Medical Issues on Dementia Case - Essay Example

?Case Study: Scenario Introduction This is the case of an elderly gentleman, Mr. P, 86 years old, diagnosed with moderate dementia who was being considered for clinical NHS care under the Mental Capacity Act. He indicated that he wanted to be brought home, but his family wanted him to be admitted to the hospital setting because he was placing too much pressure on his family, especially his daughter to care for him. He had significant limitations in his mobility and self-care, mostly in his toileting; he was also at significant risk for falls and has in fact experienced several incidents where he has fallen. After he was admitted to hospital care after a fall, he has since refused medical care and expressed his wish to be discharged to his home and be cared for by his family. His family has however expressed that it was better for him to remain in the hospital, especially as they lived about 100 miles away from the patient and could not be adequately responsive to his immediate needs. This paper shall now discuss the different issues in this paper, those relating to the care allocated to the patient, and the ethical implications of the case. In order to protect the patient’s confidentiality and anonymity, his real name will not be revealed. This confidentiality shall extend to the carers involved in his care, as well as the evaluators for his case speaking on this BBC radio show. Protecting confidentiality or anonymity of the patient is part of the ethical principles in health practice, one which would allow the patient to be open to the health professionals without fear of their personal health conditions being revealed to other people. Body The ethical dilemmas which can be identified from the scenario include the following: whether the patient has the capacity to make the decisions regarding his care; how his best interests would be judged; and issues in the care of vulnerable elderly patients. The theory relating to mental capacity relates to the fact that the lack of mental capacity involves the ability to make decisions in one’s care; it also involves the ability to understand one’s decision, its implications, as well as the balancing of such decision (Mental Capacity Act, 2005). The Mental Capacity Act has established the details on what capacity or lack of capacity is, and these details are founded on common law. The idea of capacity is that it has a significant ethical impact because it helps determine when an individual’s refusal of medical treatment must be upheld and when it must be overlooked in favour of the patient’s best interests (Mental Capacity Act, 2005). The Mental Capacity Act (2005) includes various elements of capacity, including the fact that the basis of capacity is anchored on a specific decision, allowing a person with capacity to make one decision, even if he lacks capacity to make another decision. Another element of capacity relates to a specific decision, where a person may or may not have capacity and the fact that there are no degrees of capacity (Hotopf, 2005). Finally, capacity is mostly intellectual. In effect, an individual would have capacity if he does understand the information, is able to retain it, and is able to evaluate the data in making and communicating his decision. In the case of Mr. P, as far as the specific decision of wanting to be brought home, he does have the capacity to make such decision. He does understand the implications of his decision, including the information relating to his decision, and the evaluation of information in making and expressing his decision. The presence of capacity has to be understood within the context of each patient (Kress, 2004). Although he is resistant to healthcare and as claimed by his family, he has changed significantly and does not anymore have the capacity to make sound decisions regarding his care, these claims alone are not sufficient to support a determination involving the lack of capacity. Human beings change over time and are often vastly different from each other (UK Clinical Ethics Network, n.d). Each patient’s situation has to be evaluated based on his general condition, including the environmental elements surrounding his person. In the case of Mr. P, a visit from the occupational therapist indicated that the patient manifested better mobility in his home, his walking improved and his motivation also improved. This led the OT to recommend the discharge of the patient to his home. Although the family was very much upset with the recommendation, the Mental Capacity Act also seeks to prioritize patient preferences, including past wishes, values, as well as possible options for supportive care (UK CEN, n.d). In this case, the patient did eventually agree to care in the home health setting, with the social services paying for such care. This programme was meant to reduce the burden of care on the daughter, while still protecting the patient’s preference to be cared for at home. Based on the above circumstances, the primacy was given to the best interests of the patient. This principle is placed under the Mental Capacity Act, section 1(4). The Mental Capacity Act focuses on best interests, however it does not specify what best interests are and does not indicate a standard for evaluating best interests. However, a checklist of issues seems to be important in determining best interests (Mental Capacity Act, 2005). Various accounts of best interests can be seen within the philosophical context. This context often aligns best interests with well-being. An individual’s best interests can be met by maximising the well-being of an individual. Well being can also be understood based on mental state theories. Based on these theories, well-being is understood in relation to mental states. At its most basic, which is hedonism, it is the perception that happiness is the only positive mental status, and happiness is the only negative state (Owen, et.al., 2009). The theory can be improved by ensuring that there is a higher plurality in the states of mind impacting on well-being. This theory points out that it is significant to note that an individual is going through a specific level of happiness, but this may change with time. A specific form of happiness may be rated at a particular time to be level 5 from a scale of 1-10 with 1 being the saddest and 10 being the happiest. Later, that level may increase to 6 or decrease to 4 (Owen, et.al., 2009). Happiness may therefore be relative. In considering what the best interests for a person may be, a specific ‘best interest’ may simply include high-paid work and healthy family; however, for the elderly adult, the best interest would likely change to adequate retirement plan and being healthy. The important point is in choosing a specific ‘best interest’ which with all things considered would likely lead to the highest rating at the time determination of best interest is being carried out (Owen, et.al., 2009). At the time the best interest of the patient is being considered, he thrives best in his home environment. The hospitalization is being considered due to the family’s concerns about his care, especially since they do not live near the patient and the daughter cannot anymore manage the pressure of caring for the patient. However the family’s considerations and convenience do not impact significantly on what is deemed the patient’s best interest. The best interest of the patient is affected by competing interests – the patient’s and the family’s best interests. Such competing interests have to be tempered by what is best for the patient because in the end, he is the NHS client (Manson and O’Neill, 2007). Nevertheless, in order to balance the competing interests, supportive care can still be provided for the family in order to help the daughter and the family cope with the challenge of caring for the patient. Ethical decisions may often be uncomfortable decisions, sometimes awkward and often does not evoke good emotions for any of the parties concerned. However, these are the decisions which are based on appropriately considered elements, including past wishes, medical issues, and in this case, religion. For the case of Mr. P, it may indeed not be a comfortable choice to let Mr. P go home because of the inadequate care he would likely receive at home; it may also be upsetting for the family to have Mr. P be discharged home, however, the purpose of ethical decision-making is not to pander to the convenience of parties involved. Mental capacity is a crucial concept in law and psychiatry. The Mental Capacity Act is the primary law dealing with the capacity of individuals, setting forth specific standards in order to guide patients and professionals. This act also seeks to respect the patient’s autonomy. In this case, there is an adequate determination of his mental capacity which supports his decision to be cared for at home (Okai, et.al., 2007). Mental capacity is also a concept which goes through various complications in terms of interpretation; hence, it requires more clarity in its understanding. This is also associated with the fact that mental capacity is very much related to the principle of autonomy (Okai, et.al., 2007). It is believed that a crucial first step in ensuring clarity is to consider the interdisciplinary element of mental capacity, and assess its core issues. Capacity for decisions becomes a major issue in the clinical setting in relation to the care of patients. These patients may include those who organic psychiatric disorders including learning disabilities, dementia, and other brain syndromes; it may also include those who have non-organic psychiatric disorders like depression or anorexia nervosa (Owen, et.a., 2009). For those with organic disorders, it may be easier to evaluate incapacity based on cognitive elements including intelligence; for those with non-organic disorders, it may be easier to consider incapacity in terms of non-cognitive terms, like being paranoid or too depressed to make effective decisions (Owen, et.al., 2007). In distinguishing these elements, the concerned patients and health care users would likely be oriented on appropriate decisions which can be made and how surrogate decision-making can be applied on the basis of incapacity. There are different perspectives upon which mental capacity can be understood. In terms of philosophy and legal theory, mental capacity is very much associated with autonomy (Owen, et.al., 2009). Specifically, there is a general understanding that individuals need to have such capacity in order to considered autonomous individuals. It is virtually impossible to manage oneself when one cannot make decisions. In effect, children, the mentally ill, and those who are comatose are not considered autonomous because they do not have the capacity to make rational decisions. Everyone else is considered to have the capacity needed to make rational decisions (Feinberg, 1988). As discussed by the health professionals in the BBC radio program, based on their assessment of the patient, including his capacity and other pertinent details relevant to his case, the client has sufficient capacity to make decisions for himself (Owen, et.al., 2008). He may therefore be allowed to go home. However, the family’s concerns must also be taken into consideration and supportive functions can be presented and offered to the family. This option would serve the patient’s preference while still reducing the burden of care on the family. I too would agree with their recommendations. In relation to the patient’s capacity to make the decision on his care, he has expressed his preference for home care. He has understood the implications of such decision and his values also support such decision (Palmer, et.al., 2004). Each client has the right to be attributed with individual and undivided attention. Each client has unique needs and is situated differently. There may be rules and standards relating to the assessment of capacity, however, clients do not always neatly match the specific rules and standards laid out. Individual assessment, alongside a specific analysis of options is a must for each client, as well as a significant challenge for the health professionals and family members evaluating the patient (Cole and Dawe, 2010). Under these conditions, being familiar with relevant laws and guidelines are a required for such an evaluation. Situations where creative problem solving may be applied may relate to siblings who are considered equal in terms of hierarchy in the decision making process, do not agree about what to do for a parent (Richardson, 2007). In such a case, the siblings may seek assistance from an independent health assessment body, seeking a representative to make decisions for the patient and allowing decisions to be made within the family. The decision-making process must still be based on client-based as well as resourceful interventions. Due respect for the client regardless of the decline in his mental capacity is also an important element of the decision-making process in this case (Cole and Dawe, 2010). The challenge to an individual’s mental capacity can be an overwhelming situation. It is important therefore to express empathy and sensitivity to the individual’s mental state. Taking issue and debating an individual’s mental capacity is a demeaning and embarrassing situation (Tan and Hope, 2008). Although the Mental Capacity Act does not necessitate the retrieval of an individual’s consent in carrying out an evaluation, there is a need to observe fairness and of ensuring the application of natural justice. The basic foundation of society is unrestrained freedom, unless such freedom is limited by the laws. When the society calls for the removal of a person’s right to decide on the various activities, there is still a process which has to be followed (Cole and Dawe, 2010). It is therefore important for the decision-maker to secure such process, one which fully follows applicable laws and seeks to protect the dignity of the patient being evaluated. Best interests are also not considered determining factors for capacity. Key elements of capacity include understanding and appreciation; hence, capacity and best interests is not founded on what we would believe is best for patients (Cole and Dawe, 2010). Even if patient choices may seem to be unpopular choices, these choices do not necessarily mean that the patient lacks the capacity to make rational decisions. Whether or not the evaluator assents to the patient’s choice is not exactly relevant when capacity is to be established. Objectivity is also important in order to accurately assess capacity. Under these conditions, it is important to follow rules, not be ruled or dictated by one’s emotions. Health professionals often want to help their patients, and do what is best for them (Cole and Dawe, 2010). However, this approach to care may not necessarily be founded on legal and patient’s rights. Even with the best intentions, what is believed to be beneficence may actually turn into paternalism. Paternalism usually depletes the rights of the patient (Taylor, 2005). It is therefore important to be objective and to apply laws in order to ensure that the best decision is being made for the client, and is founded on objective, not subjective or emotional concerns. In other words, the assessment for incapacity is based on objective elements. Subjective elements, even when supported by best intentions are not appropriate. The assessment of capacity is also not a risk management tool. Risk cannot be used in order to establish whether a client would have the mental capacity. Patients may opt to be in situations where they are at risk (Rudnick, 2002). This must not necessarily be used in order to determine the patient’s capacity. Patients may actually choose to accept the risk, and when an individual does understand and appreciate the risks, his preferences must be prioritized over the rest of society’s desire to protect him from such risk. Mr. P does understand that going home is not the best way for him to live, but it is what he chooses anyway. He is aware that he would not receive the best type of care and he would be at risk of falling, especially with his leg ulcers. He has chosen such risks over staying at the hospital where he does not anyway agree with or assent to some of the medical interventions due to his values and religious preferences. Sensitivity to the client is also an important aspect of the best interest decisions (Cole and Dawe, 2010). Those who are tasked to evaluate the patient may be under government employ; however they must also note that they are also working in behalf and for the client. Such evaluator has a significant burden of assessing a patient’s capacity. He or she would likely work and make decisions based on legal principles and based on the workings of the system. The patient, on the other hand, is at a very vulnerable moment in his life and would likely be confused by the application of the system (Palmer, et.al., 2004). Based on this disparity, it is important for such evaluator to protect the rights of the patients. In instances of doubt, capacity is assumed and unless such capacity is negated, patient capacity is said to exist. The evaluation must also focus on capacity, not patient values or morals, although the patient’s values and morals must not be disregarded in making best interest decisions for patients. In effect, regardless of the evaluator’s belief about the patient, and even when the evaluator perceives the patient to be eccentric or immoral in his choice, his beliefs are not relevant in establishing patient capacity (Cole and Dawe, 2010). In other words, even if health professionals do not agree with a patient’s choice, especially when the patient is putting himself at significant health risks due to his choices, the patient’s capacity has to remain intact. The assessment of capacity is therefore based on legal and objective standards. Complying with the evaluation process is important; however, the client is more important than the actual process. For evaluators, their work relates to evaluation; whereas, for patients, what is at stake is their life (Moorhead and Turkington, 2002). Patients may sometimes view the process of evaluation to be demeaning and insensitive, sometimes embarrassing. The task of evaluators therefore relates to providing support to clients safely and with sensitivity. Assessment must not be carried out as an adversarial undertaking, but it must be collaborative in nature (Moorhead and Turkington, 2002). The process which is unfolding is not a process of proving a point, but of establishing patient’s truths and capacity. Securing patient rights with due process may not necessarily give rise to a decision which is like that of a family member. Under these conditions, the patient’s rights must always be prioritized. Family decision-makers may have the best intentions for their ailing family member; however, their emotional attachment to the client must not significantly impact on the assessment of patient capacity (Cole and Dawe, 2010). Even with pressure imposed by family members, evaluators must not be influenced or prompted to act in a certain way by such family members. The proper assessment of capacity must not therefore be influenced by the previous relationship between the patient and the evaluator even if the process may impact such history. Assessing a client being met for the first time and assessing him after multiple meetings is a different process altogether (Marson, 2001). In effect, decisions must not be made on assessments from previous interactions, but must be a different process from previous meetings. New clients may be evaluated more discretely, allowing the process to unfold from the very beginning. However, the assessment of capacity is based on a sustained and ongoing management (Marson, 2001). The evaluation cannot be placed within the context of an existing evaluator and patient relationship. There must still be a clear delineation between the current status and the capacity assessment of the patient. Under these conditions, it may be more relevant to have other colleagues carry out mental capacity assessments for the patients. Conclusion The assessment process is a daunting task, and more often than not, the decision can have life-changing effects on the patient. For Mr. P, the best decision is to allow him to make the decision regarding his care and to go home. Even if such decision may not be the best decision, medically, it is his decision in the end. The possibility of improving the patient’s health is not totally lost in this case as the patient consented to supportive care at home, thereby reducing the burden of care on his family. Where the right ethical decisions are made, the client’s best interests would always likely be met or protected. References Cole, J. and Dawe, N. (2010). Assessing capacity for admission to long-term care homes: A training manual for evaluators [online]. Available at: http://www.ccac-ont.ca/Upload/central/General/ConsentandCapacityTrainingManual.pdf [Accessed 25 June 2013]. Hotopf, M. (2005). Assessment of mental capacity. Clinical Medicine, 5(6), pp. 580-84 Kress, K. 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