Arthur – 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 Mental Capacity Act should be followed, including allowing people to make unwise decisions
- The assessment of capacity can be carried out by the ambulance crew as they are potentially the decision maker, (provided the diagnostic element of the mental capacity test is met)
- The Code of Practice gives some guidance on the transport of a person as part of a best interests decision
Arthur is 68 years old and worked as a postman for most of his working life. Arthur has been living on his own in a Local Authority flat for 15 years since the death of his wife. He is very lonely and socially isolated. He has always been a drinker but has now taken to drinking at home. His neighbours look in from time to time but are put off by his poor personal hygiene and the state of the flat. Over the past couple of years, a group of mainly younger men from the local area have started to use Arthur's flat as a place to “crash out” when drinking and there is some casual drug usage. Arthur is only too pleased to have their company.
One Saturday afternoon a neighbour heard a loud thud and the door being ajar, looked inside to find Arthur sprawled on the floor. Having failed to wake him the neighbour called for an ambulance and the crew are now in attendance.
Current decision making issues for the professionals involved
The professional dilemma for the ambulance crew is where does their duty of care start and stop in a situation where the person appears to be under the influence of alcohol, drugs and is experiencing hallucinations. The challenge for professionals is, when the person is sober they are capacitated, where someone makes an unwise decision this needs to be respected.
At what point is the personal safety of the ambulance crew of greater importance than remaining in the immediate environment with Arthur?
The ethical decision
The dilemma for the professionals is about making immediate decisions about Arthur’s need for medical treatment away from his residence. Does the presumption of capacity outweigh any question over his ability to make decisions about his immediate medical needs? Is there any evidence that would suggest the ambulance crew should assess Arthur’s capacity to make decisions? Could they act in his best interests and take him to an Accident and Emergency Department for assessment?
- Discussion: What is ethical practice when it is recognised someone needs urgent medical treatment but is refusing?
- Discussion: What is the relationship between the Mental Health Act and the Mental Capacity Act? I.e. when might either act be used in preference to the other?
- Discussion: How would a judgement be reached that there is sufficient information for the “diagnostic test” to be met and thus allow an assessment of capacity of Arthur?
- Discussion: Should the professionals involved refer Arthur under “adult safeguarding” as an “adult at risk”?
Discussion: how would Arthur’s capacity to make decisions about medical treatment be assessed in this crisis situation, if 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 Arthur for this decision? How can Arthur be supported?
- Where should the bar be set concerning Arthur’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 by the ambulance crew?
- What guidance does the Code of Practice give that you would need to take into account in such a situation? (chapter 4)
- Discussion: If you concluded that arthur did not have mental capacity to make the decision in relation to being taken to hospital for medical assessment, could he be transported in his best interests and could any restraint be used if necessary?
Poll question 1
Should Arthur be left at his flat as he is refusing to go to hospital??
- Not sure
- Should Arthur be left at his flat as he is refusing to go to hospital??
Poll question 2
Do you think Arthur has capacity to make decisions about medical treatment for his leg injury?
- Not sure
- Do you think Arthur has capacity to make decisions about medical treatment for his leg injury?