CPP Flashcards
What are 3 key components of valid consent?
Be sufficiently informed
Make a voluntary decision
Have capacity
What is capacity?
The ability to make a decision. It is time and task specific
What are the 3 central themes of the Mental Capacity Act 2005?
Empower people to make decisions for themselves
Participation
Protecting people who lack capacity
What are the 5 key principles of the Mental Capacity Act 2005?
- Presume capacity
- Offer support to maximise capacity
- Unwise decisions
- Best interests
- Least restrictive option
How is capacity assessed?
Assess by person who is most informed about the decision to be made aka doctor
2 stage process:
- is there an impairment or disturbance of the mind or brain?
- Does this impairment or disturbance affect a person’s ability to understand the information, retain the information, weigh up the information, or communicate their decision?
Examples of a disturbance or impairment of the mind or brain that may result in altered capacity
Dementia Severe psychiatric illness Severe learning difficulties Delirium e.g. infection, or electrolyte abnormalities Head injuries Effects of prescribed medication Effects of alcohol and drugs
What are the 3 key situations where there may be a lack of capacity?
- Temporary lack of capacity e.g. unconscious after RTA
- Patient permanently lacks capacity after formerly having capacity e.g. due to dementia
- A patient that has never had capacity e.g. severe learning difficulties
What is an ARDT?
Advanced decision to refuse treatment
Legally binding, made when patient has capacity to refuse specific treatment should they lose the ability to make decisions, and must be 18 or over
If refusal pertains to life-sustaining treatment, must be written with refused treatment specified and a statement stating the decision applies even if the person’s life is at risk, and signed with a witness
Who are proxy decision makers?
People who can make decisions on the behalf of adults who lack capacity e.g. Lasting power of attorney, deputy of court
When would an ARDT be considered not legally binding?
It is not valid e.g. due to no capacity at time, inconsistency in person, or does not meet criteria if life-sustaining treatment is refused
It is not applicable e.g. patient has capacity, not specific to current situation, circumstances not anticipated by patient
There are doubts about its existence
What is an LPA?
Lasting power of attorney
Person (donee) is appointed by a patient (donor) to have the power to make decisions for them when they (donor) lose capacity
Can be responsible for health and welfare decisions OR financial and property decisions
Both must be over 18 and may make all decisions or only specific decisions
Must be certified by independent third party (doctor or lawyer) and registered with Office of the Public Guardian
Lifestyle drift
Policy drift from recognising and attempting to address wider societal health issues to focusing on individuals’ and lifestyle and health issues. In essence it is a shift from big policy to smaller individual focus and change.
5As of access to healthcare
Affordable Available - GP, walk-in centres Accessible - transport links, wheelchair access, etc. Accommodating - out-of-hours appt Acceptable
Factors affecting health
Genetics
Environment - access to green space, air pollution, busy roads, home environments
Social circumstances - supportive friends/family, smoking, drinking, employment
Education
Lifestyle - diet, exercise, smoking, drinking, stress, social support
Economic circumstances - stress of financial hardship, ability to socialise and buy healthy food
Access to healthcare
Inequity
Lack of fairness or justice
Smoking from SoDH perspective
Early socioeconomic circumstances and education have been found to be more important than adult socioeconomic circumstances
Difficult to quit if pt has mental health disorders, is under a lot of stress, lacks social support
In pregnancy:
200% higher incidence of sudden infant death syndrome
20-30% higher likelihood of stillbirth
40% of higher rate of infant mortality
Sense of agency
A pt’s ability to act and control their own lives
Can be diminished by social isolation, poverty and psychological distress over the life course
Marmot Review (2010)
An English review of recommendations made by the WHO Commission on Social Determinants of Health:
- give every child the best start in life e.g., Sure Start
- enable all to maximise capabilities & control over their lives e.g., improve educational outcomes & life skills across the social gradient
- create fair employment and good work for all e.g., stress mx, promote wellbeing, labour market programmes to reduce long term employment
- healthy standard of living for all e.g., taxation, benefits, tax credit and pensions
- develop healthy and sustainable places & communities e.g., green spaces, urban planning, energy efficiency, reduce social isolation
- promote ill health prevention e.g., flu jabs
Proportionate Universalism
Defined as the ideal of universal change with a proportionate level of aid or action done with a scale and intensity proportionate to the level of disadvantage
Cause of the cause
Attempts to tackle the root of health behaviour problems to bring about more sustainable health change
The life-course model
Disadvantage starts before birth and accumulates throughout life
As suggested by the Marmot Review
5 principles of motivational interviewing
- Express empathy through reflective listening.
- Develop discrepancy between clients’ goals or values and their current behavior.
- Avoid argument and direct confrontation.
- Adjust to client resistance rather than opposing it directly.
- Support self-efficacy and optimism.
LPA vs Advanced Decision
LPA takes priority over AD if LPA is made after AD
AD takes priority if AD is made after LPA
Deputy of court
Appointed by court to make decisions in the best interests of a patient who lacks capacity
Best interests definition
Aims to ensure that the decision taken is the best course of action for this particular person’s wellbeing and to strike a balance between respecting their autonomy as far as possible and protecting them from risks to their health and welfare
The decision maker may be the patient’s LPA or Deputy of Court or consultant in charge of pt care
Assessing best interests of pt
Involve the person in the decision making.
Consider all the relevant circumstances.
Find out the person’s opinion/beliefs/values
Consider any advance statements.
Consult significant others.
Choose the least restrictive option.
Advance statements
Different from advance decision
Broader expression of pt’s wishes, including requests for treatment
Not legally binding
Independent Mental Capacity Advocate
Appointed if pt has no family or friends and undergoing significant medical treatment
Independent Mental Capacity Advocate represents and supports vulnerable individuals who lack capacity but does not make a best interests decision (falls to doctors)
Meets pt individually to determine wishes, access health/social care records, may challenge doctors decision
Court of Protection
Jurisdiction over mental capacity act and has power to appoint deputy of court
Last resort in resolving disputed or complex cases when determining capacity or dispute relating to pt’s best interests
Duty of candour
Acknowledge wrongdoings and inform pt or family
Apologise
Provide remedy
Explain short and long term effects of error made
Deprivation of Liberty Safeguards (DoLS)
Used if pt is under continuous supervision and not free to leave as they lack capacity e.g. pt in a nursing home
Achieved via local authority
Used in pt who lacks capacity to give care in least restrictive way without depriving liberty
Depression and anxiety statistics
5-10% prevalence in primary care, higher rates in hospital in-patients
4th cause of disability worldwide
Common mental health disorders
Depression Panic disorder Generalised anxiety disorder Obsessive compulsive disorder Social anxiety disorder Post traumatic stress disorder
Core depression features
Depressed mood (2-5% prevalence, avg. age 25-29) Loss of interest or pleasure in activities that are normally pleasurable Decreased energy/increased fatigability
Additional depression symptoms
Loss of confidence/self-esteem Excessive guilt and unworthiness Recurrent thoughts of death or suicide, any suicidal behaviour Reduced concentration Agitation or psychomotor retardation (slowed movement) Inappropriate anger or irritation Sleep disturbance Change in appetite/weight
Cyclothymia
Oscillation of mood between high (hypomania) to low moods with normal moods in between
Considered to be a milder form of bipolar disorder hence, greater risk of developing bipolar disorder
More common in women
Tx: psychotherapy (CBT), mood stabilisers (lithium, carbamazepine, sodium valproate), antidepressants, antipsychotics (quetiapine)
Depression risk factors
Female gender (with children > without children)
Single men > married
Unemployment
Low SES
Certain occupational groups e.g. doctors, vets
Other psychiatric disorders/substance misuse
Chronically physically ill pts
Marginalized people
Anxiety definition & prevalence
Anxiety is considered an abnormal/pathological response when the severity is out of proportion to the threat or when it outlasts threat
Affects 1 in 10
Symptoms of anxiety (psychological, somatic, autonomic, behaviours)
Psychological: worrying thoughts, increased alertness, fear, poor concentration, sleep disturbance
Somatic: muscle tension, increased respiration, breathlessness
Autonomic: increased HR, sweating, dry mouth, urge to urinate or defecate
Behaviours: avoidance of danger, develop safety behaviours
Different anxiety disorders
Phobias Obsessive compulsive disorder Post-traumatic stress disorder Social phobia Panic disorder Generalised anxiety disorder Mixed anxiety and depression disorder
Generalised anxiety disorder
Excessive uncontrollable worry about everyday things which affects daily functioning and causes physical symptoms (free-floating stress)
Dx: worry present more days than not for at least 6months
Intensity, duration, and frequency of worry disproportionate to issue
Panic disorder
Recurrent episodes of severe anxiety lasting mins (may be longer)
No particular trigger, associated with fear of dying, losing control, or going mad
Symptoms: palpitations, chest pain, choking, dizziness, and depersonalisation common
Leads to avoidance of situations where panic attack is likely
Phobias (needle/blood phobia)
Needle/blood phobia will cause a vasomotor response resulting in a drop in blood pressure and pt may faint
Monitor BP in in-pt to identify needle phobia
Obsessive compulsive disorder
Obsessive thoughts (unwanted/unpleasant thoughts/images/urges) -> anxiety -> compulsive behaviour (repetitive act/ritual) -> temporary relief
Post traumatic stress disorder (definition & diagnosis)
Distressing intrusive memories/dreams/images of a traumatic event with/out avoidance of places/conversations that remind of the event
If symptoms < 1mo = acute stress disorder hence, no active tx required
Symptoms > 1mo = warrants assessment to establish if PTSD
Symptoms of PTSD
Alcoholism IVDU Antidepressant use Missing work and job problems Smoking 15x greater risk of suicide
Stepped care for GAD
Step 1: active monitoring and psycho-education (re dx)
Step 2: low-intensity psychological therapies
Step 3: medication
Step 4 (severe anxiety with risk of self-harm): high intensity psychological therapies, medication, specialist services and inpatient care (rare)
Stepped care for depression
Step 1: active monitoring and psycho-education Step 2: low-intensity psychological therapies, group CBT, or poss. medication Step 3: high-intensity psychological therapies (CBT, interpersonal therapy, behavioural activation), poss. medication Step 4 (severe depression at risk of self harm): medication, high intensity psychological therapy, electroconvulsive therapy, specialist services, poss. inpatient care
Cognitive behavioural therapy
Behavioural part: Changing behaviour leads to change in emotions and cognitions
Cognitive part: Addresses cognitive distortions regarding self, others, the world
1st line tx for phobias, panic disorder, social anxiety disorder, OCD, PTSD
60% recovery rate in GAD
Goal oriented, with short-term and time-limited session (8-12)
Social interventions for psychological disorders
Improve social network
Assistance e.g. debt, supported employment, relationships, housing
Structured activities throughout day
Regular exercise
Medication for depression
Serotonin selective reuptake inhibitors (SSRIs): fluoxetine, sertraline, citalopram, paroxetine
Serotonin and noradrenaline reuptake inhibitor (SNRI): venlafaxine, duloxetine
Noradrenergic and specific serotonergic antidepressant (NaSSA)
Mirtazapine - particularly useful if sleep or eating is affected
Most effective against moderate severity depression
Medication for anxiety
SSRIs: fluoxetine, sertraline, citalopram, paroxetine
Benzodiazepines: diazepam, lorazepam
Beta blockers: propanolol
Pregabalin
Others: SNRIs (venlafaxine), NaSSAs (mirtazapine)
Catatonia
Stupor/unresponsiveness OR excitement with echolalia (meaningless repetition of someone’s speech)
Seen as a modifier of affective disorders e.g. depression
Tx: lorazepam (1st choice), or electroconvulsive therapy (if life-threatening)
Cotard syndrome
Pt believes they are dead and organs are rotting hence cannot diet as already dead
