adults with incapacity Flashcards
who has capacity?
never assume
- Everybody 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.
legislation
Adults with Incapacity (Scotland) Act 2000
what is the adults with incapacity act
- 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.
- 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 lives as far as they are able to do so.
defining capacity
3 aspects
the ability of power to
- receive information
- receive knowledge
- do or understand something
why is capacity important?
- 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
what is incapacity?
Inability to enter into legally binding contracts
- legal definition in AWI act
Refers to adults
- “Adult” means a person who has attained the age of 16yrs or older
in AWI, incapable means incapable of (5)
- Acting
- Making decisions
- Communicating decisions
- Understanding decisions
- Retaining the memory of decisions
what makes amanda incapable
- Amanda is currently being treated as inpatient in a psychiatric unit due to an acute psychosis associated with her bipolar disorder.
- She believes that the post-crown inside her tooth is being used as a tracking device from the CIA.
- She wishes you to remove the tooth.
she is unable to act or make a decision currently
how is communication defined for AWI
A person CANNOT be considered to be lacking capacity because of a lack or deficiency in communication – if that 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.”
In other words, If a patient cannot speak in order to communicate their decision
- Can they write it?
- If so, give them a pen & some paper
- If a patient cannot write or speak in order to communicate their decision
- can they sign or use gestures?
- If so, facilitate this for them…
- can they sign or use gestures?
how to aid adult communication
- Find out how the person communicates – ask!!!
- Check if they are wearing or have with them their normal aids
- Ensure a quiet, well lit environment
- Allow adequate time
- Use technology – loop systems, spelling boards, ipad etc
- Consider communication adjuncts
what part of AWI does john potentially fufil?
he has a dento-alveolar abscess
he has a learning difficulty
understanding decsisions
unable to understand the treatment needed to manage source of infection
if someone has dementia what part of AWI do they potentially fufil?
retaining memory of decision
e.g. unable to recall decision made in previous appointment
how to assess capacity
Decision or action specific
- NOT ‘all or nothing’
Consider ‘residual capacity’ – some not all
- Patients may be able to make some decisions for themselves, but may lack capacity to make other decisions
Capacity may fluctuate
Time needed to explain corresponds to complexity of decision - scale
to demonstrate capacity individuals should be able to
BMA 2003
- Understand in simple language what the treatment is, its purpose and nature and why it is being proposed
- Understand its principle benefits, risks and alternatives;
- Understand in broad terms what will be the consequences of not receiving the proposed treatment e.g. infection spread
- Retain the information long enough to use it and weigh it in the balance in order to arrive at a decision
(Scotland – “retain the memory of the decision”)
assessment of capacity should seek to determine if the patient (9)
- Is capable of making and communicating a choice
- Understands the nature of what is being asked & why
- Has memory abilities to allow them to retain information you have given
- Is aware of alternatives
- Is aware of risks & 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 e.g. family member
- Is not under undue influence from you or anyone else
communication style when trying to assess an adult’s capacity (4 parts)
- Keep language appropriate
- Break up information into sections
- Ask the pt to explain to you what you have discussed with them
- Assessing retention – ask the pt at another appointment and relevance to them
5 key principles underpin AWI (scotland) Act 2000
- Benefit
- Minimum necessary intervention
- Take account of the wishes of the adult
- Consultation with relevant others
- Encourage the adult to exercise ‘residual capacity’
benefit in terms of AWI
- Any treatment must benefit the patient
- Without treatment that benefit would not be possible
- Any intervention must improve or enhance their life
minimal necessary intervention according to AWI
Treatment shall be the least restrictive option in relation to the freedom of the adult
- Least for pt to be out of pain and comfortable
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
take account wishes of adult in terms of AWI
Past and Present wishes
- 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?
consultation with relevant others in terms of AWI
- We may not know the patient that well.
- The patient’s family, friends or other people of relevance are likely to know the person much better. (they will be more likely to trust them)
- Relevant others should be consulted with regard to what they think that the patient would have wanted
who to consult in AWI case
- 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 learning disability have
- 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. CHECK
encourage residual capacity in terms of AWI
We must identify if there are any decisions which the patient can make for themselves
In 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
2 types of powers of attorney
continuing POA
welfare POA
POA
powers of attorney
- Granted by the adult while s/he still has capacity
- Can be a family member or a trusted friend
- Similar procedure to making a will
- Certified by a lawyer
- Registered with the Public Guardian
- Referred to as a ‘Proxy’
welfate POA
- Powers only come into effect when the adult is incapable of decision making
- Must take into account the adults wishes
- Matters relating to health & personal welfare
- Must be registered with the Office of the Public Guardian see. Photocopy in records
continuing POA
only covers financial affairs and property
Guardianship order
e.g. Down syndrome once reach 16 (parents legally before)
- Court appointed
- Requires 2 medical reports
- Continuous management of welfare and financial matters
- Powers to deal with property, finance & even marital affairs
- Usually appointed for 3years
who can consent for dental Tx?
- Patients with capacity
- Welfare Powers of Attorney
- Welfare Guardians
- Medical & Dental* practitioners under Section 47 of AWI Act (General Authority to Treat) need special trained GDP
Remember
- Relatives who are NOT welfare powers of attorney or welfare guardians CANNOT consent on another adult’s behalf
when can dental tx be given without consent
medical emergency
- where treatment is necessary for the preservation of life or to prevent serious deterioration, urgent cases, a necessity to treat
- Large bleed, infection spread
matter of clinical judgement
who can issue certificates of incapacity
- Medical practitioner primarily responsible for the patients care (GMP)
- Consultant in charge of the patients care
- Dental practitioners*
- Registered nurses*
- Optometrists*
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 a 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
got a proxy to consent- do you need an AWI to treat
Even where a proxy has been appointed a Certificate of Incapacity MUST also be completed
how to attain an AWI certificate as GDP
- Unlikely to have power to sign AWI section 47 form
- Therefore, required to liaise with GMP - time
- The GMP should assess capacity of the patient
- Therefore, required to liaise with GMP - time
- If satisfied of incapacity GMP should provide you with an Adults with Incapacity form
- Provide GMP with details to avoid inappropriate generalisation - specific
if pt incapable of consenting to nonemergency dental care what is needed
an AWI section 47 form completed, so have an Adults with incapacity certificate
understand dental treatment by (3)
- What the treatment is, its purposes and nature and why it is being proposed
- The principal benefits, risks and alternatives and be able to make a choice
- Understand in broad terms what the consequences will be of not receiving the proposed treatment
explain in their own words
3 aspects of assessing retention of decision
- Does the individual remember the decision; and/or
- Does the individual make the same decision consistently given the same information; and/or
- Does the individual agree with a record of that decision when presented with a record of it
by Medical Welfare Commision
what to do when a pt lacks capacity to consent (3)
- Develop a treatment plan which considers the 5 principles of the adult with incapacity (Scotland) Act 2000
- Identify any relevant people that are required to be involved in the decision-making process for the person who lacks capacity
- Obtain a Section 47 Certificate which legally permits treatment
a ‘proxy’
welfare POA, welfare guardian or a person authorised under an intervention order with power in relation to any medical treatment can be called a ‘Proxy’
- Should have the appropriate documentation to confirm this
Important to ensure
- The proxy has the correct documentation to confirm their legal position in relation to making decisions for the person who lacks capacity
- The certificate is in date
can you request more than 1 section 47 certificate
yes
so can run in parallel with each other or 1 single form for Tx and prevention care
only get for elements of Tx they are unable to consent to (e.g. can consent to scaling and restorations but maybe not endo)
e.g
-
Single form
- For defined treatment
- And lasting 3 years for examinations, scaling and supervised hygiene
