Susie – scenario for training
Mental Capacity Act workbook
Commissioned by, and hosted here on the MCA Directory on behalf of, the members of the NHS Eastern Region Safeguarding Adult Forum facilitated by Eleanor Sherwen & Sarah Robinson.
View here online or order a DVD or workbook
For participants to recognise that
- The principles of the Mental Capacity Act are law
- Assessment of capacity must be decision specific
- People (the patient) can make decisions that are unwise which may result in serious consequences to their health
- If it is decided that the person lacks capacity, the decision maker, must make a best interests decision based on; a balance sheet approach, consultation and taking into account the patient’s current views and wishes as well as any expressed previously
- There are decisions that may need to be discussed with legal services for support and potential referral to Court of Protection
Susie, a writer and poet is 61. Susie has lived with her partner Sarah for 20 years after the end of her marriage. She has no children. They formalised their relationship into a Civil Partnership 4 years ago. Susie has suffered from frequent bouts of depression but has always relied on Sarah to help her through. She copes by being able to lose herself in her writing and creativity. Susie was diagnosed with an advanced cancer of the stomach about 2 months ago. Because of her depression and health problems she has found it impossible to concentrate long enough to return to her work. She is deeply unhappy. During a particularly challenging time 3 weeks ago, she attempted to take her own life by taking a vast quantity of paracetamol and alcohol. She was found by Sarah but has since been diagnosed with severe kidney failure and some liver damage. Susie has accepted some sessions of dialysis at home but is now refusing any further treatment. Susie has often taken Sarah with her to see the GP. The GP saw both Susie and Sarah at home a couple of days ago, when Susie had developed a chest infection. Susie told the GP that she had no intention of having any further treatment. .
Current decision making issues for the professionals involved
Sarah has arranged to see the GP to clarify whether Susie has the right to refuse medical treatment. The GP is now faced with a series of issues. Sarah is the next of kin but the Lasting Power of Attorney is in the process of being registered. The GP needs to respond and link with the other professionals involved. Susie is adamant that she doesn’t want any further treatment. However, there are questions about Susie’s capacity to make decisions related to her medical treatment.
The ethical decision
If it was Susie’s intention to end her life, how should her doctors respond to her apparent wish to die, through her refusal of further medical treatment? How far do doctors have a moral duty to promote and maintain the person’s life, despite the patient’s complex medical and psychological issues?
Discussion: Do you feel from what you have seen and heard that an assessment of capacity should be carried out? (think principle one and principle three of the mca) what evidence is there that she cannot make a decision?
- Discussion: What might be the differences between her ability to consent to treatment (or her refusal of treatment) and her potential lack of mental capacity to make a specific decision?
Discussion: How should the assessment of capacity be carried out if you feel this is appropriate?
- What do you believe to be the specific question (decision) that the assessment of capacity should be based on?
- How specifically is the diagnostic element of the test met?
- What would you anticipate to be the relevant type of information that should be given to Susie for this decision? How can Susie be supported?
- Where should the bar be set concerning Susie’s ability to weigh up the relevant information?
- Where someone has apparent fluctuating capacity, what is best practice in situations where there are issues of consent to treatment?
- How would an assessment of capacity be recorded?
- What guidance does the Code of Practice give that you would need to take into account in such a situation? (chapter 4)
Discussion: If it is decided that susie lacks capacity about this specific decision, how would you approach making a best interests decision?
- What would you need to take into account? What options are there?
- Who would you involve in the process of best interests decision making?
- How could you involve Susie in the process of best interests decision making?
- What weighting would you give Susie’s past wishes?
- How would you expect the least restrictive principle to be demonstrated in Susie’s situation?
- In what circumstances would you need to refer for legal advice?
- How would you record a best interest decision? For example, using a balance sheet approach
- What guidance does the Code of Practice give about best interests decision making? (chapter5)
- What is your decision for Susie?
Poll question 1
Do you believe it is in Susie’s best interests to further renal dialysis?
- Not sure
- Do you believe it is in Susie’s best interests to further renal dialysis?
Poll question 2
Would you refer Susie’s situation to your legal services for advice?
- Not sure
- Would you refer Susie’s situation to your legal services for advice?
Cases from the court of protection
Case C a woman who had attempted to end her own life because of her depression, and was now refusing further medical treatment. Decision: the woman had capacity to make her own decisions re medical treatment therefore she could not be forced to have treatment.
In a legal case  EWCOP 80 Kings College NHS Foundation Trust v C and V  EWCOP 59 (MacDonald J). The judge concluded that the person had capacity despite other medical expert opinion suggesting that the patient didn’t have capacity to consent to her life saving medical treatment of renal dialysis. The judge commented in detail on how assessments of capacity should use the process of “weighing information” by the person. “The temptation to base a judgment of a person’s capacity upon whether they seem to have made a good or bad decision, and in particular on whether they have accepted or rejected medical advice, is absolutely to be avoided. That would be to put the cart before the horse or, expressed another way, to allow the tail of welfare to wag the dog of capacity. Any tendency in this direction risks infringing the rights of that group of persons who, though vulnerable, are capable of making their own decisions. Many who suffer from mental illness are well able to make decisions about their medical treatment, and it is important not to make unjustified assumptions to the contrary.”