Adults With Incapacity

Question 1

We must never assume that someone does not have capacity. What should we do? (4)

Answer 1

• Everyone should be treated equally
• everyone should be assumed to have capacity unless proven otherwise
• Responsibility upon healthcare practitioners to assess capacity
• For those who lack capacity, care must be facilitated to ensure equality in the provision of care

Question 2

What is the adults with incapacity act?

Answer 2

• A framework for safeguarding the welfare and managing the finances of adults who lack capacity due to mental illness, learning disability or a related condition, or an inability to communicate in any way at all

Question 3

What is the aim of the adults with incapacity act?

Answer 3

• The act aims to protect people who lack capacity to make particular decisions, but also to support their involvement in making decisions about their own loves as far as they are able to do so
• This is because sometimes they are able to make simple decisions but not more complex ones

Question 4

Capacity is the ability to…? (3)

Answer 4

• Receive impressions
• Receive knowledge
• Do or understand something

Question 5

Why is capacity important? (5)

Answer 5

• Decision making - capacity is key to autonomy
• Everyone has the right to say what happens to their body
• Everyone also has the right to say what they don’t want to happen to their body
• In terms of healthcare, competent adults have the right to refuse treatment
• Failure to treat adults who do not have capacity may constitute negligence

Question 6

What is incapacity?

Answer 6

• Inability to enter legally binding contracts

Question 7

What is an ‘adult’ in relation to the AWI act?

Answer 7

• ‘adult’ means a person who has attained the age of 16 years or older

Question 8

For the purposes of the AWI act, incapable means incapable of…? (5)

Answer 8

• Acting on something
• Making decisions
• Communicating decisions
• Understanding decisions
• Retaining the memory of decisions

Question 9

Can a person lack capacity because they are unable to communicate?

Answer 9

• A person CANNOT be considered to be lacking capacity because of a lack or deficiency in communication - if the lack or deficiency can be made good by human or mechanical aid
• There is an onus on involved personnel to ensure that the individual with a communication difficulty is supported to maximise their communication

Question 10

What can se do to make communication easier for people who may find it difficult to communicate? (6)

Answer 10

• Find out how the person communicates - ask
• Check if they are wearing or have with them normal aids
• Ensure a quiet, well lit environment
• Allow adequate time
• Use technology - loop systems, spelling boards, ipad etc
• Consider communication adjuncts

Question 11

What do we need to consider when we are assessing capacity? (5)

Answer 11

• Decision or action specific
• NOT all or nothing
• consider residual capacity
• Capacity may fluctuate
• Patients may be able to make some decisions for themselves, but may lack capacity to make other decisions

Question 12

Give a list of situations where an adult does NOT have impaired capacity because of it? (10)

Answer 12

• They are in care
• They have a mental health condition
• They have difficulties with speech or writing
• They have addiction issues
• They have a brain injury
• They have a physical disability
• They are in prison
• They have a neurological condition
• They are not behaving rationally
• They disagree with you

Question 13

To demonstrate capacity, individuals should be able to…? (4)

Answer 13

• Understand in simple language what the treatment is, its purpose and nature and why it is being proposed
• Understand the principle benefits, risks and alternatives
• Understand in broad terms what will be the consequences of not receiving the proposed treatment
• Retain the information long enough to use it and weigh it in the balance in order to arrive at a decision

Question 14

An assessment of capacity should seek to determine if the patient…? (9)

Answer 14

• Is capable of making and communicating a choice
• Understands the nature of what is being asked and why
• Has memory abilities to allow them to retain information you have given
• Is aware of alternatives
• Is aware of risks and benefits involved
• Is aware of personal relevance to them
• Is aware of the right to (and how to) refuse treatment
• Has ever previously expressed a view or opinion on the subject
• Is not under any influence from you or anyone else

Question 15

What should we as clinicians do when assessing capacity? (4)

Answer 15

• Keep language appropriate
• Break up information into sections
• Ask the patient to explain to you what you have discussed with them
• Assessing retention - ask the patient at another appointment

Question 16

What are the 5 key principles that underpin the AWI act?

Answer 16

1. Benefit (it must benefit the patient)
2. Minimum necessary intervention (to get the patient comfortable)
3. Take account the wishes of the adult (listen to them)
4. Consultation with relevant others
5. Encourage the adult to exercise ‘residual capacity’

Question 17

What must we consider in relation to the principle ‘benefit’ in the AWI act? (3)

Answer 17

• Any treatment must benefit the patient
• Without treatment that benefit would not be possible
• Any intervention must improve or enhance their life

Question 18

What must we consider in relation to the principle ‘minimum necessary intervention’ in the AWI act? (3)

Answer 18

• Treatment shall be the least restrictive option in relation to the freedom of the adult
• We must always seek to avoid the most invasive treatments, when simpler alternatives are available and likely to be successful
• It does not refer to the simplest or least complex solution

Question 19

What must we consider in relation to the principle ‘Take account the wishes of the adult’ in the AWI act? (2)

Answer 19

• We must try and find out what the patient previously (or currently) wanted regarding their dental treatment
• Are there relatives or close friends who can help us find out - it is our duty to try to find this out

Question 20

What must we consider in relation to the principle ‘consultation with relevant others’ in the AWI act? (3)

Answer 20

• We may not know the patient that well
• The patient’s family, friends and other people of relevance are likely to know the person much better
• Relevant others should be consulted with regard to what they think the patient would have wanted

Question 21

One of the principles in the AWI act is to ‘consult with relevant others’. Who might we consult? (4)

Answer 21

• The nearest relative and primary carer of the adult
• Any guardian, continuing attorney or welfare attorney of the adult who has powers relating to the proposed intervention
• Any person whom the sheriff decides
• Any other person appearing to the person responsible for authorising or effecting the intervention to have an interest in the welfare of the adult or in the proposed intervention

Question 22

What must we consider when we are ‘encouraging residual capacity’?

Answer 22

• We must identify if there are any decisions which the patient can make for themselves
• Is so far as it is reasonable or practicable to do so, encourage the adult to exercise whatever skills he or she has concerning property, financial affairs or personal welfare as the case may be, and to develop new such skills

Question 23

What are the 2 different types of power of attorney that we need to be aware of?

Answer 23

• Continuing power of attorney

- Welfare power of attorney

Question 24

Who can the power of attorney be for an adult and how is this processed? (6)

Answer 24

• Granted by the adult while they still have capacity
• Can be family member or trusted friend
• Similar procedure to making a will
• Certified by lawyer or medical practitioner (actually has to be done by a lawyer)
• Registered with the public guardian
• Referred to as a ‘proxy’

Question 25

What is a welfare power of attorney and when does the power come into place? (5)

Answer 25

• Powers only come into effect when the adult is incapable of decision making
• Must take into account the adults wishes
• Matters relating to health and personal welfare
• Must be registered with the office of the public guardian
• As a dentist we need to see the documents and have a copy of them in our records

Question 26

What is continuing power of attorney?

Answer 26

• Only covers financial affairs & property

Question 27

What are guardianship orders? (6)

Answer 27

• These are for someone who has never had the capacity to consent
• Court appointed
• Requires 2 medical reports
• Gives the guardian continuous management of welfare and financial matters
• Powers to deal with property, finance & even marital affairs
• Usually appointed for 3 years

Question 28

Who can consent for dental treatment? (4)

Answer 28

• Patients with capacity
• Welfare powers of attorney
• Welfare guardians
• Medical and (specially trained) dental practitioners under section 447 of AWI act (General authority to treat)

Question 29

Can relatives who are not welfare powers of attorney or welfare guardians consent on another adult’s behalf?

Answer 29

NO

Question 30

What does general authority to treat mean?

Answer 30

• Prior to AWI act (2000), treatment without patient or proxy consent could only be given in an emergency
• Large numbers of adults who were incapable of consenting but who did not have a proxy
• Since most dental treatment does not constitute ‘emergency’ treatment NO treatment provision was made
• General authority to treat provided a valid certificate of incapacity is issued for the treatment given AND
• Provided the principles of the act are observed… treatment may be given
• Common law allows medical treatment to be given in an emergency to patients who cannot consent

Question 31

What constitutes to an emergency situation in dentistry? (2)

Answer 31

• If there is a big bleed

- If there is a spreading infection - to eye or down to throat

Question 32

Who can issue certificates of incapacity? (5)

Answer 32

• Medical practitioner primarily responsible for the patient’s care (GMP)
• Consultant in charge of the patient care
• Dental practitioners*
• Registered nurses*
• Optometrists*
• • if they are specially trained

Question 33

What is a certificate of incapacity and what are the regulations around it? (4)

Answer 33

• A certificate issued by ‘other’ healthcare professionals is only valid for their area of practice
• A dentist can only authorise dental treatment
• A dentist can only complete section 47 form if they have completed the required training
• Even where a proxy has been appointed a certificate of incapacity MUST also be completed

Question 34

Look at slide The GDP and AWI

Answer 34

Hard to put in a question

Question 35

Look at summary slides

Answer 35

:)