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Mental Capacity Assessments: Assessing and supporting understanding and communication 6th February 2016

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Isla Jones, Highly Specialist Speech and Language Therapist, Health and Ageing, Kings College Hospital

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Anna Volkmer, Highly Specialist Speech & Language Therapist South London and the Maudsley NHS Foundation Trust NIHR Doctoral Research Fellow, Division of Psychology and Language Sciences, UCL

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Question

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• How many of you feel that you have adequate training to support a person with a communication difficulty during a mental capacity assessment?

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Video of someone with aphasia

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• Do you think you could assess this person’s capacity to make a decision on issues surrounding discharge from hospital?

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Training to support capacity assessments: What is the difference?

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• Social work assessors of mental capacity were trained in facilitative and supportive communication techniques

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• Assessors who did receive training in communicating with people with aphasia were found to more accurately assess an aphasic person’s decision-making capacity.

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• The researchers note that, in this research study, it was not the person with aphasia who owned the communication barrier but rather the assessor’s skills and confidence which were the stumbling block. Carling-Rowland et al, 2014

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Capacity in the NHS: Case Study

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Mrs B (late 60s) Caribbean descent 3 CVA’s (with moderate aphasia) Known to become verbally and physically aggressive Worsening visual difficulties – cataracts Increased distress due to visual difficulties ?Can she consent to a cataract operation 5

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Prioritising SLT support: Risks of no SLT:

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• Ongoing visual difficulties = ongoing anxiety and distress • Difficulties in comprehension/expression = reduced likelihood of engaging with procedure and increased likelihood of verbal and physical aggression • Ongoing impact on daily care and long-term independence

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Benefits of SLT:

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• If appropriately supported more likely to engage • Likely improved vision = reduced distress and improved behaviour • Could support independence for future care

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Background: mental capacity • 26% medical inpatients may lack capacity

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 Assessment is subjective, complex

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 Current practice is inadequate

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 Inaccurate assessment risks excluding people from decision-making / asking people to make uninformed decisions

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 Risks of non-involvement:  adherence,  health outcomes,  costs

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Clinical context: patients with communication difficulties

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 Two of four abilities tested in MCA functional assessment involve communication skills  MCA requires adjustments to assessment:

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‘A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success’ (MCA (2005) section1(3))

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 Hospital staff may not recognise or know how to support communication difficulties

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Mental Capacity Act Code of Practice

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• The MCA recommends seeking the professional opinion of an SLT to support capacity assessment of individuals with communication difficulties.

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• Complex issues may require fuller assessments, for example by different experts within the team including psychologists, SLTs and medical staff.

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• The assessor or assessors can be anyone “directly concerned” with the individual at the time the decision needs to be made.

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• The “decision-maker”, or person who ultimately makes a judgment about whether an individual has capacity to make the decision, should be the person who will take action in that individual’s best interests if the assessment finds they lack capacity.

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Different roles of a speech and language therapist • Assessor

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• Challenger • Facilitator • Supporter • Information giver and or presenter

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• Expert ‘role’ • Decision-maker

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• Trainer

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• Advocate • Educator

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• Evidencer

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Psychiatry of Old Age Clinical Excellence Network consensus document (forthcoming 2016)

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People with communication difficulties most often fail a capacity assessment on:

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• People with dementia (even mild) fail on understanding (Moye 2004, Moye 2007)

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• People with aphasia often make “all the right noises” yet do not understand the information provided (Kagan & Kimelman, 1995).

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• People with brain injuries most often present with a lack of insight which means they are unable to judge risk (Report by the Acquired Brain Injury and Mental Capacity Act Interest Group House of Lords Select Committee Post-Legislative Scrutiny Report into the Mental Capacity Act, 2014)

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What are the indicators for referring a patient to an SLT when planning a capacity assessment?

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• DO NOT refer to SLT if; - Non-English speaker - Hearing/Visual impairments Seek support from appropriate sources e.g. BSL interpreter • DO refer to SLT if; - If the patient has any of the above AND additional cognitive or communication difficulties refer to SLT - Aphasia & / or Cognitive communication difficulties (e.g. due to stroke or TBI or dementia) AND unreliable yes/no for basic personal information OR unable to follow basic instructions

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6 basic questions as a communication screen

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• Is your surname (correct name)? • Is your first name (incorrect name) • Do you live in Paris? • Do you live in (correct place)? • Show me the floor window and light • Nod your head twice and touch your chin

(Jayes et al, 2014)

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Do you think communication training could add value to your practice in assessing people with communication difficulties?

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Capacity assessments should not only be used as a means of assessing capacity BUT as a means of establishing someone’s preferences should they lack capacity to make this specific decision

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References

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• Acquired Brain Injury and Mental Capacity Act Interest Group (2014) Acquired Brain Injury and Mental Capacity. Recommendations for Action following the House of Lords Select Committee Post-Legislative Scrutiny Report into the Mental Capacity Act: Making the Abstract Real.

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• Care Quality Commission (2013) Monitoring the use of the Mental Capacity Act Deprivation of Liberty Safeguards in 2012/13. Available from: http://www.cqc.org.uk/sites/default/files/documents/dols_2014.pdf [Accessed 05 October, 2013) • Carling-Rowland, A., Black, S., McDonald, L. & Kagan, A. (2014) Increasing access to fair capacity evaluation for discharge decision-making for people with aphasia: A randomized controlled trial. Aphasiology, 28(6): 750–765.

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• Jayes, M. (2015) Development of the Mental Capacity Assessment Tool Kit. Verbal Presentation. Psychiatry of Old Age CEN Meeting, November 2015.

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• Kagan, A. & Kimelman, M.K. (1995) Informed consent in aphasia research: Myth or reality. Clinical Aphasiology, 23, 65–75.

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• Lai, J.M. & Karlawish, J (2008) Assessing the Capacity to Make Everyday Decisions: A Guide for Clinicians and an Agenda for Future Research. American Journal of Geriatric Psychiatry, 15,101-111.

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References

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• Moye, J., Karel, M.J.M., Azar, A.R. & Guerrera, R.J. (2004) Capacity to consent to treatment: Empirical comparison of three instruments in older adults with and without dementia. The Gerontologist, 44(2): 166–175.

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• Moye, J., & Marson, D. C. (2007). Assessment of decision-making capacity in older adults: an emerging area of practice and research. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 62(1), P3-P11. • Psychiatry of Old Age Clinical Excellence Network (forthcoming Bulletin 2016) Consensus opinion on SLT role in Mental Capacity Assessment.

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• Ripley, S. et al. (2008) Capacity assessments on medical inpatients referred to social workers for care home placement. The Psychiatrist, 32, 56-59.

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• Sessums, L. L., Zembrzuska, H. & Jackson, L.L. (2011) Does This Patient Have Medical DecisionMaking Capacity? Journal of the American Medical Association, 306(4), 420-7.

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• Volkmer, A. (2016) Dealing with Capacity and other Legal Issues with Adults with Acquired Neurological Conditions: A guide for SLTs. J&R Press, UK.

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• Williams, V. et al. (2012) Making Best Interests Decisions: People and Processes. London, Mental Health Foundation.

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Thank you for listening Anna

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@volkmer_anna

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Isla

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[email protected]

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[email protected]