Mel Palmer explains how home care staff should apply the Mental Capacity Act 2005 in the case of a service user who is self-neglecting and refusing to take his medication. She is MCA provider manager for the Social Care Institute for Excellence and United Kingdom Homecare Association. (UKHCA) This article was originally written for the UKHCA and English Community Care Association (ECCA) newsletters.
George uses our home care services. He is self- neglecting and refusing to take his medication. We think his mental capacity may be an issue – what should we do?
Who does the Mental Capacity affect?
Anyone who is paid to work with someone who might lack capacity to make some of their own decisions must work within the Mental Capacity Act and follow the code of practice. In some cases, people lack the capacity to consent to particular treatments or types of care. Home care staff will often be the first to notice this. You may think the treatment is necessary for their well-being or to protect them from future harm. The code of practice explains how you should assess whether someone has capacity to make a particular decision, and where they don’t, how you should reach decisions on their behalf.
Applying the five principles
It is essential that you and your staff follow the five principles of the Act. These are:
1. Always presume that someone has capacity unless the evidence tells you otherwise.
2. Do all you can to help someone understand and make decisions about their care and treatment.
3. People are allowed to make unwise decisions. An unwise decision does not necessarily mean that they lack capacity.
4. Any decisions you make on behalf of someone who lacks capacity must be made in their best interests.
5. Always look for the least restrictive option to meet their needs.
So, there are two distinct steps. Firstly, assess George’s capacity to understand the implications of not taking his medication. If your assessment shows that he lacks capacity to make decisions about taking his medication, then consider what would be in George’s best interests.
Who is the decision-maker and what are their legal responsibilities?
It is worth noting here that if the decision is about prescribing medication then the decision-maker is the prescribing doctor. In this case the doctor would also be responsible for assessing George’s capacity and running the best interests process.
The GP has a statutory responsibility under the Mental Capacity Act to consider the nature of the medication and its impact on George. Research has shown that antipsychotic drugs are being prescribed far too often as a first resort. In the majority of cases prescribing is inappropriate and the impact is that people’s lives are being shortened.
1) Assessing capacity
George has the right to make unwise decisions about his medication if he has capacity. Have you done everything reasonably possible to help George understand the implications of refusing to take his medication? For example, have you asked him what he thinks will happen if he does or does not take his medication? Is he aware of the risks? Has a senior member of your team been to see George to tell him that you are concerned and why? Have you considered whether there are any underlying medical issues that may be affecting his ability to understand? Have you explored with him whether there may be other reasons for his decision, for example is he having trouble swallowing? Or does he believe that the side-effects are not worth it? Have you involved people who are close to him whom he may trust or who may be able
to communicate more clearly with him? Even with this support, is he still unable to understand or weigh up the information and communicate his views?
2) Best interests decisions
If your assessment shows that George lacks capacity then the decision-maker needs to decide what would be in his best interests. If the decision relates to assisting with the administration of the medication then the person doing the administration is the decision-maker. It is important that the decision-maker involves family, carers and the prescribing doctor to help make the best decision for George. Have you asked George if you can contact his GP? If George also lacks capacity to consent to this, then in his best interests you may contact the GP or the prescriber of the medication.
If the care package has been arranged by the local authority, you should discuss your concerns with the care manager. Consider what may already be known about George’s wishes, feelings, beliefs and values. You will then need to weigh up all the information to determine the least restrictive option to meet his needs. Consider the level of risk to George. What is the likelihood of that risk occurring and if it did what would the impact be? You need to take account of any stress that would be caused to George if he is given medication against his will.
As noted above, any decision to change George’s medication rests with the prescribing practitioner. In this case, the GP must decide how essential the medication is, and whether there are alternatives that may meet George’s best interests. In conjunction with the family and care manager, where applicable, you will need to decide how best to administer without causing undue stress. How can you support George in a way that is least restrictive of his rights? These answers will help you to reach a decision that is in George’s best interests.
Remember, keep a record that demonstrates you or the GP have carried out an assessment, any decisions that you have made on George’s behalf, how that decision was reached and the date that you and or the GP will review this.