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.
What a great piece of writing… You grabbed me all the way through to the last sentence. Powerful.
Thank you father, glad you enjoyed it.
This resonates with me in a deep way. Having been in the field for a long time, then moving into the ED as an RN I often find myself frustrated with the way we hold people as you described. I’m still trying to adapt to what I see as keeping people against their will but we describe as keeping people “safe”. Many times I’ve wondered what would happen to my mental stability if I were locked in a 15×15 room with someone watching me at all times.
Christine- Thank you for taking the time to read and I am glad we have a similar view. I do not like how we strip peoples belonging/dignity when they come to get help and are already in a vulnerable state. In addition I wish we had actual mental health providers to treat the patients and/or a national data base to know a bit more of their history. I am determined to change the way we treat mental health patients back home. Maybe we can join forces and use some of the tools I am gathering here 🙂
Beautiful piece. As a nurse, as a mom, as a human…knowing when to step aside is very difficult. In America, we have learned helplessness AND lack of accountability. We create victims so they are never at fault for anything. If they can’t breathe or make “normal” decisions, someone else is at fault. As a nurse, we know this. We purchase insurance to help us with this because we know that every patient, family member, doctor, and administrator is ready to blame us for any consequence. We go into this field because we want to help and advocate for what’s right but instead, we keep trying to CYA and prevent all freedoms a patient has a right to.
I hate the way we strip out mentally challenged patients. We are doing more harm than good to many of them.
Agreed Marcella!! I find refreshing that mental health patient here are not strip away of there belonging.
Well said dear friend. In England there is definitely less of a CYA attitude when treating patients. And doctors are also more comfortable about talking end of life care, things that make nursing a bit easier on this side of the pond.
Terrific storytelling. I really love these posts.
Thank you for taking the time to read them
A really nice piece of writing! I know, not easy but worth the effort. Congrats and thanks for this.
Thank you my faithful reader.
Fantastic piece of writing, a really interesting read.
Thank you for taking the time to read it. I know you have a busy schedule 🙂
I’m hooked! What happened to the old man? Did he stay or did he go? In the US we would not let him sit up in a chair initially because if he fell and broke his hip we would be blamed. We let lawsuits dictate a lot of our care. Do you think it will be hard to return to the American way of practicing medicine?
Hello Lorraine- He ended up staying and we transferred him to the ward. After a while I think he felt sorry for me and climbed back into bed, he still did not want the mask on. Since he was not “active” his resting oxygen level stayed around 85%, he was alert and talking so the doctors were pleased with it.