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CASE PRESENTATION

CASE PRESENTATION. G Mustafa. WHY A CASE PRESENTATION? . Interesting Issues most of us will face What to do in these cases Awareness of the services available. Case scenario. Mrs S C 64 yr old female. Known patient of Bipolar Affective Disorder (F31) dx in 1981

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CASE PRESENTATION

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  1. CASE PRESENTATION G Mustafa

  2. WHY A CASE PRESENTATION? • Interesting • Issues most of us will face • What to do in these cases • Awareness of the services available

  3. Case scenario • Mrs S C 64 yr old female. • Known patient of Bipolar Affective Disorder (F31) dx in 1981 • Enhanced care plan : CPN,SW, regular community FU. • Medication : Lithium citrate Aripiprazole Sodium Valproate

  4. Case Scenario (cont.) • Compliance with medication has been a problem • Encouraged to participate in relapse prevention planning • Becomes unwell too quickly to recognize the symptoms • Frequent hospital admission with manic psychotic episodes

  5. Case scenario (cont.) • On one of these admissions, she met Mr A, who was an inpatient himself • Mr A, was an depressed alcoholic admitted after an overdose • They remained in contact even after discharge

  6. Social History • Husband died 2 years ago, marriage lasted 25 yrs. • Has 2 children – Son lives in Canada Daughter lives nearby • Normally rings son 1 -2 /week. • Relationship with the daughter is good untill she has a relapse . • S C lives on her own in a Bangalow

  7. SOCIAL AND FINANCIAL HISTORY • The bungalow is in her daughter’s name • Does not work , gets benefits and pension (£1200/month) • Has a shared bank account with her daughter. • Has a private savings account in her own name.

  8. CURRENT ADMISSION • Relapse of her symptoms • Grandiose delusions, pressure of speech , pressure of thought, sexually disinhibited, agitated and elated mood. Persecutory delusions, self neglect, no insight. • She was putting lot of effort to make her self fit and ‘ trim down’ for the ‘new man in her life (Mr A)’ • Not willing to be admitted , hence section 3 admission.

  9. Issues • There were concerns from the ward staff , CPN, and S C s daughter that she was spending her money inappropriately. • Her relationship with Mr A had evolved to be more intimate since she had been unwell. • Alot of concerns regarding capacity to manage her finances – bank details passed on to Mr A, bought him new fridge, oven etc.

  10. Points of View Mrs S C • Trusts this new man in her life • She wants him to be the next of kin. • She loves him and has been talking about marrying him • She wants her daughter to give her back her bank cards and house keys . • She disagrees that she is being exploited and thinks that her daughter was jealous! • Believes she is spending her money wisely

  11. Points of View DAUGHTER • Does not want to see mum when she is unwell. • Dad opened a joint account in mum and daughters name, • The Bungalow is in daughters name, with mum having the right to stay and pay the bills. • Strongly believes that she is being exploited by Mr A • She thinks she is protecting her mum by not giving her a lot of money to spend and not consenting for the house keys to be given to mum as eventually will end up with Mr A

  12. Points of View Staff – CPN + SW+ CN • Known S C for a long time (>10 yrs) • Normally when pt is well, she is very careful with her spending and is a very reserved person • Prominent manic features = sexual and financial disinhibition • Had a very platonic relationship with Mr A prior to being unwell.

  13. Points of view Mr A • Believes S C was fine and not manic (whilst inpatient) • Says have a lot in common with S C, enjoys sharing thoughts. • Has a valid explanation for why S C has been giving him some money • Very upset that he has been falsely accused

  14. What would you do in this case?

  15. This is what actually happened • Identified as a vulnerable adult • Capacity was assessed, found to lack capacity in managing her finances appropriately. But had reasonable understanding of what she wanted to do with her life in relation to Mr A. • A ‘’safegaurding adult’’ multidisciplinary meeting was held. • Pt was given a reasonable amount of money every week – agreed with the pt. • Advance Directive or LPA was to be made once the pt was well.

  16. LEARNING NEEDS. • ASSESSING CAPACITY and the MCA 2005 • Role of third party or proxy decision makers – LPA, AD • Safeguarding adults – vulnerable adults

  17. Whats in The Code? • Guidance on how to use MCA 2005, covering England and Wales , implemented in 2007. • The Code has statutory force – have a legal duty to have ‘regard’ to it. • What if you disregard The Code?

  18. What it covers • Decisions about day-to-day matters e.g. what to wear, or what to buy when doing the weekly shopping etc. • Decisions about major life-changing events, such as whether the person should move into a care home or undergo a major surgical operation.

  19. What it doesn’t cover? • Decisions concerning family relationships -consenting to a marriage or a civil partnership -consenting to have sexual relations -decree of divorce on the basis of two years’ separation -dissolution of a civil partnership -consenting to a child being placed for adoption / making of an adoption order -discharging parental responsibility for a child in matters not relating to the child’s property • Mental Health Act matters • Voting rights • Unlawful killing or assisting suicide

  20. MENTAL CAPACITY ACT 20055 PRINCIPLES • 1. A person has capacity unless proven otherwise • 2. A person is not to be treated as unable to make a decision untill you have tried everything practical to help them make a decision • 3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision. • 4. An act done, or decision made must be in the person’s best interests. • 5. Before acting or deciding anything, consider whether it could be done in an equally effective way but less restrictive to the persons freedoms

  21. MENTAL CAPACITY ACT 20055 PRINCIPLES • 1. A person has capacity unless proven otherwise • 2. A person is not to be treated as unable to make a decision untill you have tried everything practical to help them make a decision • 3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision. • 4. An act done, or decision made must be in the person’s best interests. • 5. Before acting or deciding anything, consider whether it could be done in an equally effective way but less restrictive to the persons freedoms

  22. MENTAL CAPACITY ACT 20055 PRINCIPLES • 1. A person has capacity unless proven otherwise • 2. A person is not to be treated as unable to make a decision untill you have tried everything practical to help them make a decision • 3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision. • 4. An act done, or decision made must be in the person’s best interests. • 5. Before acting or deciding anything, consider whether it could be done in an equally effective way but less restrictive to the persons freedoms

  23. MENTAL CAPACITY ACT 20055 PRINCIPLES • 1. A person has capacity unless proven otherwise • 2. A person is not to be treated as unable to make a decision untill you have tried everything practical to help them make a decision • 3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision. • 4. An act done, or decision made must be in the person’s best interest. • 5. Before acting or deciding anything, consider whether it could be done in an equally effective way but less restrictive to the persons freedoms

  24. MENTAL CAPACITY ACT 20055 PRINCIPLES • 1. A person has capacity unless proven otherwise • 2. A person is not to be treated as unable to make a decision untill you have tried everything practical to help them make a decision • 3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision. • 4. An act done, or decision made must be in the person’s best interests. • 5. Before acting or deciding anything, consider whether it could be done in an equally effective way but less restrictive to the persons freedoms

  25. Assessing capacity Two-stage test for assessing capacity. • Does the person have an impairment of the mind or brain, or is there some sort of disturbance affecting the way their mind or brain works? (It doesn’t matter whether temporary or permanent.) • Does that impairment or disturbance mean that the person is unable to make the decision in question at the time it needs to be made?

  26. Assessing capacity Two-stage test for assessing capacity. • Does the person have an impairment of the mind or brain, or is there some sort of disturbance affecting the way their mind or brain works? (It doesn’t matter whether the impairment or disturbance is temporary or permanent.) • Does that impairment or disturbance mean that the person is unable to make the decision in question at the time it needs to be made?

  27. Assessing ability to make a decision • Does the person have a general understanding of what decision they need to make and why they need to make it? • Does the person have a general understanding of the likely consequences of making, or not making, this decision? • Is the person able to understand, retain, use and weigh up the information relevant to this decision? • Can the person communicate their decision (by talking, using sign language or any other means)

  28. Lack of capacity • Comprehension • Memory • Judgement • Communication

  29. Lack of capacity • A person lacks capacity if - they have an impairment or disturbance that affects the way their mind or brain works, AND - the impairment or disturbance means that they are unable to make a specific decision at the time it needs to be made.

  30. So..... When assessing someone's capacity: • Starting assumption must be that they have capacity • Understanding what is meant by capacity and lack of capacity • Assessing capacity is decision AND time specific. • Capacity must not be judged simply on the basis of their age, appearance, condition or an aspect of their behavior. • It is important to take all possible steps to try to help people make a decision for themselves

  31. Making decision for pt lacking capacity – BEST INTEREST • Don't make superficial judgements or discriminate • Take into account anything and everything you think is relevant. • Can you justify the decision to be in the pts best interest?

  32. ADVANCED CARE PLANNING. (ACP) • Can help when deciding best interest. • Used mostly in palliative care cases. • Continuing process of documented discussion b/w individuals and their carers • Addressing concerns, beliefs, treatment preferences etc. • They can change their minds so ACP is not compulsory. • Tools for ACP- LCP, GSF, PPC.

  33. THIRD PARTY DECISION MAKERS • LASTING POWER OF ATTORNEY – LPA • COURT APPOINTED DEPUTIES – CAD • INDEPENDENT MENTAL CAPACITY ADVOCATES - IMCA

  34. LPA • Replaced Enduring Power of Attorney • Authority to make particular decisions on pts behalf. Best interest still applies. • Covers decisions on personal welfare and property- health and social care decisions. • Formal document www.publicgardian.gov.uk • Needs to be registered with Office of Public Guardian. • One person can have more than one LPA.

  35. Court Appointed Deputies - CAD • CAD only appointed if in best interest of pt. • CAD appointed with limited scope and for short period. • Welfare, property and financial decisions. • CAD cannot make decisions about life sustaining treatments. • Where possible court should make decision itself.

  36. Independent Mental Capacity Advocates – IMCAs • New Breed! • Advocates not decision makers. • Best interest decisions. • Protect very vulnerable people. • Instructed in cases of pt with no LPA, NOK etc.

  37. Advance decisions to refuse treatment. • AKA – Living Wills, Advance Directives. • Only relevant if a persons lacks capacity • Advance decisions to REFUSE treatment are legally binding. • Anything else is not legally binding but should be considered in best interest decisions. • You may be liable for assault if you disregard a valid advance decision.

  38. NEW INSTITUTIONS. • COURT OF PROTECTION – resolve disputes re capacity and best interest. • OFFICE OF THE PUBLIC GAURDIAN- oversee proxy decision makers.

  39. Questions to Ask Yourself? • What decision has to be made? • Does the person have capacity to make decisions? • What support is needed to help pt make it? • If no capacity – is there LPA or CAD ? If involves treatment is there advance decision to refuse? • If not, am I the decision maker? • If I am, what are my obligations? – Best interests

  40. Safeguarding Adults DoH Guidance

  41. Definitions • Vulnerable Adult: ‘ A person aged 18 or over, who is or may be in need of community care services by reason of mental or other disability, age or illness; AND who is or may be unable to take care of him or herself,or unable to protect him or herself against significant harm or exploitation”. • Abuse: ‘Abuse is a violation of an individual’s human and civil rights by any other person or persons.’’

  42. Guidance • Type of • What degree of abuse justifies intervention? – who decides - Significant harm

  43. Guidance Working through a process of assessment to evaluate: • Is the person suffering harm or exploitation? • Is the intervention in the best interests of the vulnerable adult and/or in the public interest? • Does the assessment account for the depth and conviction of the feelings of the person alleging the abuse? Local agencies are to collaborate and work together. The lead agency will be local Social Services Authority but all agencies should designate a lead officer.

  44. Issues about capacity • Rights of all people to make choices and take risks should be taken into account • The vulnerable adult’s capacity is the key to action since if someone has ‘capacity’ and declines assistance this limits the help that he or she may be given

  45. Derby safeguarding adults procedure

  46. Derby and Derbyshire Safeguarding Vulnerable Adults Partnership • Derby City Council • Derbyshire County Council • Derbyshire Police • Derbyshire Probation • Derby Hospital NHS Foundation Trust • Chesterfield Royal NHS Foundation Trust • Derby City Primary Care Trust • Derbyshire County Primary Care Trust • Derbyshire Mental Health Trust • Tameside and Glossop Primary Care Trust • Health Care Commission • Crown Prosecution Service • Commission for Social Care Inspection • Derbyshire Advocacy • Derbyshire Rape Crisis • Age Concern Derby & Derbyshire • Derbyshire Victim Support • Derbyshire Independent Mental Capacity Advocate Service • The Westwick Group (Independent Care Provider) • Derbyshire Centre for Inclusive Living

  47. How it works? • Based on DoH guidance • STAGE ONE: ALERTING OTHERS IN OWN AGENCY • STAGE TWO: MAKING A REFERRAL • STAGE THREE: INITIAL DECISION • STAGE FOUR – STRATEGY MEETING • STAGE FIVE: SAFEGUARDING PLAN CASE CONFERENCE

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