An audit of mental capacity assessment on general medical wards

Introduction

Patients require adequate information, freedom from coercion and mental capacity in order to make valid healthcare decisions. Capacity is the ability to consider and communicate a particular decision for oneself. In England and Wales, all decisions relating to people over the age of 16 who temporarily or permanently lack capacity are governed by the Mental Capacity Act (MCA) (2005), ¹ which was fully implemented in 2007. The Act states clinicians are responsible for assessing patients’ capacity to consent to medical treatment and the Code of Practice sets out a two-stage test. ² First, an adult must be presumed to have capacity unless there is evidence of an ‘impairment or disturbance of the function of the mind or brain’. Second, the impairment must affect their ability to make the decision in question. A person is considered to lack capacity if they are unable to understand, retain or weigh up the possible options, or to communicate their decision. All practical steps should be taken to enable him to participate in decision making, by, for example, making sure that he is able to hear the information provided and, if not, either providing a hearing aid or information in another form. In some cases, incapacity is likely to be temporary and if so, a decision should be deferred until the person regains capacity if at all possible.

Where a person lacks capacity to make a particular decision, the clinician is responsible for determining what is in their best interests, unless they have given someone lasting power of attorney, in which case, the appointed person would make decisions on their behalf.

The Code of Practice states that clinicians must weigh up what is in a person’s best interests by considering not only their clinical situation but also finding about their past and present wishes, beliefs and values, either from the patient themselves or from relatives or carers.

Several studies have estimated the number of patients who lack capacity on general medical wards by conducting interviews to assess their understanding of their current medical condition and treatment. One such study in London prior to the implementation of the MCA concluded that approximately 40% of patients lacked capacity. ³ Studies in USA, Canada and Germany, where capacity is assessed in a comparable way, concluded that a similar proportion of patients lacked capacity (26–37%).^4–6 Incapacity was associated with increasing age, cognitive impairment and learning disabilities ³ and was more common in hospitalized elderly people than those living at home (26% vs. 2.8%), suggesting that acute illness may also be a risk factor for incapacity. ⁶

While the MCA sets out standards for the assessment of capacity and the management of patients who lack it, it is unclear how this guidance has been implemented as, as far as we are aware, it has not been audited on general medical wards in England and Wales since the Act was implemented in 2007. We, therefore, set out to audit documentation of capacity assessment on the general medical wards of an English-teaching hospital.

Methods

We sought to verify compliance with the specific recommendations laid out in the MCA, a process better known as audit, and did so in agreement with the local trust’s audit team, who confirmed that we did not need to seek approval from the local research ethics committee.

We audited the clinical notes of all inpatients (n = 95) on the general medicine wards in an English-teaching hospital from the first contact with medical professionals (ambulance, emergency department or medical assessment unit staff) until the weekend of the audit, which was in September 2010. The notes contained entries from doctors, nurses, physiotherapists, occupational therapists and speech and language therapists.

We recorded demographic characteristics (age, gender, marital status and living arrangements), presenting complaint, past medical history and whether capacity assessment had been documented. Where an assessment was found, we noted the decision in question, the reason for assessing capacity, whether it was re-assessed and the final conclusion regarding the patient's capacity. In the case of patients who lacked capacity, we noted if carers or persons with lasting power of attorney were consulted.

The criteria for querying capacity were based on previous studies, which had shown high rates of incapacity amongst certain patient groups. We judged that patients with a learning disability, ⁷ a neurological disorder,^8,9 a psychiatric diagnosis requiring treatment in secondary care, ¹⁰ delirium, ¹¹ dementia or an Mini-Mental State Examination (MMSE) score of 23 or less, ¹² or an Abbreviated Mental Test (AMT) score of 6 or less, required capacity assessment.

Data were analysed with the Statistic Package for the Social Sciences (SPSS) version 20.

Results

We audited the clinical notes of all general medicine inpatients (n = 95) for information relevant to mental capacity. The patients’ mean age was 78.6 years; 57 (60%) were female. The most common presenting complaints were confusion (24), respiratory (22) or gastrointestinal symptoms (21), while 25 were admitted with symptoms suggesting they were systemically unwell, such as weight loss, drowsiness or self-neglect, as shown in Figure 1. Many patients had more than one presenting complaint (mean 2.0).

OPEN IN VIEWER

Figure 1.

Frequency of presenting complaints.

In all, 52 (55%) patients had conditions where capacity was likely to be impaired, the most common being delirium (26) and dementia (15), with a small number of patients having other diagnoses, as shown in Figure 2. While 24 patients were delirious on admission, confusion was later documented in the medical notes of two others. The majority of patients with delirium had no identified precipitant; however, four had a brain tumour or an intra-cerebral metastasis, three had Wernicke's encephalopathy, one had encephalitis and one an exacerbation of chronic obstructive pulmonary disease (COPD).

OPEN IN VIEWER

Figure 2.

Prevalence of risk factors for incapacity amongst medical inpatients.

Capacity assessments were documented in the notes of seven (7.4%) patients and related to decisions about whether they should undergo a medical or surgical procedure (3), enter residential care on discharge from hospital (2), be permitted to self-discharge (1) or required additional treatment for an on-going mental health disorder (1).

All of these capacity assessments followed a disagreement with the medical team about the decision in question. There was evidence of re-assessment in four cases, and in one case, medical staff attempted to enhance capacity by providing a hearing aid. Discussion with family members or carers was recorded in six cases. In all but one case, the medical team concluded that the patient lacked capacity.

Discussion

We audited the notes of medical inpatients to determine how frequently capacity assessments were documented. While 52 patients had a condition which might impair their capacity, such as dementia, delirium or learning difficulties, only seven (7.4%) patients had a capacity assessment documented in their notes and all seven of these patients disagreed with their medical team about how they should be treated.

Previous studies have shown that 26–40% of medical inpatients lacked capacity to consent to their current treatment.^3–6 It is likely, therefore, that our population contained a number of incapacitous patients who were being treated without valid consent; however, as we did not directly assess capacity, we are unable to determine exactly how large this group was. It is likely that these individuals agreed with their medical team and, therefore, their incapacity went unnoticed, as they did not obstruct the proposed care. The failure to identify these patients is particularly concerning as they may not have been afforded the safeguards provided by the MCA, for example, they are less likely to have had the pros and cons of their management discussed with them, and their premorbid wishes may have been ignored. One recent study concluded that 74% of patients undergoing percutaneous endoscopic gastrostomy (PEG) insertion and 22% of patient undergoing an upper gastrointestinal (GI) endoscopy lacked capacity to consent. ¹³ While this study did not identify patients undergoing procedures without adequate safeguards in place, there is clearly a risk of this happening given the number of patients whose incapacity is overlooked. Both procedures carry a risk of serious complications and performing them without valid consent would be both ethically indefensible and leave the medical staff involved at risk of litigation. It should be emphasized, however, that in our study we were unable to determine whether patients were being treated in their best interests and do not have any evidence that patient care was compromised.

Many factors may contribute to the lack of documented capacity assessments, such as time pressure, a reluctance to endanger routine care or to undermine the doctor–patient relationship. There is evidence to suggest, however, that doctors may lack the knowledge and skill to assess capacity in the manner outlined in the Code of Practice. Surveys designed to assess doctors’ knowledge of the Act have shown that only 70% of doctors working in one Emergency Department were able to outline the steps involved in capacity assessment, ¹⁴ while most general physicians believed that patients ‘automatically’ lacked capacity if they had poorly controlled schizophrenia or had previously lacked capacity. ¹⁵ They also found assessing capacity difficult in practice: doctors overlooked 73% of cases of incapacity on general medical wards in London. ³ A meta-analysis of eight studies looking at both inpatient and community settings revealed that clinicians only recognized 42% of incapacitous patients. ⁶ One possible reason for this is that ‘there is no unequivocal test of understanding’, ¹⁶ and doctors often make a ‘normative judgement’, and conclude that a patient has capacity if they favour the same treatment as they would, even if the patient has not demonstrated an ability to weigh up the pros and cons. ¹⁷

It is, therefore, possible that introducing a structured format for discussing important decisions might improve detection of incapacity. A systematic review by Sessums et al. ⁶ identified nine approaches which had been compared to a ‘gold standard’ in clinical practice. One of these is the Aid to Capacity Evaluation (ACE), a set of eight questions used to assess patient’s understanding of their own medical condition and management options, which takes about 10–20 min to perform and provides good agreement with assessment by a forensic psychiatrist. ^5,18 The tool has only been used in Canada thus far, but as the assessment of incapacity is very similar to that in England and Wales, the tool could be adapted for use here.

There may also be a role for simplifying the documentation relating to patients with long-term cognitive impairment, who are unlikely to regain the ability to make decisions about their medical care. In Scotland, for example, while major decisions relating to cognitively-impaired patients must be considered independently, there is a standard piece of documentation that allows healthcare workers to perform personal care and simple medical procedures without reassessing the capacity on each occasion. ¹⁹

Conclusions

Our audit revealed that the assessment of capacity can be overlooked in the context of acute medical care, particularly in those patients who comply with treatment. We only audited practice in one hospital, however, and a nationwide audit would be required to establish how widespread problems with capacity assessment are, and help build a strategy for identifying incapacitous patients and ensuring their rights, while minimizing the burden on busy clinicians.