Best interests decisions: professional practices in health and social care

Abstract

This paper reports on data collected in 2011 from a national study about the operation of the best interests principle, a key feature of the Mental Capacity Act (MCA) 2005 for England and Wales. The objective was to provide a picture of current professional practices in best interests decision-making. Four contrasting sample sites were selected, in which National Health Service trusts, social care and other organisations were recruited to participate. A multimethod design was followed, including an online survey with 385 participants, followed by qualitative research through a telephone survey of 68 participants, and face-to-face semi-structured interviews following up 25 best interests cases, with different perspectives on the process in 12 of those cases. The current paper reports only on the qualitative findings. The findings indicate that the MCA was successful in providing a structure for these practitioners, and that the five principles of the MCA were in general adhered to. A variety of perceived risks led to best interests processes being undertaken, and a typical scenario was for a period of hospitalisation or ill health to trigger a best interests decision process about a social care and or a life decision. The study supported previous research in finding the notion of capacity the most difficult aspect of the MCA, and it provides evidence of some specific capacity assessment practices, including problematic ones relating to 'insight'. Best interests decisions were often made by consensus, with practitioners taking on different roles within the process. Meetings played a key part, but other ways of involving people lacking capacity and significant others were also important. It was recommended that the issues highlighted in this research could be clarified further in the Code of Practice, or within risk guidance.

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

“…This is consistent with data reported by previous studies [e.g., 16,17,34]. One participant in the current study expressed concern that sometimes staff may not assess patients' capacity to consent to surgery.…”

“…In certain settings, more senior doctors tend to carry out assessments and this appears to be related to perceptions of professional hierarchy and responsibility. This trend has been reported in earlier studies [16,17,35]. In other settings, professionals external to the treating team may be asked to complete assessments because of their specialist knowledge and skills.…”

“…This often related to working with particular patient groups, for example those with mental health conditions or those with communication needs. Participants in previous studies have expressed similar concerns, and like certain participants in the present study, have reported preferring to assess capacity jointly or to refer patients to more specialist or senior colleagues for assessment, instead of attempting to assess them themselves [16]. …”

“…One participant in the current study expressed concern that sometimes staff may not assess patients' capacity to consent to surgery. Other studies have identified situations in which capacity assessments are not completed but are indicated [15,16,34]. Failure to complete a capacity assessment in these situations means that patients may be denied the right to make important decisions about their treatment, care…”

A Relative Safeguard? The Informal Roles that Families and Carers Play when Patients with Dementia are Discharged from Hospital into Care in England and Wales

“…To date, there has been only limited analysis of how professionals conform with the MCA when residence capacity is assessed and when decisions are made to discharge dementia patients from hospital and relocate them into long-term institutional care (Emmett, Poole, Bond and Hughes, 2013;Williams et al, 2012). Most often, these decisions are made within the privacy of clinical and social care teams, unless patients are 'unbefriended' and there is a duty to appoint an Independent Mental Capacity Advocate (see below) or there are concerns that older people may be deprived of their liberty 4 in hospitals or care homes, which triggers the additional scrutiny of the Deprivation of Liberty Safeguards (DOLS) under the MCA (Ministry of Justice, 2008).…”