Mental capacity is the ability to make and communicate our own decisions. In the United States healthcare setting mental capacity is not a phrase we often hear. The term is mostly applied to legal proceeding. But in England is it is part of the initial Accidents & Emergency (A&E) aka Emergency Department assessment and our daily medical jargon.

So how do I assess a person’s mental status back home? We do a quick assessment asking the patient a standard set of questions. What is your name? Where are you? What year/month/date is it? Why are you here? These questions determines whether the patient is alert (A) and oriented (O) to person (name), place (hospital, town), time, and situation. The short hand of full mental capacity is they are A and O x 4. Or a person with dementia you might say they are A and O x 3 minus time. Neither of these are used in England, rather you state whether or not they are confused or if they have mental capacity. But capacity is a fluid thing, and whether or not a patient holds it can change from one moment to the next, as I discovered during the peak of the pandemic.

Getting your needs met…

He was a cantankerous cunning man to say the least. He arrived to the resuscitation area barrel chested with an oxygen level of 67%, only responsive to verbal stimuli. We started our symphony of actions: oxygen delivery, intravenous access placement, arterial blood gas, and cardiac monitoring among other things. He had a history of chronic obstructive pulmonary disease, COPD, and had not been using his home continuous positive airway pressure CPAP machine for the last week.  The bustling aroused him, no longer hypoxic, he clearly knew where he was.

With his alertness he vocalized his needs; he wanted a chair to sit in. I explained we did not have any chairs in the resuscitation area. I offer pillows and repositioning for comfort, he declined. Then his bodily functions kicked in and he wanted to use the loo. As I handed him the urinal bottle with a coy look he said “that’s the wrong end.” I told him I would bring a bedside commode; he glared straight into my eyes and said “never” and I knew he meant it. I put forth my defense stating he needed to remain on the monitor and he required oxygen. He rebutted with the fact both are portable.

Begrudgingly I obtain and wheelchair and assisted him into it. As we were about to wheel off he held his hand up to stop me, stating he no longer had to go but with a twinkle in his eye he said “this will do.” And with that he had the chair he wanted to sit in. He duped me. I still smile seeing him proudly sit in his wheelchair defending his own needs, a man that first arrive barely conscience.

He did not want the mask…

The evening proceeded with him being placed on Bi-PAP and removing the lifesaving pressurized oxygen mask every five minutes or so.  Both myself and my colleagues struggling to convince him to put it back on. He had previously stated in writing that he did not want to be intubate, (have a tube and machine breath for him) or have CPR done if his heart was to stop. We confirmed these were still his wishes.  In England we use the term ceiling of care:  the highest level of care you provide the patient. His ceiling of care was Bi-PAP. The nurse and I were constantly struggling to determine if he was capable of understanding what it meant not to wear the Bi-PAP mask.  We asked him direct questions

“Do you understand what will happen if you do not wear the mask that is providing you with oxygen?”

Looking at us straight in the eye he responded “yes, I will stop breathing” taking a breath he continued “and I will die”. At one point I asked him why he wanted to die. With a glum expression he just looked away and put the mask back on.

His calloused hands had been pushing me away or shooing me off throughout me shift.  I knew I could not force the mask on his face, so I just waited. I was trying to make him understand through words and pointing at the monitor, showing a slowly depleting oxygen level 74%, 73%, 70% till his eyes closed and his body soften allowing me to put the mask on without resistance. Two minutes later with appropriate oxygenation he would regain his feistiness and the mask would come off again. And the measure would repeat. 

Did he have mental capacity? Or was he too hypoxic, (lack of oxygen) or hypercapnic, (too much carbon dioxide in the blood) to truly understand his actions.

What is Mental Capacity?

Mental capacity assessment is part of 2005 The Mental Capacity Act of the United Kingdom applying to England and Wales. It is time and decision specific, and can fluctuate over time. The five statutory principles consist of one, presumption of capacity. Second, supporting the patient to make a decision. Third, knowing that unwise or eccentric decisions do not prove a lack of capacity. Fourth, confirming the decision is in the patient’s best interest. And lastly, that the least restrictive intervention should be sought.

The first stage of an assessment of capacity is to determine if the person has an impairment or disturbance in the functioning of their mind or brain. If not, the assessment ends, they have capacity. A disturbance could be altered mental status due to intoxication, learning disability, mental health condition or dementia.

In stage two of the assessment you determine if the person retain information to make the decision; situation awareness and repeating it back. If yes, can the person use the information as part of the decision process? Can they communicate the decision and understand the information and consequences. 

Did he have capacity?

The mental capacity of the heartwarming cantankerous gentleman was intact. He did have an impairment of the brain, hypoxia, but he was able to answer everything appropriately and understood very clearly the consequences of his action.

Mental health concerns such as self-harm or a suicide attempt get the same assessment. An elegantly dressed woman addicted to codeine presented to the A&E with a paracetamol (acetaminophen / Tylenol) overdose. She was no longer able obtain straight codeine and had resorted to the combo tablets, co-codamol (Tylenol #3 in the United States).  She told me all her debt had been recently settled and things were all arranged, so what was the point. Her addiction was taking over her life and she was ready to give in.

Mental Health and Mental Capacity, a quick glance

She came into the A&E voluntarily and verbalized the consequences of her actions; permanent liver damage with the paracetamol (acetaminophen) overdose and respiratory depression with codeine overdose. She had mental capacity. And with that capacity she was also allowed to go smoke outside with a hospital escort. The hospital is a no smoking facility but it does provide an outside smoking area for patients. As one nurse put it, the patient understands the harm of smoking and who are we to take away that freedom just because they came to the hospital.

On a side note…

(I feel in the United States we preach about our freedoms but you lose many of them the moment you walk through the hospital doors. Like the freedom to smoke. And your care is dependent on your insurance coverage, therefore how free are we really? But I will leave that discussion for another day.)

We administered the antidote for the overdose after she returned from having “her fag” (cigarette). With in an hour she was evaluated by a mental health nurse. I was not part of the mental health evaluation but it is like a mini therapy session to evaluate the patient’s risk of self-harm. Prior to the mental health nurse evaluation, they will access a background check and review the patient’s history. Therefore, once the mental health nurse arrives, they are aware of the patient’s mental health history, social history and community resource the patient has accessed.

In this instance the patient presented with para suicidal behavior. Parasuicide is an apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is not death. For example, a sub lethal drug overdose or wrist cutting. The patient was not content with her evaluation and proceeded to self-discharge, leaving against medical advice. Since she had full capacity she was allowed to leave even though she had come in with a suicide attempt.

After speaking with the mental health nurse it turned out the patient had been offered many resources and declined the services.  It reminded me of my cantankerous man. We can provide the oxygen mask but they have to want it on for it to makes a difference.

Remembering back home

I recall a mental health nurse relaying to me “we cannot hold them against their will if they have full mental capacity.” Still fresh are years of stripping people of their belonging, clothing, cell phones and dressing them in spiced color scrubs. All personal belongings would be placed in a secure locker only to be released at time of discharge. Followed by a metal detector wand search and then leaving them in a hollow room for hours at times without a television or clock. A certified nursing assistance would be sitting outside the room watching their movements or at times looking at their own phone. An environment easily to induce mental instability, don’t you think? 

At what point do we as health care providers walk away and let things be? What is our responsibility to the patient, if the patient does not want our help?

Which way is better? In the USA we strip patients of their freedom when they present with a self-harm presentation. In the England there is the ability to look at the whole picture and take their mental capacity into account. Mental health though is a topic that I will go delve into more detail in the coming months.

Listening to patient

But, learning to walk away from a patient that no longer wants your help is not a natural instinct for nurses or any healthcare professional. Although, it is a task that I am learning to do, because when it comes down to it, it is not about me but about the patient. Like the saying goes, you can bring a horse to water but you can’t make it drink. Part of being a nurse is learning to work through the feeling that you cannot help everyone. At times helping is just being there for them, no advice, no suggestions, just listening. 

Mental capacity is there to remind us that they still have a voice, even if it is one we don’t agree with. Like the mandate states, eccentricity does not give way to mental capacity. Listening to what they want and why, even if it means bringing them that damn chair against your nursing judgement. 

Disclosure: This is a reflective piece on the manner in which a pediatric mental health crisis is being handled by two different health systems in two parts of the world. The statements written here are my own personal opinions, and not reflective of the hospitals that have employed me. Mental health is a complex subject and this reflection is only a pin point of information on the topic. Patient details have been changed to maintain patient privacy.

The Patient, A Child

The ambulance phone rings alerting me of an incoming patient: a teenager who is refusing care, and will be arriving in police custody. The patient has had increase aggressive behavior the last two days leading to assaulting multiple family members today. He has behavioral disorders, and possibly undiagnosed mental health issues.

The patient arrives handcuffed and is brought to a bed for evaluation. He refuses to have his vital signs check, and hurls his body towards anyone that gets close. The police are blocking the door after his third attempt to bolt out. I attempt to reason with him, talking in a calm steady voice. “We want to help you and keep you safe. I need to check your blood pressure.” But as I get close, he tries to bite me. He glares into my eyes as he gathers his spit in his mouth, preparing to send it my way.  I take a step back, a safety stance, but with space, he starts banging his head against his knees. It doesn’t provide enough harm, and he moves towards the head rail.

I stop a moment and try to imagine what it is to be this child. You are out of control. You do not know how to gain control of your body again. You have never been given the tools to cope with big emotions. You are mad at yourself for hurting your family. You are unable to go home.

Is home a safe place? The police are the ones who took you away. Can you Trust them? No one is advocating for you. Everyone talks about you as though you are not there. What adult has ever helped you out?

As a nurse, I am blinded to his home environment. I only get a glimpse of it from the police report. But one thing is clear, his home life is unpredictable and unstable.

One of the hardest parts of my job has been placing children in four-point restraints, the strapping down of each of their limbs to prevent violent behavior. I will never get used to it, nor should I. Prior to placing a patient in restraints, whether child or adult, I do attempt to deescalate the situation, verbally and environmentally.

In the United States

This happened often during my years working in the United States; this patient, this situation, a familiar one. Back home the patient would have been strapped down soon after arrival. The idea behind restraints is to protect the patient and the staff from harm. The patient is then medicated with an appropriate sedative via an intramuscular injection. Only after the patient is sedated are the four-point restraints removed. Usually, we would remove the restraints within an hour, but during that time, we complete the blood work, including an alcohol level and drug test. The patient is continuously monitored one to one, one patient to one staff member.

Once the patient is medically cleared, a consultation by a social worker is started with a final disposition to either a mental health facility, or back home with community support. This process can take as little as three hours, or as long as three weeks, depending the complexity of the case. We always keep the threat of restraints available in case the patient attempts to harm staff, or themselves. There are times I remember where a patient would be restrained three or four times over a 24-hour period.

In England

Now, working in England, I find the use of four-point restraints extremely rare. After six months here, I have yet to see it done. Instead, I find the practice is to guard ourselves against the patient. If restraining the patient is required, security personnel apply the restraints. It is so rare used that nurses are not trained in restraints. You are not even allowed to restrain a toddler with a blanket hold for suturing.

On a side note, one of the most magical things I have seen in A&E (Accident and Emergency, the British equivalent to the American ER) is a three-year-old with a deep laceration being sutured while standing with only the use of topical analgesia (LET cream) and distraction.

It was only after six months here in England I faced my first pediatric patient in a full-blown mental health crisis. When the police brought him in, handcuffed, I could not use my American training of putting him in restraints, or even hold him down to protect myself. I had to maintain a safe distance, and gently use the deescalating techniques I had learned through my years of nursing.

None of them worked. He was attempting to jump off the hospital bed, hitting his head against his knee, and trying to bite me, and the police. He yelled, “Don’t touch me!” And “Let me go. I want to go home.” Through short clear statements, we attempted to explain to him that we wanted to help him, that we wanted to keep him safe. But by this time, his rational thought process was gone. He was in fight, or flight mode. We removed the handcuffs in an attempt to provide comfort, and present the A&E as a safe place, but it only allowed him the freedom to swing his arms more fiercely.

Holding him down for a moment, we managed to administer two intramuscular injections of a benzodiazepine, Rapid tranquillization, since he was placing himself and others at risk, per policy. As the medication worked to slow down the surge of neurotransmitters, he became limber and stood like an overcooked noodle. He still refused to sit on the bed. The banging against the wall continued, but now played out in slow motion, allowing me to place my hand, and then a pillow, between his head and the wall.

Two hours after his arrival, I found myself in a sort of dance with him. I stood nearby, my arms in an arc, guarding his every move, ready to catch him if he fell. I spent another hour sidestepping and monitoring his every move, never touching him, or holding him down. Finally, tired, he sat on the floor, still unwilling to fully let his guard down. There, in a closed-off hallway, still sitting, he fell asleep. I let him sleep an hour, and when I gently woke him up; I could calmly move him onto a bed. Still guarded, he fell back asleep sitting up on the bed. I gently nudged him into a prone position once he was sound asleep. No blood tests were done. He was transferred to the pediatric ward with a designated mental health nurse. After the patient would wake up, he would get a full mental health evaluation by a designated mental health provider, all to be done within a day.

After so many years of putting children and adults in physical restraints, strapped down to a bed, and having to scratch their nose for them, I am glad to know I can take a break from this for now.  The comfort for me lies knowing that, even though this patient will have trauma from this event, being tied down to bed will not be one of them. And even though it required me to “dance” with him for over four hours, applying chemical restraints with intramuscular injections, it was physically harder, but emotionally, much lighter – probably, I think, for both of us.