Difficult Capacity Cases—The Experience of Liaison Psychiatrists. An Interview Study Across Three Jurisdictions

Abstract

BackgroundAssessment of capacity for treatment and discharge decisions is common in the general hospital. Liaison psychiatrists are often asked to support the treating medical or surgical team in difficult capacity assessments. However, empirical research on identification and resolution of difficult capacity cases is limited. Some studies have identified certain patient, decisional, and interpersonal factors which cause difficulty, but no study has explored how these issues are resolved in practice. Our study therefore aimed to describe how experienced liaison psychiatrists identify and resolve difficult capacity cases in a general hospital setting.MethodsWe carried out semi-structured interviews with 26 liaison psychiatrists from England, Scotland, and New Zealand, on their most difficult capacity cases. Thematic analysis was used to examine types of difficulty and how these were resolved in practice. Summaries were prepared and example quotes extracted to illustrate phenomena described.ResultsWe identified four types of difficulty in capacity assessment, spanning both clinical and ethical domains: 1) Difficulty determining whether the decision is the patient's own or driven by illness, 2) Difficulty in applying ethical principles, 3) Difficulty in avoiding personal bias, and 4) Procedural difficulties. The liaison psychiatrists presented as self-reflective and aware of challenges and pitfalls in hard cases. We summarized their creative strategies to resolve difficulty in assessment.ConclusionPractitioners approaching difficult capacity cases require both clinical skills, e.g., to uncover subtle illness impairing decision-making and to consider interpersonal dynamics, and ethical skills, e.g., to negotiate the role of values and risks in capacity assessment. Education and training programmes should incorporate both aspects and could include the resolution strategies identified in our study. Practitioners, supported by health and social care systems, should work to develop self-aware and reflective capacity assessment practice.

Mental capacity in practice part 1: how do we really assess capacity?

“…Despite being in place for more than 15 years, problems with the understanding and implementation of this legislation persist (Emmett 2013a, 2013b; Evans 2007; Hotopf 2005; Jackson 2002; Kane 2022; Kim 2022; Luke 2008; Esegbona v King's College Hospital NHS Foundation Trust [2019]). Mental capacity assessments are often inconsistently applied and do not make adequate use of MCA criteria (Brown 2013; Owen 2013).…”

“…What role might you play in supporting the gastroenterologist to assess capacity? Psychiatrists, especially in liaison settings, may often be asked to see patients refusing intervention in order to perform a ‘formal’ capacity assessment (Kane 2022). This may be based on a misunderstanding of the MCA, as all clinicians are expected to be competent to assess capacity (Box 2).…”

Shades of grey: choice, control and capacity in alcohol-related brain damage

“…27 In an interview study, liaison psychiatrists recommended that clinicians assessing capacity in patients with ARBD should carry out repeat assessments, incorporating evidence of the patient's real-world decision-making. 1…”

“…( 5) Explore Mr X's own beliefs and values and how he might best be engaged and supported in his decision-making. 1 Does he have family, friends or a trusted key worker who might help him to take information on board? Would he consider visiting a care home to get a concrete sense of what life might be like there?…”

“…In a recent qualitative interview study, they noted that good verbal skills in these individuals can hide significant cognitive and functional impairment, and executive dysfunction can be associated with a lack of 'follow through' on care plans made with healthcare professionals. 1 Previous literature has raised further clinical and ethical considerations. For example, when is the right time to carry out a capacity assessment?…”