MOD F TECH 43 Mental Health

Question 1

What is mental illness?

Answer 1

Involves a wide range of problems:

• Depression
• Anxiety
• Confusion

Occurring to such an extent that it is difficult to cope with everyday life.

Question 2

Incidence

Answer 2

• One in ten adults
• One in five children
• 10 million days lost in 2006
• 5,500 suicides per annum

Which is more than the number who die on our roads!

Question 3

Categories

Answer 3

Psychosis

• Hallucinations
• Delusions
• Impairment in perception
• Unable to distinguish reality from imagination

Neurosis

• Anxiety and depression
• Perception of reality intact
• More prone to emotional disturbance

Question 4

Types of Psychosis

Answer 4

• Manic-Depression (Bipolar Disorder)
• Schizoaffective Disorder
• Mania
• Delusional (Paranoid) Disorders
• Psychotic Depression
• Schizophrenia

Question 5

Manic Depression

Answer 5

Bipolar disorder used to be called ‘manic depression’. As the name suggests, it is characterised by mood swings or episodes that are far beyond what most people experience in their lives.

• Low feelings of intense depression and despair
• High feelings of elation ‘manic’
• Mixed

Question 6

Mania

Answer 6

A severe medical condition characterised by extremely elevated mood, energy, and unusual thought patterns.

There are several possible causes for mania, but it is most often associated with bi-polar disorder, where episodes of mania may cyclically alternate with episodes of clinical depression

Question 7

Schizoaffective Disorder

Answer 7

The diagnosis of schizoaffective disorder is given to someone who experiences both symptoms of a mood disorder like depression and symptoms of the type experienced with schizophrenia at the same time, or within days of each other.

Generally, two subtypes of the disorders:

• bipolar (schizoaffective, manic or mixed type.)
• unipolar (schizoaffective, depressed type).

Question 8

Delusional (Paranoid) Disorders

Answer 8

• Delusional Disorders are a form of Psychosis in which a person has paranoid delusions which are often long-lasting, and do not have an obvious physical/medical cause.
• Occasionally, in older people, they may be accompanied by the person hearing noises, sounds, other people talking, which don’t exist (called auditory hallucinations).

Question 9

Psychotic Depression

Answer 9

Psychotic depression is a distinct and acute clinical condition along the spectrum of depressive disorders. It can manifest itself in many ways and be mistaken for schizophrenia.

It often induces physical deterioration,

mortally dangerous acts toward self or others, or completed suicide.

Question 10

Schizophrenia

Answer 10

A group of psychotic disorders characterized by major disturbances in thought, emotion, and behavior - disordered thinking in which ideas are not logically related, perception and attention are faulty, bizarre disturbances in motor activity, flat or inappropriate emotions, reduced tolerance for stress of interpersonal relations, causing patient to withdraw from people and reality, often into a fantasy life of delusions and hallucinations, due to a misinterpretation of reality.

Question 11

Treatment

Answer 11

•Drug therapy

–Tranquilisers

–Antidepressants

–Lithium

•

•Electro-Convulsive Therapy

•

•Psychotherapy and Counselling

•

•Behaviour Therapy

Question 12

There are four main types of drug used for this most-common form of treatment:

Answer 12

•Minor tranquillisers

–Relief of stress and anxiety

•

•Major tranquillisers

–Control the symptoms of severe mental illness particularly schizophrenia

Question 13

Drug therapy

Answer 13

•Anti-depressants

–Help people feel less despairing

–

•Lithium Carbonate (lithium salts)

–Help to control emotions to a level where patients can begin to deal with the problems underlying their distress

–These drugs, however, can have side effects which are distressing and unpleasant and may even be addictive

–Some people come to rely on these drugs and lose the wish to work out their underlying problems

Question 14

Electro-convulsive therapy

Answer 14

The passing of an electrical current through the front of the brain

•

•Considered effective in relieving the symptoms some forms of severe depression where response to anti-depressant drugs is inadequate or too slow to avert the risk of suicide.

•

•It does, however remain a controversial treatment

Question 15

Psychotherapy and counselling

Answer 15

Aim to help the patient understand the origins of their illness so that they can come to terms with their problems

Question 16

Behaviour therapy

(behaviour modification)

Answer 16

Aims to modify problem behaviour to that appropriate to the patient’s situation

This form of treatment is particularly successful in the treatment of certain phobias

Question 17

Task 1

Answer 17

• Role of The Ambulance Service
• Responsibilities of Ambulance Staff
• Admission procedures & Role of Approved Social Workers

Question 18

Approved Social Worker

Answer 18

• Authorised to initiate compulsory (formal) admissions and must be present
• Ambulance crews should work under their direction
• It is not normal for a social worker to be present for informal admissions

There is no legal requirement for the social worker to travel in the ambulance having authorised and provided written evidence of authorisation to initiate formal admission

It is, however good practice, as the patient is in the legal custody of the person who authorised the admission

Question 19

Your responsibilities to the patient

Answer 19

You should:

• Not be in a hurry
• Evaluate the situation
• Keep your own emotions under control
• Be honest with the patient
• Avoid force if possible
• Offer the same courtesy that you extend to physically ill patients
• Remember that there are few mental illnesses which prevent the sufferer responding to a reasonable approach

•

•As part of your responsibility to the patient carry out a suicide and self-harm risk assessment and complete the appropriate paperwork

Question 20

Suicide
and
Self-Harm
Risk Assessment Form

Answer 20

Question 21

Your responsibilities to relatives

Answer 21

Relatives should generally be told:

• What you are doing and why
• Which hospital the patient is being admitted to

During this distressing time they need support with kindness and sympathy. You can ease distress by your manner and approach during your removal of the patient

Question 22

Ambulance Service Approach

Answer 22

• Approach
• History
• Examination
• Capacity
• Management
• Compulsory Assessment

Question 23

Mental Health Act 1983

Answer 23

• Section 2
• Section 3
• Section 4
• Section 131
• Section 135

Section 136

Question 24

Working in groups produce a chart on flipchart paper to summarise

Answer 24

• Group 1 – Section 2 and Section 131
• Group 2 – Section 3 and Section 135
• Group 3 – Section 4 and Section 136

Question 25

Mental Capacity Act

Answer 25

The Mental Capacity Act (MCA) 2005

The implementation is as follows, from April 2007:

• The Department of Health introduce the Independent Mental Capacity Advocates (IMCAs)
• The ill treatment or neglect of a person who lacks capacity has become a criminal offence
• The Code of Practice for the Act is available
• From October 2007 the remainder of the Act including the Court of Protection and the Office of the Public Guardian will begin.
• There is no legal basis for next of kin
• There is no current mechanism for a person to nominate another to consent to treatment on their behalf, or to be consulted about their treatment?

•

• That as the law stands, if you lack capacity in the future there is no statutory mechanism whereby you can state your wishes for your future care with confidence that your wishes will be taken into account?
• Current common law lacks consistency
• People’s autonomy not always respected
• People can be viewed as incapable because of diagnosis
• No clear legal authority for people who act on behalf of a person lacking mental capacity
• Limited options for people who want to plan ahead for loss of mental capacity
• No right for relatives and carers to be consulted
• Enduring Powers of attorney seen as open to abuse

•

Question 26

Which Patients are Affected?

Answer 26

• Mental capacity could affect anybody
• Over 2 million people in England and Wales lack mental capacity to make some decisions for themselves
• Up to 6 million family carers, carers, health and social care staff

Question 27

What is Mental Capacity?

Answer 27

• Lack of capacity
• The act is intended to assist and support people who lack capacity and to discourage anyone who is involved in caring for some-one being overly restrictive or controlling
• Provides a legal framework for acting and/or making decisions on behalf of people who cannot make decisions for themselves

Question 28

Principles of the Act

Answer 28

•Assume a person has capacity unless proved otherwise

•

•Do not treat people as incapable of making a decision unless you have tried all you can to help them

•

•Do not treat someone as incapable of making a decision because their decision may seem unwise

Question 29

Implications for Practitioners

Answer 29

• Information, training and knowledge of Code of Practice
• Understanding what is an assessment of capacity and how to determine best interests
• Being aware someone may have an Lasting Power of Attorney (LPA), an advance decision, or written statement of wishes and feelings
• Do things or, take decisions for people without capacity in their best interests
• Before doing something to someone or making a decision on their behalf, consider whether you could achieve the outcome in a less restrictive way

Question 30

Who may lack capacity

Answer 30

For the purposes of this Act, a person lacks capacity in relation to a matter if he/she:

1.has an impairment of or disturbance in the functioning of the mind or brain – diagnostic test.

and

2. the impairment is sufficient that he lacks capacity for a particular decision – decision specific

Can be permanent or temporary.

Question 31

Assessing Capacity

Answer 31

• A person’s age, appearance, condition or behaviour does not by itself establish a lack of mental capacity
• The Code of Practice gives guidance to staff about how to assess including how information could be given and how to help the person to communicate

•

•Assessment of capacity should be specific to the decision needing to be made at the particular time

•

•A test of Capacity is outlined

Question 32

Ability to make decisions

Answer 32

Act says in 3(1)….a person is unable to make a decision for himself if he is unable:

a) to understand the information relevant to the decision
b) to retain that information
c) to use or weigh that information as part of the process of making that decision, or
d) to communicate his decision (whether by talking, using sign language or any other means).

●

Question 33

‘Best Interests’ – section 4

Answer 33

All decisions must be made in the best interests of the person who lacks capacity

The person must:

• involve the person who lacks capacity
• have regard for past and present wishes and feelings, especially written statements
• consult with others who are involved in the care of the person
• there can be no discrimination

Question 34

Provision of Care and Treatment

Answer 34

•Assessment of capacity is an integral part of any assessment about care or treatment

•

•If a person has no welfare LPA or advance decision to refuse treatment they can still be provided with the care or treatment they need

•

•The person providing the care or treatment decides what is in their best interests

Question 35

Emergency Situations

Answer 35

• Act allows care and treatment to be given as almost always in the persons best interests to give urgent treatment without delay
• Exception: when the person giving treatment is satisfied an advance decision to refuse treatment exists

Question 36

Making Decisions about Care and Treatment

Answer 36

Staff should demonstrate that they have:

•

• Taken reasonable steps to assess capacity to make a decision
• Reasonably believe that the person lacks capacity to make that decision
• Reasonably believe that the decision is in their best interests.

Question 37

Recording

Answer 37

•All staff involved in the care/treatment of a person who may lack capacity should record why they had a ‘reasonable belief’ and how they determined ‘best interests’ decision making.

•

• This should be on the PRF.
• Staff may need guidance on keeping adequate records to explain their actions i.e. why they had a reasonable belief of lack of capacity

Question 38

Restraint

Answer 38

Staff will be protected from liability if they:

• Reasonably believe the person lacks capacity
• That it needs to be done in their best interests
• That it is necessary to protect them from harm
• It must be proportionate and reasonable

IF PHYSICAL FORCE HAS BEEN USED, AN IR1 SHOULD BE SUBMITTED DETAILING THE TYPE OF RESTRAINT USED AND THE DURATION IT WAS USED FOR

Question 39

Patients who may Plan Ahead

•Lasting Powers of Attorney

•

•Advance Decisions to Refuse Treatment

•

•‘Statements of wishes and feelings’

Answer 39

•The Act enables people to appoint someone to make decisions on their behalf for a time when they may lack capacity. There are two types of LPA

–‘Property and affairs’ which replaces the current Enduring Power of Attorney

–‘Personal welfare’ which is a new way to appoint someone to make health and welfare decisions

–

• A person can only make an LPA when they have capacity
• If the person lacks capacity and has a welfare LPA, they will be the decision maker on all matters relating to that persons care and treatment unless the LPA specifies limits
• LPAs have to act in the persons best interests
• If the decision is about life-sustaining treatment, the LPA will only have the authority to make the decision if it specifies this.

Detailed guidance is available in the Code of Practice

Question 40

Advance Decisions to Refuse Treatment (ADRTs)

Answer 40

•Allows refusal of specified treatment in advance

•

•Must state what treatment and in what circumstances

•

•Only come into effect when the person lacks capacity

Question 41

Advance Decisions

Answer 41

The Advance Decision must be

•

• Valid
• Applicable

•

• Advance decisions do not need to be in writing except for decisions relating to life sustaining treatment
• A local Guidance Document has been produced by the Mid Trent Cancer Network
• In the absence of an advance decision, people’s views and wishes, whether written on not, should be used to assist in planning appropriate care and ‘best interests’ decision making.
• Any knowledge about wishes and feelings is important but not legally binding in the same way as an advance decision

Training materials available:

• MCA Poster – issued to each Ambulance Station
• Assessing Capacity Flow Chart

The full text of the Act and the Code of Practice is available on website address: www.dca.gov.uk/legal-policy/mental-capacity

Question 42

Scenario – Bess

Answer 42

Bess is a 78 yr old widow who lives with her son and daughter in law. Bess has dementia, is hard of hearing and her ability to understand information varies day to day.

In the last 2 weeks Bess has collapsed twice. GP thinks she may need a pacemaker so refers to a cardiologist for an assessment. Before the appointment arrives, Bess collapses at home. An ambulance is called but when it arrives, she has recovered and refuses to get into the ambulance.

What should the ambulance crew do? Discuss…..

Question 43

Scenario - Michael

Answer 43

You are called to attend Michael who is a man with severe Parkinson’s Disease. Michael is unconscious and his breathing is very laboured.

•

A neighbour tells you that Michael has informed her that in such circumstances, he does not wish to be resuscitated and she thinks he may have written this down.

•

•What factors do you need to consider? Discuss…..