What are 3 key components of valid consent?
Be sufficiently informed
Make a voluntary decision
Have capacity
What is capacity?
The ability to make a decision. It is time and task specific
What are the 3 central themes of the Mental Capacity Act 2005?
Empower people to make decisions for themselves
Participation
Protecting people who lack capacity
What are the 5 key principles of the Mental Capacity Act 2005?
- Presume capacity
- Offer support to maximise capacity
- Unwise decisions
- Best interests
- Least restrictive option
How is capacity assessed?
Assess by person who is most informed about the decision to be made aka doctor
2 stage process:
- is there an impairment or disturbance of the mind or brain?
- Does this impairment or disturbance affect a person’s ability to understand the information, retain the information, weigh up the information, or communicate their decision?
Examples of a disturbance or impairment of the mind or brain that may result in altered capacity
Dementia Severe psychiatric illness Severe learning difficulties Delirium e.g. infection, or electrolyte abnormalities Head injuries Effects of prescribed medication Effects of alcohol and drugs
What are the 3 key situations where there may be a lack of capacity?
- Temporary lack of capacity e.g. unconscious after RTA
- Patient permanently lacks capacity after formerly having capacity e.g. due to dementia
- A patient that has never had capacity e.g. severe learning difficulties
What is an ARDT?
Advanced decision to refuse treatment
Legally binding, made when patient has capacity to refuse specific treatment should they lose the ability to make decisions, and must be 18 or over
If refusal pertains to life-sustaining treatment, must be written with refused treatment specified and a statement stating the decision applies even if the person’s life is at risk, and signed with a witness
Who are proxy decision makers?
People who can make decisions on the behalf of adults who lack capacity e.g. Lasting power of attorney, deputy of court
When would an ARDT be considered not legally binding?
It is not valid e.g. due to no capacity at time, inconsistency in person, or does not meet criteria if life-sustaining treatment is refused
It is not applicable e.g. patient has capacity, not specific to current situation, circumstances not anticipated by patient
There are doubts about its existence
What is an LPA?
Lasting power of attorney
Person (donee) is appointed by a patient (donor) to have the power to make decisions for them when they (donor) lose capacity
Can be responsible for health and welfare decisions OR financial and property decisions
Both must be over 18 and may make all decisions or only specific decisions
Must be certified by independent third party (doctor or lawyer) and registered with Office of the Public Guardian
Lifestyle drift
Policy drift from recognising and attempting to address wider societal health issues to focusing on individuals’ and lifestyle and health issues. In essence it is a shift from big policy to smaller individual focus and change.
5As of access to healthcare
Affordable Available - GP, walk-in centres Accessible - transport links, wheelchair access, etc. Accommodating - out-of-hours appt Acceptable
Factors affecting health
Genetics
Environment - access to green space, air pollution, busy roads, home environments
Social circumstances - supportive friends/family, smoking, drinking, employment
Education
Lifestyle - diet, exercise, smoking, drinking, stress, social support
Economic circumstances - stress of financial hardship, ability to socialise and buy healthy food
Access to healthcare
Inequity
Lack of fairness or justice
Smoking from SoDH perspective
Early socioeconomic circumstances and education have been found to be more important than adult socioeconomic circumstances
Difficult to quit if pt has mental health disorders, is under a lot of stress, lacks social support
In pregnancy:
200% higher incidence of sudden infant death syndrome
20-30% higher likelihood of stillbirth
40% of higher rate of infant mortality
Sense of agency
A pt’s ability to act and control their own lives
Can be diminished by social isolation, poverty and psychological distress over the life course
Marmot Review (2010)
An English review of recommendations made by the WHO Commission on Social Determinants of Health:
- give every child the best start in life e.g., Sure Start
- enable all to maximise capabilities & control over their lives e.g., improve educational outcomes & life skills across the social gradient
- create fair employment and good work for all e.g., stress mx, promote wellbeing, labour market programmes to reduce long term employment
- healthy standard of living for all e.g., taxation, benefits, tax credit and pensions
- develop healthy and sustainable places & communities e.g., green spaces, urban planning, energy efficiency, reduce social isolation
- promote ill health prevention e.g., flu jabs
Proportionate Universalism
Defined as the ideal of universal change with a proportionate level of aid or action done with a scale and intensity proportionate to the level of disadvantage
Cause of the cause
Attempts to tackle the root of health behaviour problems to bring about more sustainable health change
The life-course model
Disadvantage starts before birth and accumulates throughout life
As suggested by the Marmot Review
5 principles of motivational interviewing
- Express empathy through reflective listening.
- Develop discrepancy between clients’ goals or values and their current behavior.
- Avoid argument and direct confrontation.
- Adjust to client resistance rather than opposing it directly.
- Support self-efficacy and optimism.
LPA vs Advanced Decision
LPA takes priority over AD if LPA is made after AD
AD takes priority if AD is made after LPA
Deputy of court
Appointed by court to make decisions in the best interests of a patient who lacks capacity
