Reflective log: Next of Kin

1. Think of a recent therapy session or event.

I had a meeting to decide the next of kin for a patient who had severe language impairments. The patient had had a LMCA infarct and presented with global aphasia. On impairment based assessment (picture/ object naming etc) the patient did not perform well. He was able to match objects to pictures and understood single words. He was inconsistent with 2 and 3 stage instructions. However in context the patient laughed appropriately at jokes and appeared to understand some conversation in context when given gestures. I had a meeting with the patient’s nephew, his nephew’s daughters, the OT, the discharge coordinator and the carer support worker.

2. Describe the session/experience

I gave feedback on the patient’s communication and fed back the results from my language assessments. I gave examples e.g. he laughs appropriately at jokes in context and he was not able to match spoken sentences to pictures. I then answered questions on whether I thought the patient had capacity, stating that I thought he had capacity for decisions which were simple, concrete and in context. I gave the patient an object of reference (his house keys) and asked him who he wanted as his next of kin, having his nephew on his left side and a picture of his niece on his left side. I asked the question in different ways and the patient responded consistently.

3. What did this session make you feel?

I felt under pressure to make a decision that could have a large impact for the patient. I decided to break down the information I did know and apply it to the new situation, being clear that I thought the patient had capacity for some specific situations.

4. What would you want to change, and why?

- introduce the topic to the patient before the meeting.

- get a second opinion from the psychology team.

5. What has this session has taught you?

- Give examples of the type of decisions I feel a patient can make.

- I can use objects of reference/ total communication to support a patient’s comprehension during a capacity assessment.

- Carer support workers have a lot of knowledge about NOK, power of attorney, paying bills etc.

6. What do you need to learn or find out before the next event?

- Capacity – do more research on this.

- Next of kin – the powers

- Power of attorney – what this means and how you go about getting this. 

Capacity Assessments

Key areas needed for capacity:

1. Understand the information.
2. Indicate a clear Yes/No response.
3. Weigh up the impact of the different choices.

Often weighing up the necessary information is the most difficult for patients since it involves abstract thinking.

Advice from my supervisor:

• Decide if a patient has capacity as a MDT e.g. you might not know enough about the consequences of a decision.
• Ask the same question in different ways.
• You can only decide if a patient has capacity for a single decision/ question, capacity may be different for different decisions.

Mental Capacity act 2005

The mental capacity act aims to:

Ensure that people are given appropriate help/ support to enable them to make their own decisions.

-        Assist and support those who might lack capacity

-        Discourage those who care for them from being overly restrictive/controlling

-        Balance people’s rights to autonomy with safeguards for person’s who do not have capacity.

 

Core principles

-        The person is assumed to have capacity – the assessor needs to demonstrate a lack of capacity.

-        Attempts need to be made to allow the patient to participate in decision making.

-        If a patient does not have capacity whatever decisions are made must be in their best interests (considering  their ‘past and present wiehes/ feelings’, consulting relevant others).

What is a lack of capacity?

1.     Lack of capacity is decision specific e.g.  a patient may have the capacity to: Make decisions about some treatments but not others.

2.     Mental capacity fluctuates from time to time. Therefore we have to identify the optimal opportunity to discuss things with the patient.

 

Lasting Power of Attorney (LPA)

-        Enables people to appoint attorneys to make personal welfare decisions (including healthcare and medical treatment decisions) on their behalf for a future time when they might lack capacity.

-        Different people (attourneys) may be appointed to take different decisions e.g. finantial vs. health.

-        Example decisions: about: where the donor should live, day-to-day care, giving/refusing consent to a medical examination/treatment.

-        Is unable to consent/ refuse a treatment for the donor if the donor is able to make a decision.

-        An attorney has no power to consent/ refuse life sustaining treatment unless the LPA document explicitly says so and cannot demand treatments the medical team does not believe are clinically necessary.

Is the clinician liable for the decisions they make?

-        The act ensures that health/ social care staff receive statutory protection from liability for certain acts as long as they can prove that they were in the patients best interests and carried out in accordance with the principles of the act.

-        Clinicians are not protected against negligence e.g. do something in the patients interests but in a negligent fashion.

 

The court of protection

-        Takes on all of the decisions related to mental incapacity.

 

IMCA Independent Mental Capacity Advocate

-        Provide independent safeguards for people who lack capacity to make certain important decisions and have no one close to them.

-        Appointed in 2 circumstances: 1. When a serious medical treatment is being proposed, 2. Where there is a proposal to arrange accommodation/ change accommodation.

Factors that affect capacity

-        Fatigue – keep sessions short, allow for rest periods, choose the time of day when the person is at their best.

-        Complex language – simplify.

-        Amount of info – provide only relevant info

-        Cultural/ ethnic/religious factors – consider whether someone else could assist e.g. a member of a community group/ religious group.