Darren – 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
- • 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 patients current views and wishes as well as any expressed previously
- Defensible decision making is important by the Dentist & Learning Disability Nurse
- There are decisions that may need to be discussed with legal services for support and potential referral to Court of Protection
Darren, aged 22, has a mild to moderate learning disability. Darren has lived with his parents since birth and they are now in their early seventies. His mother is the carer for his father who has Parkinson's disease. Darren communicates with words and gestures, and he is an excellent "mimic" of other people's language patterns. He doesn't necessarily understand what he is saying all the time. He attends a local day centre 3 days per week. Darren doesn't like people touching his face or head. He doesn't like needles to the point where this is now a phobia. Darren will scream if he sees pictures of needles on the TV. His dental hygiene is poor. He has recently seen a community based dentist who has recommended treatment at the regional dental unit at the local hospital.
Current decision making issues for the professionals involved
The decision for the professionals, the dental surgeon and his community learning disability nurse involved is whether the urgency of the treatment is such that it needs to be carried out soon or could Darren have a desensitisation programme which would support him through the dental treatment? The professionals need to consider whether it is appropriate to assess Darren’s mental capacity in relation to the decision they require him to make.
The ethical decision
The ethical issue for the professionals involved (the surgeon and the community nurse), is whether Darren’s learning disability is such that he cannot make a decision about his treatment and therefore cannot consent to the proposed dental extractions. If it is decided that he lacks capacity, how far should any restraints (e.g. physical or sedative medication) be used to allow the treatment to be carried out? At what point do these become a potential deprivation of his liberty?
Discussion: Do you feel from what you have seen and heard that an assessment of capacity should be carried out?
- What evidence is there that Darren cannot make a decision about his dental treatment?
- Think of the challenges to the principles: Principle one - presume capacity; Two - support people in decision making; Three - an unwise decision doesn’t necessarily indicate a lack of capacity How are these principles to be applied in Darren’s situation?
- Discussion: What is the relationship between a person’s ability to consent to treatment and the person’s mental capacity?
Discussion: How should an assessment of capacity be carried out if you feel this is appropriate to a specific decision?
- 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 Darren for this decision? How can Darren be supported? Would there be a need to involve others in the assessment for Darren’s situation?
- Where should the bar be set concerning Darren’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 darren lacks capacity about his dental treatment decision, how would you approach making a best interests decision?
- What would you need to take into account? What options are there? Where there are several decisions involved, how would such a complex situation be dealt with?
- Who would you involve in the process of best interests decision making?
- How could you involve Darren in the process of best interests decision making?
- What weighting would you give Darren’s present and past wishes?
- How would you expect the least restrictive principle to be demonstrated in Darren’s situation? How would you evaluate the potential use of restraints and when these may be considered to be depriving Darren of his liberty for his dental treatment?
- In what circumstance would you need to refer for legal advice?
- How would you record a best interest decision(s)? For example, using a balance sheet approach?
- What guidance does the Code of Practice give about best interests decision making? (chapter 5)
- What is your decision for Darren?