11- Consent, capacity and advanced care planning

Question 1

what is consent

Answer 1

• ‘permission for something to happen or agreement to do something’*
• in medicine often involves a patient providing permission for a treatment or investigation

Question 2

three types of consent

Answer 2

1. Informed
2. Expressed
3. Implied

Question 3

how can consent be provided

Answer 3

1. Written consent- most legally binding
2. Oral consent- less legally substantial

• ensure documented in notes
  1. implied consent- least legally binding
• may be misinterpreted

Question 4

why is consent importnant

Answer 4

• patient has right to preserved their body integrity
• if consent not obtained- dr can be sued for battery
• promotes good dr patient relationship

Question 5

refusal of consent

Answer 5

• competent adult has the right to refuse lifesaving treatment
• patient can withdraw consent at any time

Question 6

valid consent

Answer 6

• patient must be fully informed
• patient must be competent to provide consent
• consent must be voluntary

Question 7

informed consent

Answer 7

• nature of treatment/investigation
• why it is needed
• how the procedure will be performed
• riska dn benefits
• alternative treatments
• likely success

Question 8

Capacity- competent consent

Answer 8

Mental Capacity Act 2007

1. Patient must understand relevant info provided - could ask patient to repeat back info
2. Retain information
3. Weigh up pros and cons to make informed decision
4. Communicate decision to doctor (talking, sign or writing)

Question 9

special circumstances of consent

Answer 9

doctorss can provide treatment without consent when

• emergency situtation with an incompetent adult
• mentally ill patients
• children <16 yrs

Question 10

Consent in minors
Young children and older children who are not Gillick competent cannot consent for themselves. In British law the patient’s biological mother can always provide consent. The childs father can consent if the parents are married (and the father is the biological father), or if the father is named on the birth certificate (irrespective of marital status). If parents are not married and the father is not named on the birth certificate then the father cannot consent.

Answer 10

Young children and older children who are not Gillick competent cannot consent for themselves.

• In British law the patient’s biological mother can always provide consent.
• The childs father can consent if the parents are married (and the father is the biological father), or if the father is named on the birth certificate (irrespective of marital status).
• If parents are not married and the father is not named on the birth certificate then the father cannot consent.

Question 11

Gillick and fraser competence

Answer 11

• Gillick competency is often used in a wider context to help assess whether a child <16 has the maturity to make their own decisions and to understand the implications of those decisions.
• The Fraser guidelines still apply to advice and treatment relating to contraception and sexual health.

Question 12

Consent forms used in UK NHS

Answer 12

Question 13

Principles used when a patient lacks capacity

Answer 13

• Make care of patient first concern
• Treat patients as individuals and respect their dignity
• Support patients to be involved
• Treat patients with respect and do not discriminate against them
• Use any advocates the person may have previously identified
• Decisions must take into consideration what the person would have wanted should they have had the capacity to make a decision

Question 14

things to consider when a patients lacks capacity

Answer 14

• Is lack of capacity temporary or permanent?
• Which options would provide overall benefit?
• Which option is least restrictive of patient’s future choices?
• Has patient any previously expressed preferences (advanced decision/statement)?
• Have you considered the view of those close to the patient and whether they believe this is in the patient’s best interests?
• Any decision made must be in the best interests of the person

Question 15

2 stage test for capacity (MCA 2005)

Answer 15

1) Does the person have an impairment/disturbance of their mind or brain?

→ temporary or permanent, as a result of illness or external factors (such as EtOH) or drug use)

2) Is this impairment/disturbance sufficient that the person is unable to make a specific decision when they to?

Question 16

who to consult if a person lacks capacity

Answer 16

• Next of kin (NoK)
• Family/friends
• Persons involved in care
• IMCA (independent mental capacity advocate)
  
  • If no representatives exist and decision can wait
  • Decision long term placement
    
    • Only advises, final decision with healthcare team

Question 17

if person lacks capacity and no LPA/ valid advanced statement

Answer 17

best interest decision made

Question 18

best interest decision principles

Answer 18

Encourage participation of the person

You should do whatever is reasonably possible to permit and encourage the person who lacks capacity to take part, or to improve their ability to take part in making the decision.

Identify all relevant circumstances

You should try to identify all of the things that the person who lacks capacity would take into account if they were making the decision for themselves.

Find out the person’s views

You should try to find out the views of the person who lacks capacity, including:

1. Their past wishes and feelings about the matter to be decided;
2. Their present wishes and feelings about the matter to be decided;
3. Any beliefs or values that would be likely to influence the decision in question (for example religious, cultural, moral or political beliefs); and
4. Any other factors that the person would be likely to consider if they were making the decision or acting for themselves.

Question 19

remember that capacity is

Answer 19

• time specific
  
  • e.g. if drunk
• decision specific
  
  • patient may be able to consent to some things e.g. take para , but not others e.g. for operation

Question 20

define lasting power of attorney

Answer 20

A lasting power of attorney (LPA) is a way of giving someone you trust, your attorney, the legal authority to make decisions on your behalf if you lose the mental capacity to do so in the future, or if you no longer want to make decisions for yourself.

There are two types of LPA:

• LPA for financial decisions
• LPA for health and care decisions.

Question 21

LPA for health and care decisions

Answer 21

This covers health and care decisions and can only be used once you have lost mental capacity. An attorney can generally make decisions about things such as:

• where you should live
• your medical care
• what you should eat
• who you should have contact with
• what kind of social activities you should take part in.

You can also give special permission for your attorney to make decisions about life-saving treatment.

Question 22

define public guardian

Answer 22

The role of the Public Guardian is to protect people who lack capacity from abuse. The Public Guardian, supported by the Office of the Public Guardian (OPG), helps protect people who lack capacity by: Setting up and managing a register of Lasting Powers of Attorney (LPA);

Question 23

define deputies

Answer 23

You can apply to become someone’s deputy if they ‘lack mental capacity’. This means they cannot make a decision for themselves at the time it needs to be made. They may still be able to make decisions for themselves at certain times.

People may lack mental capacity because, for example:

• they’ve had a serious brain injury or illness
• they have dementia
• they have severe learning disabilities

As a deputy, you’ll be authorised by the Court of Protection to make decisions on their behalf.

Question 24

define independent mental capacity advocate

Answer 24

IMCAs are a legal safeguard for people who lack the capacity to make specific important decisions: including making decisions about where they live and about serious medical treatment options. IMCAs are mainly instructed to represent people where there is no one independent of services, such as a family member or friend, who is able to represent the person.

Question 25

define independent mental health advocate

Answer 25

Independent Mental Health Advocates (IMHAs) support people with issues relating to their mental health care and treatment. They also help people understand their rights under the Mental Health Act.

Who can get an advocate?

Advocates can support people who are

• detained under the Mental Health Act (except under short term sections 4, 5, 135 and 136)
• conditionally discharged restricted patients
• subject to a Community Treatment Order
• subject to guardianship
• being considered for S57 or S58A treatment, or Electro-Convulsive Therapy

Question 26

what are Deprivation of liberty safeguards (DoLs)

Answer 26

The Deprivation of Liberty Safeguards is the procedure prescribed in law when it is necessary to deprive of their liberty a resident or patient who lacks capacity to consent to their care and treatment in order to keep them safe from harm.

→ for vulnerable people who need care that may be restrictive

Question 27

test used to see whether a person is being deprived of their liberty

Answer 27

acid test

Question 28

acid test

Answer 28

two questions

• is the person free to leave
• is the person subject to continuous supervision and control

Question 29

DOLs example

Answer 29

Ben has learning disabilities and Prader-Willi syndrome. There are concerns about his health because his weight has been increasing steadily and now stands at 120kg.

Staff in his residential home have tried to support Ben to limit what he eats and to make healthy choices but with little effect.

Ben has been assessed as lacking capacity to make decisions about the amount and type of food he eats (this is common among people with Prader-Willi syndrome). It has been proposed that it is in Ben’s best interests to stop him going into the kitchen, and always supervising him when out, to prevent him spending all his money on, or stealing, food. An application is made by the home manager for standard authorisation because they believe that the restrictions would deprive Ben of his liberty.

Question 30

what settings can DOLs be used

Answer 30

• care homen
• hospital

Question 31

advance care planning

Answer 31

A voluntary process of person-centred discussion between an individual and their care providers about their preferences and priorities for their future care, while they have the mental capacity for meaningful conversation about these

• must respect the persons wishes and emotions
• helps patients feel a greater sense of invovlement

Question 32

who should have an advance care plan

Answer 32

• Patients with cognitive impairments who may be at risk of losing capacity
• Patients with chronic conditions that may deteriorate eg dementia, kidney, heart, liver, neurological diseases
• Recent decline in functional status and increased frailty
• Patients with recent decline which could include multiple falls and increased hospital admissions
• Patients facing major surgery or high risk treatments eg chemotherapy
• Patients with acute life threatening conditions that may not be reversible

Question 33

how the mental capacity act and advance care plans can be used

Question 34

outputs from advance care discussion

Answer 34

• advance statements
• advance decision to refuse treatment
• nomination of a lasting power of attorney
• context specific treatment recommendation

Question 35

Advance statements

Answer 35

. These are not legally binding but should be considered carefully when future decisions are being made. They can include any information the person considers important to their health and care.

Question 36

advance decision to refuse treatment

Answer 36

These are for decisions to refuse specific medical treatments and are legally binding.

a patient cannot request treatment, but can refuse treatment

Question 37

context-specific treatment recommendations

Answer 37

e.g. emergency care and treatment plans such as CPR- DNACPR

Question 38

DNACPR

Answer 38

do not attempt cardiopulmonary resuscitation

• means if heart or breathing stops healthcare team will not try to restart it
• decision made by patient and/or doctor
• doctor makes final decision→ i.e. if they dont think you should have CPR then they can decide
  
  • you cannot demand CPR
  • not legally binding

Question 39

if a patient is unable to make or discuss DNACPR decision in advance then what should the doctor do

Answer 39

doctors should first check to see if you have an Advance Decision to Refuse Treatment (ADRT) that says that you do not want CPR. They should also check to see if you have a Lasting Power of Attorney (LPA) for health and care decisions.

Question 40

ReSPECT form

Answer 40

• Holistic approach
• A process which creates individualised recommendations for a persons care in emergency situation, inc CPA
• Helps to initiate difficult conversations
  
  • Explore individuals preferences for their care and realistic treatment
  • Records agreed clinical recommendations if they cannot express decision at the time
• Developed by many groups: RCUK, BMA, RCGP, GMC, CQC, RCN

Helps develop shared understanding of a person’s condition, circumstances and future outlook

Question 41

why is the respect process needed

Answer 41

• helps patients feel involved with their care and future decisions
• recognised person as a hole
• allows patients express what care they would like and care they would not like
• reframes the DNAR

Question 42

ReSPECT is not the same as DNACPR

Answer 42

• More than a DNACPR
  
  • Records patients preferences and ceilings of care for treatment
• Does include section regarding CPR however aims to come to a joint decision between clinician and patient where:
  
  • The patients values and health goals are considered
  • The clinician can give opinion and also information regarding life saving treatment such as CPR