ICM - Ethics Flashcards
What is Deprivation of liberty (DOLs)
The deprivation of liberty safeguards (DoLS) protect people who do not have the mental capacity to consent to treatment.
They apply to people who lack mental capacity who live in a:
-care home
-hospital
-supported living environment
The safeguards make sure that any treatment a person in that situation receives is appropriate and in their best interests.
How does DOLS apply to ICU?
Normally Formal legal authority is required to deprive someone of their liberty.
The starting point is that there is no deprivation of liberty, even if the patient cannot consent to the arrangements, where:
* The patient is so unwell that they are at immediate risk of dying anywhere other than in hospital; and
* The arrangements for delivering treatment to the patient are the same as they would be if the patient were able to agree to them
Formal authority should be sought where:
* There are specific contingency plans either (1) to prevent the patient leaving if they are physically capable of leaving; or (2) to prevent family members from removing them from the hospital; and/or
* The patient is subject to section 17 of the Mental Health Act 1983 (i.e., on leave from a mental health hospital to receive care in intensive care)
How would you approach a situation where there are disagreements on the patients best interests?
[1] Have you formally established that the patient lacks capacity for this decision?
● A person must be assumed to have capacity unless it is established that they lack
capacity for this decision.
● A person is not to be treated as unable to make a decision unless all practicable
steps to help them to do so have been taken without success.
● A person is not to be treated as unable to make a decision merely because they
make an unwise decision.
[2] Have you assessed
● The patient’s past and present wishes and feelings?
● Beliefs and values that would be likely to influence the patient’s decision?
● Any other factors that might influence the patient’s decision or the situation?
[3] Have you talked to
● Anyone named by the person as someone to be consulted?
● Anyone interested in their welfare (for example, family and friends)?
● Any donee (the recipient of a gift or power of appointment) on a lasting power of
attorney?
● Any deputy appointed for the person by the court?
[4] Local steps to resolve disagreement:
● Discussion with another clinician and/or team.
● Best Interests meeting (ensure equal representation between family and team).
● Document areas of agreement and disagreement.
● Allow time for reflection.
● Discuss with medical director (or appropriate corporate medical team member) at the earliest opportunity.
[5] Formal steps to resolve disagreement:
● Seek a second opinion, external to the Trust.
● Try mediation. Suitable mediators can be found from the Civil Mediation Council or NHS Resolution (faster, cheaper than litigation and more likely to preserve relationships).
● Take legal advice, including the option of an application to the Court of Protection
What is capacity and what is the Mental Capacity Act?
- Capacity is the ability to make a decision.
- It must always be assumed that individuals have capacity to make decisions for themselves unless it is proven otherwise
- Every effort should be made to support the individual to make a specific decision for themselves.
- A capacitous patient has the right to make an irrational or unwise decision.
The Mental Capacity Act 2005 provides the legal framework in England & Wales through which to determine whether an adult has capacity to make a decision for themselves. Assessment of mental capacity requires asking two questions:
1. Can the person understand the information relevant to making the decision, retain that information for long enough to make it, use and weigh the information, and communicate the decision?
- If they cannot, then why not? They will only lack capacity to make the decision for purposes of the Mental Capacity Act 2005 if they cannot make the decision because there is an impairment or disturbance in the functioning of the individual’s mind or brain? (for example, delirium, stroke, intoxication, traumatic brain injury).
Capacity assessments should be recorded in sufficient detail, including the reasons for doubt, contents of the assessment, findings and how decisions have been reached in the individual’s best interests.
Is capacity time specific?
Having been assessed as lacking capacity to make
a decision on one occasion does not mean that the individual will lack capacity on the next. Drugs, alcohol or organic illness (including delirium) may all cause capacity to fluctuate. Can the decision wait?
Is capacity decision specific?
:Capacity is not “all or nothing” but is decision
specific. It should not be assumed that an individual who lacks capacity for one
medical decision lacks capacity for ALL medical decisions
What are the criteria for valid consent?
Requires:
patient must be legally capable of giving consent (competent)
consent must be informed
consent must be specific
consent must be freely given
consent must cover that which is actually done
Things that should be covered in consent discussion (PP-BRAN)
process involved
person performing procedure
benefits
significant risks that would affect the judgment of any reasonable patient
alternatives
what would happen if nothing is done
How is consent given?
Implied: e.g when pt allows blood to be taken. Not sufficient for more major procedures.
Verbal: just as valid as written, needs to be documented in the notes.
Written
What do you understand by the Mental Health Act?
The Mental Health Act (2007) refers to a law used in England and Wales which provides a legal framework for both informal and compulsory care and treatment of people diagnosed with having a mental disorder.
A mental disorder is described as any disorder or disability of the mind and can include any of the following:
Mental illness
Personality disorder
Learning disability
Disorders of sexual preference (e.g. paedophilia)
Anyone under the influence of drugs and/or alcohol is specifically excluded from detainment under the Mental Health Act.
Under what situations can the patient be detained under the MHA? What are the differentsituations in which this can happen?
Can be voluntary, involuntary or an emergency.
Voluntary - Section 131
Involuntary
- Section 2 - Section 2 of the Mental Health Act is used for compulsory detention for assessment.
A person can be detained under section 2 only if both of the following apply:
The person suffers from a mental disorder that warrants detention in hospital for assessment for at least a limited period.
The person ought to be detained in the interests of their own health or safety or the protection of others.
The maximum period a person can be detained for assessment is 28 days,
-Section 3
A person can be detained under section 3 only if all the following apply:
The person suffers from a mental disorder of a nature or degree that makes it appropriate for them to receive treatment in hospital.
It is necessary for the health or safety of the person or the protection of others, that the person should receive treatment which cannot otherwise be provided unless the patient is detained.
Appropriate medical treatment is available for them.
The maximum period a person can be detained under this section is 6 months,
Emergency
-5-2 - an emergency order where an inpatient who is a voluntary patient in hospital can be detained for up to 72 hours for a mental health act assessment.
Only one doctor (usually the one in charge of the patient’s care) is required to make an application for this section.
- 5-4 - is similar to section 5(2), but a patient can be detained by a nurse for up to 6 hours to allow further assessment by medical staff.
Policer powers
135 - Removal of a person from private property to a place of safety
136 - Removal of a person from a public place to a place of safety without a warrant
What is a duty of candour?
Every health and care professional must be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress.
1 This means that health and care professionals must:
- tell the person (or, where appropriate, their advocate, carer or family) when something has gone wrong
- apologise to the person (or, where appropriate, their advocate, carer or family)
- offer an appropriate remedy or support to put matters right (if possible)
-explain fully to the person (or, where appropriate, their advocate, carer or family) the short and long term effects of what has happened.
What is an IMCA?
An Independent Mental Capacity Advocate (IMCA) is an advocate appointed to act on your behalf if you lack capacity to make certain decisions. (See our pages on the Mental Capacity Act 2005 for more information what ‘lacking capacity’ means.)
In England, IMCAs are appointed by a local authority, and in Wales they are appointed by a local Health Board or other NHS body in Wales.
What is a DNACPR form?
A Do Not Attempt Cardiopulmonary Resuscitation order (DNACPR) is a document that formalises decision-making about whether an individual should be treated with CPR, in the event of a cardiac arrest.
It is a form of an advanced directive and is a key consideration in the management of patients with progressive life-limiting illnesses, those approaching the end of life, and significantly frail patients.
What is Best Interests?
- a person’s past and present wishes and feelings
- the beliefs and values that would likely to influence their decision if they had capacity
-the other factors that they would like to consider if they were able to
What is the lasting power of Attorney?
Authority donated by an individual to a 3rd party which permits them to make decision for them in the event of future incapacity.
They can be allocated for financial or health and well being
