Further training on the role of IMCAs within critical care is required, and good practice examples should be shared with other units to improve referral rates to the IMCA service and ensure that vulnerable patients are properly represented.

In a landmark judgment in the English Court of Protection, the judge (Charles J) found it to be in the best interests of a minimally conscious patient for clinically assisted nutrition and hydration (CANH) to be withdrawn, with the inevitable consequence that the patient would die. In making this judgment, it was accepted that the patient’s level of consciousness — if CANH were continued and rehabilitation provided — might improve, and that he might become capable of expressing emotions and making simple choices. The decision to withdraw treatment relied on a best interests decision, which gave great weight to the patient’s past wishes, feelings, values and beliefs, and brought a ‘holistic’ approach to understanding what this particular patient would have wanted. We draw on our own experience of supporting families, advocating for patients and training healthcare professionals in similar situations to consider the implications of the published judgment for policy and practice with patients in prolonged disorders of consciousness and their families.

People who lack capacity to make certain decisions have a statutory right to be represented by an independent mental capacity advocate (IMCA). However, there is concern among the organisations that provide IMCA services about the lower than expected number of referrals (instructions) by trusts in the NHS. The authors discuss possible reasons for the low instruction rate and how this could be improved. A case study of a woman with mental health problems is used to demonstrate how the role of the IMCA works in practice.

No abstract

This chapter discusses mental health advocacy in the UK and how the history of mental health care has influenced current practice, as well as how the advocacy sector in general has shaped government policy and legislation. The emphasis is on England and Wales, although advocacy delivery in Scotland and Northern Ireland is also considered. The chapter first defines advocacy and outlines its history in the UK before analyzing recent developments in the country. It then examines the principles of advocacy (independence; empowerment; representation, information, support; accountability; confidentiality), together with different forms of advocacy in the UK and key legislation, including the Mental Capacity Act 2005 and the Mental Health Act 1983 in England and Wales. Finally, it looks at issues and challenges faced by mental health advocates with regard to ethics and values, such as conflicts of interest and duty, the nature of professional obligations and neutrality, and social justice.