Reflections on mental capacity assessments in general hospitals

Abstract

Research suggests that a significant proportion of inpatients in general medical wards may lack capacity to make treatment decisions, a situation that often goes unrecognised by clinicians. We would like to briefly discuss two cases from a non-psychiatric setting, where a mental disorder served to inhibit the individual's ability to weigh-up associated risks when deciding to refuse potentially life-sustaining healthcare interventions. In both cases the history of mental disorder was well established yet, for markedly different reasons, the respective presentation was such that the influence of the disorder on decision-making was not evident to the treating teams.

Medical Patients’ Treatment Decision Making Capacity: A Report from a General Hospital in Greece

“…This means that physicians identified as incompetent, less and different patients than those rated as such by the investigators. It seems that our results largely confirm that of previous research [ 6 , 18 , 23 ], which showed that only a small proportion (25-42%) of incapable patients in medical wards are recognized by their physician as such. The replication of this finding suggests that a proportion of patients in medical wards of general hospitals are undergoing treatment while they lack capacity to provide valid informed consent.…”

An exploration of mental capacity assessment within acute hospital and intermediate care settings in England: a focus group study

“…Most previous studies have focused on assessments for two different groups: people with learning disabilities and those with mental health conditions [e.g., 32,33]. In the current study, most participants indicated that they did not carry out assessments for these groups of patients very often.…”

How do health and social care professionals in England and Wales assess mental capacity? A literature review

“…For example, SLTs might be involved in assessments for people with communication difficulties [36,40]. Two studies [36,38] described the involvement of mental health specialists (e.g., liaison psychiatrists or mental health nurses) in capacity assessments for patients with mental health conditions. The authors of two case studies [38] suggested that multidisciplinary assessments of these patients' decision-making abilities were more accurate when they involved psychiatrists with specialist knowledge of mental health presentations.…”

“…Two studies [36,38] described the involvement of mental health specialists (e.g., liaison psychiatrists or mental health nurses) in capacity assessments for patients with mental health conditions. The authors of two case studies [38] suggested that multidisciplinary assessments of these patients' decision-making abilities were more accurate when they involved psychiatrists with specialist knowledge of mental health presentations. Participants in two studies [33,36] suggested that the choice of assessor could depend on which discipline understood the nature of the decision a patient was being asked to make and the decision options available to her/him.…”

“…Design / method Population studied Study aim Key findings Study quality limitations lack capacity to consent to them. Linn et al (2013) [38] Case studies Patients with mental health conditions on general medical hospital wards (n=2).…”