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Case Scenarios: Mental Capacity / Best Interests Decisions

Introduction

These scenarios are intended to provoke thought and discussion with respect to issues related to mental capacity / best interests decisions and associated social work themes and topics.

It is recommended that the student is given the initial scenario and suggested questions, and then asked to consider the relevant issues and what action they might take.  Following this the real life outcome can be shared and discussed further.

The scenarios are based on real life situations (with a few amendments) and the outcomes are the actual turn of events.  However, it is possible to interpret the scenarios differently to open up discussion and there are some suggestions to support further debate and reflection.  Students might feel that the actual outcome was not the correct one and should be encouraged to express and analyse their views in an evidence based manner.

All names have been changed to maintain confidentiality.

Mary

Mary has been admitted to hospital following a fall at home. She is 85 years old and lives on her own. Up until this point she has managed independently with some support from her daughter (who lives 50 miles away) and her neighbours. The fall has resulted in a marked reduction in Mary’s mobility and currently she is unable to weight bear, requiring full support with her personal care needs. At times she is also getting confused.  Mary has been assessed by a physiotherapist who feels that the best option would be for her to move into a nursing home.  Her daughter supports this recommendation as she feels that she would not be able to offer her mother the support she needs if she returned home.  However, at this stage Mary has not been assessed by a social worker and there is the potential for her needs to be met at home with a package of care.  Mary has stated that she does not want to go into a nursing home.

  • What are the issues?
  • Do you think Mary has capacity to make this decision?
  • If you do, why?
  • If no/not sure – why not, what are the concerns?
  • Who should take responsibility for the assessment of capacity?
  • Who else should be involved?

Joe

Joe is a 42 year old man with Down’s Syndrome. He has a supported living tenancy and shares his home with one other person. Joe and his housemate receive support from a provider during the day but not in the evenings and at night. Recently Joe has been frequenting a local pub where he has made friends with a group of men. He has become involved in their business and delivers packages for them during the day for which he receives a small amount of money. Joe does not know what these packages contain but believes that they are washing machine spares. Joe’s support staff have spoken to him about these activities and have told him that he must stop. They have tried to ban him from going to the pub. Joe says that the men from the pub are his friends and he can do what he likes.

  • What are the issues?
  • Do you think that Joe has capacity to decide whether to be involved with these men?
  • If you do, why?
  • If not, why not and how have you reached this decision?
  • What other concerns might you have about Joe’s situation and how might you address these?
  • Who would you involve?

Shobna

Shobna is an older woman with a severe learning disability who has recently moved from long term hospital accommodation to her own home in the community. Following her move it is discovered that she has been suffering from an untreated problem with her throat for many years, which has led to issues with swallowing and reflux. In order to investigate further it is necessary for Shobna to have a gastroscopy.  She does not communicate verbally and needs total support in all areas of her life to make her needs known.  She has no contact with any family members. The consultant in charge of Shobna’s care has asked her support staff to sign a consent form for this treatment.

  • What are the issues?
  • Do you think that Shobna has the capacity to consent to this treatment?
  • If yes, explain how you have reached this decision?
  • If not, why not?
  • Who should be involved in any best interests decision and who should the decision maker be?
  • Have you any other concerns about this scenario?

Cerise

Cerise has been admitted to hospital for the fourth time in a three month period. She has been suffering from health problems exasperated by her heavy smoking. She has some mental health issues which impact on her ability to manage her self-care needs. During her recent hospital stay it has come to light that Cerise has handed responsibility for her finances to a neighbour. There are concerns that this person is also giving Cerise medication that she has not been prescribed, to help her sleep. Cerise has admitted taking this medication and that she knows it was wrong to do so. However, she has not changed this behaviour following each discharge and is adamant that the neighbour is helping her and is her friend.

  • What are the issues?
  • Do you think that Cerise has capacity with respect to deciding who looks after her money?
  • If you do, why do you think that?
  • If not, why not?
  • Do you think that the neighbour has Cerise’s interests at heart?

Case study outcomes

Mary: real life outcome

Mary did have the capacity to decide where she lived. However, she was not able to move home immediately as she was not well enough. A period of time in rehab was identified for further assessment of her needs and to identify whether a package of care at home would be successful.  The assessor in this case could be the social worker (considering future accommodation) or the consultant (identifying health needs) but actually was a combination of both. Mary’s daughter was involved but it was made clear to her that, as her mother had capacity, she could not dictate circumstances. However, it was necessary to consider the daughter’s input as a potential future carer for Mary. Other professionals were also involved: nursing staff, physiotherapist etc.  Mrs Smith’s fluctuating capacity was found to be the result of a urine infection.

Issues for further discussion:

  • Input from physiotherapist – had he/she jumped to conclusions, were there pressures to discharge Mary which impacted on the recommendation to move her to a nursing home?
  • Daughter – had she been swayed by the physio’s advice and has she got legitimate concerns about her mother’s ability to cope?
  • Mary – did she have all the information she needed to make an informed decision (i.e. was she expecting to return home and life return to the way it was – this may be unrealistic)?
  • Confusion – if someone’s capacity is fluctuating how might this affect the assessment?

Joe: real life outcome

Joe has a learning disability so there were concerns about his ability to make the best decision. However, he was able to identify the issues involved and showed some understanding of the consequences of his actions. The Mental Capacity Act advises that individuals are able to make ‘unwise decisions’ and ones that we would not always agree with. It was decided that Joe did have capacity and was making an unwise decision in this case. Support staff disagreed and, although their opinions were taken into account, it was felt that their actions were designed to limit Joe’s independence rather than protect him. It is important to recognise that Joe might be placing himself at risk and even involving himself in illegal activities. It was necessary, therefore, to consider the issues under safeguarding procedures and to involve the Police. Joe was visited by a social worker and police officer who talked to him about the risks he might be placing himself under and that he might be arrested for his actions. Joe agreed to stop delivering the parcels but wanted to remain friends with the men in the pub.

Issues for further discussion:

  • Joe’s right to make ‘unwise decisions’ – what does this mean and who decides what they are?
  • Support staff – what are their motivators, why might they disagree with the decision?
  • Conflicting views – what might be the consequences for Joe?
  • Safeguarding – how might this be approached, do you think it was appropriate to involve the Police?

Shobna: real life outcome

Shobna did not have capacity to make this decision due to her severe learning disability and inability to understand the information required. The decision maker was the consultant (reluctantly!) as he/she was responsible for administering the treatment. However, he/she should not have asked support staff to sign a consent form as no person is legally able to do this for another adult. The consultant must make a best interests decision and proceed accordingly after consulting all parties. In this case Shobna had no family so it was necessary to consult with those that knew her well (staff, advocate, community nurse). It might be appropriate to refer to an Independent Mental Capacity Advocate (IMCA) but in this case it was not necessary as the decision was minor in nature.

Issues for further discussion:

  • Communication – what happens if a person cannot communicate verbally, does this automatically mean that they do not have capacity?
  • Signing consent forms – who is able to do this and what happens when the person themselves cannot?
  • IMCA – what do they do and when would you consider making a referral for their input?
  • Shobna’s health condition – in her previous accommodation this had gone unnoticed (ignored?) for many years – should this be investigated?

Cerise: real life outcome

Cerise did have capacity with respect to deciding to give her neighbour responsibility to look after her money. She was well aware of the risks involved and prepared to accept that this person might misuse her trust. Cerise valued the relationship she had with the neighbour even though they could not really be considered friends. There were some concerns about the neighbour spending Cerise’s money but she herself did not want to change this arrangement so, although there was a safeguarding planning meeting, no further action was taken. From Cerise’s numerous admissions to hospital, however, it was identified that she was struggling to look after herself so alternative housing options were discussed with her. She was keen to live somewhere with more support and eventually moved to an extra care housing tenancy. The added benefit was that the neighbour then decided to no longer offer his/her services and Cerise received tenancy support which helped her to manage her money independently.

Issues for further discussion:

  • Unwise decision – was Cerise making one, do you agree with the outcome of the assessment?
  • Safeguarding – do you agree with the action taken, if not what else could have been done?
  • Professional judgements – did you make any assumptions, what was behind these, how might they impact on your actions?

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