Isabella – 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 should be followed
- The Code of Practice gives some guidance on the futility of treatment
- Recently revised guidance on DNACPR, must be considered
- There are decisions that may need to be discussed with legal services for support and potential referral to Court of Protection
Isabella is 24 years old (known as Issie), she is a mature student studying for a B.Sc. in Psychology at university. She lives and studies away from home. Issie has cerebral palsy (ataxic), epilepsy and increasing issues with her swallowing, which has resulted in recent episodes of aspiration pneumonia. She is now on thickened fluids. She uses a wheelchair and relies on the carers for a lot of her personal care needs. She lives in specially adapted accommodation at the university and has a team of personal assistants who support her 24 hours per day. Her only relative is her mother who lives abroad and has alcohol problems. She has all but given up on Isabella.
Late on Saturday evening under the care of a temporary support worker, Isabella collapsed and was admitted to hospital. She is currently unconscious as a result of her choking and an epileptic seizure.
Current decision making issues for the professionals involved
Issie has had treatment at this hospital before so there is some medical information on file. However, the Junior Doctor now needs to establish further background information to assist her in planning the next few hours of her care. Issie’s health situation is not yet stable. She is unconscious and therefore she lacks capacity. There appears to be an incomplete picture as to what actually happened before admission. The Junior Doctor, Dr Simmons, is discussing Issie’s situation with her personal assistant, to establish relevant information to what would be in her best interests, including whether she has made any advance decisions to refuse medical treatment.
The ethical decision
The dilemma for the professionals is about making immediate decisions about Issie’s care, assessing what plans to put in place if her health deteriorates; balanced with a lack of knowledge about the person, in a late evening/ night time situation. She lacks capacity because of her current health status. The situation raises questions about when treatments of a life-saving nature might become futile, who should be consulted, when might it be appropriate to withdraw medical treatments?
Discussion: The code of practice gives guidance on situations where medical treatment may become futile. How should the doctor and the team proceed?
- What are the issues in terms of futility of a specific treatment, if Issie’s situation cannot be stabilised?
- How would quality of life be assessed in Issie’s situation?
- When might it be appropriate to consider whether a DNACPR should be put in place? What does current guidance suggest would be the process to follow?
- Would the information given by the personal assistant (PA) raise concerns for you in terms of potential safeguarding? If yes what action would you take?
Discussion: Isabella lacks capacity about her medical treatment. 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?
- Which person(s) would you involve in the process of best interests decision making?
- What are specific requirements of the Mental Capacity Act in relation to the involvement of the Independent Mental Capacity Advocates (IMCA)? Should they be involved in Issie’s situation?
- What weighting would you give Issie’s past wishes?
- How would you expect the least restrictive principle to be demonstrated in Issie’s situation?
- In what circumstances would you need to refer to legal advice in Issie’s situation?
- 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 Teresa?
Poll question 1
Issie’s mother, as her only relative, should be consulted about issie’s general health care decisions?
- Not sure
- Issie’s mother, as her only relative, should be consulted about issie’s general health care decisions?
Poll question 2
Issie’s mother, as her only relative, should be consulted about issie’s health care where there are issues around DNACPR?
- Not sure
- Issie’s mother, as her only relative, should be consulted about issie’s health care where there are issues around DNACPR?
Cases from the courts
From the court of appeal in 2014 a woman with complex medical issues, whilst she had capacity, the courts were concerned with need to make consultations with family
In a case before the Court of Appeal,  EWCA C iv 33, considered that the NHS Trust involved had not consulted the family members (her husband) in relation to a DNACPR placed on her file. It was found that an NHS Trust had a legal duty to tell a patient, with mental capacity, that a Do Not Attempt Cardiac Pulmonary Resuscitation (DNACPR) order had been placed on her medical records.
From a High Court in 2015 a young man with cerebral palsy, epilepsy, spinal deformities and other associated health conditions. The family were not consulted over the dnacpr. This was a violation under the human rights act.
In a legal case Winspear v City Hospitals Sunderland NHS Foundation Trust  EWHC 3250 (QB);  WLR (D) 468. It was found that the core principle of prior consultation before a DNACPR decision was placed on a case file applied whether the patient had or lacked capacity. The judgment, handed down on (Friday 13 November 2015), found that the decision to impose a Do Not Attempt Cardio-Pulmonary Resuscitation ‘DNACPR’ order on a 28-year-old man with cerebral palsy, without the knowledge of his family, was a violation of his Article 8 rights, under the Human Rights Act.