A question of capacity
The Mental Capacity Act requires clinicians to work with Independent Mental Capacity Advocates (IMCAs) when making decisions about serious medical treatment with patients who lack capacity and who have no family or friends to support them. GMCtoday hears from IMCA Manager, Teresa Gorczynska and clinician, Dr Paul Diggory, on how this works in practice for doctors and patients.
The Mental Capacity Act 2005 established a legal requirement to involve an Independent Mental Capacity Advocate in decisions for people when they lack capacity to make their own decisions about serious medical treatment or long-term accommodation, and have no family or friends to consult with. The IMCA regulations describe the characteristics of 'Serious Medical Treatment' as where:
- there is a fine balance between its benefits to the patient and the burdens and risks it is likely to entail
- there is a choice of treatments and a decision as to which one to use is finely balanced
- what is proposed would be likely to involve serious consequences for the patient.
IMCAs contribute to the best interest decision-making process by supporting and representing the patient and establishing the patient's current and previous wishes and preferences. They have a right to read relevant social and medical records.
The IMCA provides a further voice for the patient by asking questions such as why a particular treatment is being proposed, what the burdens and risks are and whether there are any other options. The IMCA has a duty to write a report and the clinician a duty to take account of the report. The IMCA will further support the process by checking that the Mental Capacity Act is being followed, including the requirement that the least restrictive options are being explored. As a last resort, the IMCA can formally challenge the decision-making process. However, an IMCA aims to work with the clinician to supply relevant information to ensure the right decision is made for the person.
Dr Paul Diggory, a clinician who regularly makes referrals, explains: ‘IMCAs are willing and able to undertake research into what the patient’s wishes were likely to have been, as well as unearthing contacts that a medical team may find difficult or too time consuming. The external perspective the IMCA brings to the appropriateness of procedures can be invaluable, especially when the options are finely balanced.
‘IMCAs can obtain information from or involve other organisations. They aim to help decide a patient’s best interests, which are not simply his/her best medical interests. They champion the patient’s rights; occasionally they may even access complaints procedures.
‘The service is new and doctors who have few patients may feel the process is unfamiliar and bureaucratic, but the forms can be put onto the organisation’s intranet and will be available from the local IMCA services. It does take a little time to fill in the forms but the reassurance of secondary review and extra information provided is generally worth the effort.’
Providing IMCA services across Sussex and nine London boroughs, Advocacy Partners has received 85 eligible serious medical treatment referrals in its first year of service. In providing IMCA services, Advocacy Partners has seen the benefit of an independent person contributing to the decision-making process, checking that the patient is at the centre of the process. This can provide a vital safeguard for the patient and a rights-based approach that can be particularly useful to the clinician in finely balanced or ethical decisions.
There is a list of the IMCA services at www.dh.gov.uk/IMCA
Teresa Gorczynska with Dr Paul Diggory
IMCA case study
Lucas, a man with learning disabilities, was a vocal and happy resident. His leg ulcers were managed by the district nurse team but unfortunately they became so severe that he was admitted to hospital and required an amputation.
On the Friday morning the IMCA met with the consultant who said that they were going to leave the operation until the following Monday, as they considered that if Lucas had died over the weekend this may have been kinder due to his low quality of life. The IMCA was able to feedback to the consultant information that Lucas’ carers had given, which was that he had had a good quality of life up until the previous week when the infection had dramatically increased.
Care staff had also told the IMCA that Lucas had told staff at the service that he wanted his leg amputated as he couldn't take the pain anymore. The IMCA expressed concern to the consultant about the risks the consultant had indicated to Lucas by waiting to perform the amputation.
The consultant took into account the IMCA’s submissions and rescheduled the operation for that afternoon. Lucas recovered and went back to his care home and his life.