate (IMCA) reviewed care and felt it would be in his best interests to remain in that care home receiving the care he was receiving.
His mental health has been stable, he's on no medication at all and hasn't needed any.
The EMI Residential care home has had two unannounced visits from the regulatory body CSCI this year and found to be absolutely fine. With so many professionals going in, often unannounced when we're in the area, we've also found everything to be fine. Scrutiny of the care plans show care to be fine. No families or residents have complaints/issues.
So, my patient's in a good care home receiving good care that oodles of professionals over a many months consistently see to be the case.
The home feels they may have to serve notice on him. They do not want to, they feel great warmth for him and enjoy caring for him (which they do well). They're very patient centred, if he has sleep disruption (as he does) and wants a bath at 2.00am (as he did) then he has one. When he was offered food at meal times but declined then was hungry later on he ate pizza just before midnight. They're sensitive to his care and are very accomodating.
My patient has 2 daughters. One thinks he's getting great care. She told me today that every time she visits dad,"He's happy, and that's the most important thing." She thinks he's well cared for. She wants him to stay there.
Another daughter wants him moved. She has no formal mental illness diagnosed but in the couple years I've (endlessly) seen her I'd wager good coin she's got a personality disorder. Maybe this is kinder than her sister who says she's a "vile woman" who's been "thinking of herself all her life" and "is wicked."
This daughter concedes that all major care is delivered (he is fed, washed, toileted, mobilised and so on) but that the quality of care falls short of what she wants. So she harasses staff. Daily. And generates prolific pages of complaints. Endlessly.
Protection of Vulnerable Adults (POVA) was initiated but hasn't had helpful outcomes since the daughter's malign influence hasn't been sufficient to enable police or agencies to be involved. The POVA meeting recognised she lied and mislead people and misrepresented people's views.
My patient's happy. He's happy to stay there. The care home want him to stay there. The professionals feel he's best placed there. The independent IMCA feels he should stay there. One daughter wants him to stay there. The other daughter (who's the nearest relative) makes it untenable for the staff to look after him (and has moved him 3 times already).
The evidence base is that if he were to move at this stage in his illness he'll be dead within 12 months.
Is there any lawful way we can prevent the nearest relative from visiting her father when she's impacting so negatively on the home that her father's best interests are not being served?
Sunday, 19 August 2007
Containment
I'm a doctor. The professionals I work with with most are nurses. We're part of the local health community, improving health through helping patients and supporting GP colleagues.
We try to help patients a lot, seeing every new referral within days, sorting out usually at least half a dozen (and up to 15, recently) helpful interventions to improve things with them. We invariably work with them rather than passively doing things to them. Last year I had a ward for several months with no inpatients at all . . . if we can help folk cope in the community (even with significant risk present) then we do.
Last year I managed 11 months without any use of the Mental Health Act at all, but in December had to recommend admission under a section of the Mental Health Act 1983 (MHA 1983) for one individual.
Overall we admit seldom and compulsory admission is pretty rare. Patients trust us, and rightly so.
Zarathustra has provoked discussion about assessment for treatment. Rather than derailing his thread with rambling comments I wanted really to take it away from the discussion on legislation and Code of Practice and towards implications arising from a shift in culture.
At the moment patients who have mental health problems and present criminal risk (of harming others) have their health needs treated. This is done mostly in psychiatric hospitals (and sometimes in the community) and what can't be treated isn't treated. Obviously. Because it can't be treated. When such an individual then makes threats to harm others they're then managed through the Criminal Justice route, being locked up in prison if necessary.
This makes sense to me.
If you're being bad 'cause you're ill, society believes we should treat the illness, get the person well and all is good.
If you're being bad 'cause you're choosing to be bad (and you're not ill), you go to the courts.
If you're being bad and it's all a bit of as muddle then section 35 of the MHA 1983 means that instead of remanding the person in prison they're admitted to a psychiatric hospital for preparation of reports for the court (initially for 28 days then renewed by the court for up to 12 weeks).
Courts can then make sensible decisions as to how much a person's actions are their own elective choices and how much arises through mental illness.
At present, even with mental illness being present, most folk go to prison not hospital. If you've a violently explosive personality and hit people a lot, you've tried to "get help" but that's just how you are, what can a hospital do for you? It can contain you. Keep you locked up so you don't hit people. It's not improving you, it's not helping you in any meaningful way, it's simply reducing risk to people at large through containing you. Since this role is served better by prisons, unsurprisingly most violent individuals with F60.2 Dissocial Personality Disorder (also called psychopathic) who can't be improved/cured are in prison. They're contained.
There's a fashionable idea in the corridors of power that these folk should be in hospitals. In fact, anyone who's a risk to the public and is mentally ill should be locked up in psychiatric hospitals. Given we can't cure these people and we've no way of evidencing a reduction in risk at some point in the future, they've no easy way of getting out. Ever.
Do we want psychiatric units which currently serve vulnerable, distressed individuals who are unwell to be awash with folk who are violent and essentially untreatable? If patients see mental health work not as collaborative partnership but as a scary unsafe world with folk locking people away for ever "just in case" I'd see the essence of care being thoroughly undermined and the positive culture (that we're finally coming to experience) will be lost.
Health care should do the caring for the peoples' health. Prisons and specialist forensic units should do containment. I can't see how else folk with mental health problems would ever be tempted to enthusiastically seek out and engage with mental health services.
We try to help patients a lot, seeing every new referral within days, sorting out usually at least half a dozen (and up to 15, recently) helpful interventions to improve things with them. We invariably work with them rather than passively doing things to them. Last year I had a ward for several months with no inpatients at all . . . if we can help folk cope in the community (even with significant risk present) then we do.
Last year I managed 11 months without any use of the Mental Health Act at all, but in December had to recommend admission under a section of the Mental Health Act 1983 (MHA 1983) for one individual.
Overall we admit seldom and compulsory admission is pretty rare. Patients trust us, and rightly so.
Zarathustra has provoked discussion about assessment for treatment. Rather than derailing his thread with rambling comments I wanted really to take it away from the discussion on legislation and Code of Practice and towards implications arising from a shift in culture.
At the moment patients who have mental health problems and present criminal risk (of harming others) have their health needs treated. This is done mostly in psychiatric hospitals (and sometimes in the community) and what can't be treated isn't treated. Obviously. Because it can't be treated. When such an individual then makes threats to harm others they're then managed through the Criminal Justice route, being locked up in prison if necessary.
This makes sense to me.
If you're being bad 'cause you're ill, society believes we should treat the illness, get the person well and all is good.
If you're being bad 'cause you're choosing to be bad (and you're not ill), you go to the courts.
If you're being bad and it's all a bit of as muddle then section 35 of the MHA 1983 means that instead of remanding the person in prison they're admitted to a psychiatric hospital for preparation of reports for the court (initially for 28 days then renewed by the court for up to 12 weeks).
Courts can then make sensible decisions as to how much a person's actions are their own elective choices and how much arises through mental illness.
At present, even with mental illness being present, most folk go to prison not hospital. If you've a violently explosive personality and hit people a lot, you've tried to "get help" but that's just how you are, what can a hospital do for you? It can contain you. Keep you locked up so you don't hit people. It's not improving you, it's not helping you in any meaningful way, it's simply reducing risk to people at large through containing you. Since this role is served better by prisons, unsurprisingly most violent individuals with F60.2 Dissocial Personality Disorder (also called psychopathic) who can't be improved/cured are in prison. They're contained.
There's a fashionable idea in the corridors of power that these folk should be in hospitals. In fact, anyone who's a risk to the public and is mentally ill should be locked up in psychiatric hospitals. Given we can't cure these people and we've no way of evidencing a reduction in risk at some point in the future, they've no easy way of getting out. Ever.
Do we want psychiatric units which currently serve vulnerable, distressed individuals who are unwell to be awash with folk who are violent and essentially untreatable? If patients see mental health work not as collaborative partnership but as a scary unsafe world with folk locking people away for ever "just in case" I'd see the essence of care being thoroughly undermined and the positive culture (that we're finally coming to experience) will be lost.
Health care should do the caring for the peoples' health. Prisons and specialist forensic units should do containment. I can't see how else folk with mental health problems would ever be tempted to enthusiastically seek out and engage with mental health services.
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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