Has the Mental Capacity Act changed the way SLTs work?

1. Has the Mental Capacity Act changed the way SLTs work? Rachel Flew Advanced Practitioner SLT, Lead for Stroke Aneurin Bevan Health Board Carys Holly Specialist SLT, Aneurin Bevan Health Board

2. Aims • Review themes in the literature on capacity assessment and the role of SLTs • Review criteria for mental capacity assessment and the functional components of capacity • Examine implications for SLTs via case studies • Briefly introduce our project work in ABHB

3. Literature review - themes • SLT roles in assessing decision making ability; (Tippett and Sugarman, 1996; Enderby 1994; Ferguson et al 2010; Diener and Bischof-Rosario, 2004) • Assessing capacity in presence of aphasia (Mackenzie et al 2008; Tippett and Sugarman 1996; Grisso and Appelbaum, 1998; Edelstein, 2000)_ • RCSLT statements (RCSLT 2009 – Resource Manual…Aphasia; RCSLT 2006 SLT…Critical Care; RCSLT 2006 CQ3) • Further guidance and advice Department for Constitutional Affairs, 2005. The Mental Capacity Act: Code of Practice. London, TSO

4. Mental Capacity Act (2005) A quick review

5. Capacity – key concepts • ‘Capacity’ = a person’s decision-making ability • Ability to make decisions, for example, on: • Medical treatment • Discharge destination • Finances

6. Making decisions • In terms of the Mental Capacity Act, to make a valid decision a person needs to: 1) Understand information presented relating to the decision 2) Retain the information long enough to make the decision 3) Use the information to reason 4) Communicate the decision made

7. MCA – key principle for SLTs A person is not to be treated as unable to make a decision unless all practicable and appropriate steps to help him have been taken without success

8. Involvement of SLTs in capacity assessment Incidence of communication difficulties post-stroke (O’Halloran, 2009) Barriers to involvement in healthcare decisions (Parr et al 1997, Knight et al, 2006) Communication difficulties reason why people not referred (Mackenzie et al 2008)

9. SLT roles in assessing capacity Educator Advisor Assessor Enabler Therapist Implementer

10. Educator and advisor • Staff training and awareness • Managing screening of language and cognition • Supported conversation • Communication as collaboration • Simple practical steps • Advice for individual patients

11. SLT and language assessment Receptive and expressive spoken and written language Non-verbal problem solving Method and reliability of yes/no Perseveration Presence of neologistic jargon Interaction with cognitive performance

12. Case study 1 • 75 year old female presenting with large left MCA infarct • SLT assessment indicated significant receptive and expressive language impairments and dyspraxia of speech • Ability to use AAC was limited by global aphasia and significant cognitive impairments. J would indicate yes/no but this was very inconsistent • Social work team assessed capacity independently of the MDT using written questions • They decided that J had capacity to decide on discharge destination based on her ability to demonstrate yes/no • SLT and Social work then jointly assessed and concluded that J definitely did not have capacity to make this decision

13. Case study 2 • 63 year old male presenting with 2nd CVA. Significant mobility problems, dysphagic, and severe dysarthria • Considerable concerns re: d/c home as staff did not feel he was aware of the extent of acquired limitations • Family had expressed reservations about his willingness to comply with eating regime – puree diet • Specific assessment of capacity to determine discharge destination suggested that he was able to take in, retain and reason with information well • We hypothesised that one of the factors that contributed to the presumed clinical picture was ambivalence. Communicating with others was a long drawn out process in his view and often not worth the effort.

14. ABHB Specialist assessment – what we do • SLT and Clinical Psychologist for Stroke • Use a semi-structured interview approach to supporting conversations about capacity • Standardised checklist and questions • Dual facilitators (ImplementerandEnabler) • We document how and what we did (allows others to scrutinise and duplicate if useful)

15. Resources and Materials – CAST response form • We use a form based on work developed by Professor Reg Morris - Morris, R. (2011). Decision Making and Mental Capacity. In Lincoln, N. (Ed.) Psychological Management of Stroke. Wiley-Blackwell • Specific capacity question • Documents outcome of functional assessment • Records support methods / materials • Assessment decision • Recommendations / action required

16. Resources and Materials – CAST response form

17. Our approach Strengths: • Agreement and reliability enhanced (Marson et al, 2000) • Triadic assessment – balances tension between enabler and assessor • Facilitates discussion with MDT about a person’s competence Weaknesses: • It doesn’t provide a definitive answer • Takes time and extra resources • Tension between therapist/assessor roles can have negative impact on therapeutic relationship

18. Summary Wider scope of practice Working with psychology Triadic assessment for robustness Use semi-structured interview format Document everything for repeatability

19. Practical and research questions for future work • If we had more time, could increased SLT intervention significantly improve communication potential? • What level of communication difficulty indicates a lack of capacity? • Need for development of professional guidance for SLTs

20. References • Tippett, D and Sugarman, J (1996) ‘Discussing Advance Directives Under the Patient Self-Determination Act: A Unique Opportunity for Speech-Language Pathologists to Help Persons with Aphasia’ in American Journal of Speech-Language Pathology, Vol. 5 pp31-34 • Enderby, P. (1994). ‘The testementary capacity of dysphasic patients’. Medico-Legal Journal, Vol. 62, pp 70-80 • Ferguson A, Duffield G, Worrall, L. 2010. ’Legal decision making by people with aphasia: critical incidents for speech pathologists’. International Journal of Language and Communication Disorders. Vol. 45, No. 2, pp. 244-258 . • Palmer, R and Patterson, G (2011). ‘One Size Does Not Fit All: Obtaining informed consent from people with aphasia’. Advances in Clinical Neuroscience and Rehabilitation, Vol. 11 no.2 pp30-31 • Diener, B and Bischof-Rosario, J. (2004). ‘Determining Decision-Making Capacity in Individuals with Severe Communication Impairments After Stroke: The Role of Augmentative-Alternative Communication (AAC)’. Top Stroke Rehabilitation, Vol. 11 no. 1, pp 84-88 • Mackenzie, J, Lincoln, N, and Newby, G. (2008) ‘Capacity to make a decision about discharge destination after stroke: a pilot study’ in Clinical Rehabilitation 22, 1116. • Grisso, T and Appelbaum, P (1996). ‘Values and Limits on the MacArthur Treatment competency study’ in Psychology, Public Policy and Law. Vol 2, pp 167-181 • Edelstein, B. (2000) ‘Challenges in the Assessment of Decision-Making Capacity’. Journal of Aging Studies, Vol. 14, no.4 pp 423-437

21. References Royal College of Speech and Language Therapists, 2009. Resource Manual for Commissioning and Planning Services for SCLN – Aphasia. London, RCSLT Royal College of Speech and Language Therapists, 2006. Speech and Language Therapy in Adult Critical Care. London, RCSLT Royal College of Speech and Language Therapists, 2006. Communicating Quality 3. London, RCSLT Department for Constitutional Affairs, 2005. The Mental Capacity Act: Code of Practice. London, TSO O'Halloran R, Worrall L, Hickson L. 2009. ’The number of patients with communication related impairments in acute hospital stroke units’. International Journal of Speech-Language Pathology. Vol. 11, no. 6, pp 438-449. Parr, S, Byng S, and Gilpin S. 1997. Talking about aphasia. Buckingham, Open University Press. Knight, K, Worrall L and Rose T. 2006. ‘The provision of health information to stroke patients within an acute hospital setting: what actually happens and how do patients feel about it?’. Top Stroke Rehabilitation. Vol. 13 (1) pp. 78-97. Morris, R. (2011). Decision Making and Mental Capacity. In Lincoln, N. (Ed.) Psychological Management of Stroke. Wiley-Blackwell Marson, D. C., Earnst, K. S., Jamil, F., Bartolucci, A., & Harrell, L. E. (2000). Consistency of physicians' legal standard and personal judgments of competency in patients with Alzheimer's disease. Journal of the American Geriatrics Society, 48, 911-918.

22. Contact details:Rachel.Flew@wales.nhs.ukCarys.Holly@wales.nhs.uk