It’s not enough to be aware of dementia: health professionals, like the public, also need to take the right practical approach. The
Alzheimer’s Society’s Dementia Friends initiative is a valuable tool in promoting general public awareness of dementia. Sadly, awareness is not the same as adapting behaviour and approach in practical ways when supporting those living with dementia.
Unfortunately, professionals of all types can be as guilty as ‘the public’ in this regard.
In legal terms, one of the most significant potential legal consequences following a diagnosis of dementia is the possibility that now, or at some point in the future, the person may lose the capacity to consent to a range of decisions and activities. At Harrison Clark Rickerbys, to help us effectively assess the capability of dementia clients against the relevant legal test criteria, we have reviewed the way services are delivered, how printed information is presented and staff training. We need to ensure that all staff, including those who speak to clients on the phone and make appointments, are able to identify the same as adapting behaviour and problems and difficulties. Our staff training also includes ensuring that staff who are assessing capacity are familiar with the Mental Capacity Act and its code of practice.
These steps allow us to ensure that clients are supported in the most appropriate circumstances to maximise their chances of making decisions. It also allows us to be alert to potential difficulties, so we are best prepared to ensure the decisions are those of the client and not another person.
Patience with patients
One of the things we have learned is that delivering support to a person living with dementia cannot always be achieved within limited time slots. A full assessment of legal capacity, for example, may require two or three visits. It may also require a doctor’s report and will rarely involve long meetings. We also often find that we firstly need to identify informal, non-legal matters of interest to the client, to help them ‘warm up’ their thought processes before moving to the legal issues. Relying exclusively on the use of tick boxes and checklists is not helpful or definitive in deciding the question of legal capacity.
Recent court decisions give weight to conclusions on the question of capacity where the conclusions are drawn by experienced practitioners, in various professions. The assessment processes the practitioners use must follow best practice in the field, and must follow the Mental Capacity Act and its code of practice.
Strategies for doubt
For medical professionals too there are a range of issues that can arise when capacity to consent or decide is doubtful. However, on a practical level, have you considered any of the following:
? Adapting the delivery of services and information to meet specific needs.
? Training staff in how critical capacity assessments are in delivering treatment and in relation to the relevance of powers of attorney.
? Establishing a process to follow if there are doubts about capacity.
? Establishing a process to record any ‘best interests’ decision made, which takes into account the Mental Capacity Act Code of Practice.
? Asking new patients (or existing patients at any time) about the existence of powers of attorney.
Practice-wide processes
I spoke to a dentist recently after their visit from the Care Quality Commission. The practice was asked about their knowledge and practice in relation to the Mental Capacity Act. Their knowledge was scant, and it is to be seen whether CQC refer to that in their report.
We therefore subsequently discussed the relevance of the legislation in the context of valid consent. I pointed out that assessment of capacity (and being alert for signals that it might not be there) starts with the person who takes the call making the appointment and includes the person who greets the patient on their arrival. However, ultimate responsibility lies with the person delivering the treatment.
The CQC was looking for understanding from all staff at the practice of their role in the process, and of their responsibility to advise the person delivering the treatment of concerns, if they arise. I suspect the CQC was also looking for a clear process that would be followed in the event that lack of capacity was suspected. That process could include confirming capacity, and
recording the assessment, as well as deciding how to proceed in the event of a lack of capacity.
In circumstances where urgent treatment is required by someone lacking capacity, a record of the factors taken into account when reaching a 'best interests' decision, and what the best interests decision was, would also be expected.