Consolidation Of Mental Health Practice Nursing Essay

Introduction.

This assignment analyses how effective decision-making helps facilitate holistic person-centred care. To achieve this I will look at a case study involving a patient with a diagnosis of dementia who currently lives alone at home however, due to her current mental state and the condition of her accommodation, her home is unsafe for her to live in. I will look at how the decision to assess her capacity using the Mental Capacity Act (MCA) (Great Britain (GB) 2005) and hold a best interest meeting came about. I will conclude with how the decision-making process worked and what the outcomes for the patient helped to facilitate changes to her living conditions. Finally, I will examine how different healthcare professionals work together in collaboration with family and carers, to provide the best care to the patient.

CASE STUDY.

Patient A is a 79-year-old woman, with a primary diagnosis of dementia managed by the administration of an acetyl-cholinesterase inhibitor (Galantamine). Dementia is defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (WHO 2010) as condition of disturbances in cortical functioning, such as "memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement" (WHO 2010), commonly accompanied by a deterioration of emotional control, social behaviour and motivation.

Whilst visiting Patient A, she appeared overwhelmed with the upkeep of her flat, which appeared littered with unopened mail, newspapers, magazines and flyers. This abundance of papers posed significant risks, both in terms of fire and to Patient A’s safety due to limited space, coupled with a history of falling. It became evident that Patient A was finding it difficult to get in and out of her chair safely due to having to overstretch to get over the papers, which increased the risk of her falling.

Also of note was the table on which Patient A placed her hot drinks. This too was littered with letters and flyers, causing her teacup to become unstable, thus posing a risk of tipping over and scalding her. The Kitchen posed similar issues with the work areas and floor piled with various objects, making the kitchen both a high-risk fall area and..unsuitable..for..food..preparation.

Patient A reported falling over two days previous due to stepping over items in order to open her curtains. Although this fall did not result in injury, her past fall risk history makes this an area of concern. Patient A acknowledges that her flat is becoming both a fire and health hazard and states that she would like somebody to help. However any offers to help result in a rebuttal as she feels that she needs to consider every piece of paper before disposing of it.

During the home visit, I also noted that Patient A also had several months’ worth of medication stockpiled within her home. She stated that this was due to her wanting to finish old packs of medication prior to commencing on her dosset boxes. However, her medication self-administration was sporadic at best, with the amount stockpiled suggesting that Patient A had not been consistent in taking her medication for a few months.

I discussed this case with patient A’s Community Psychiatric Nurse (CPN) and the Social Work Team. We discussed whether Patient A had capacity to understand fully the risks posed by her hoarding and whether she understood the importance of maintaining her medication regime. Due to these concerns, Patient A’s CPN and I planned a subsequent visit. An environmental assessment and the administration of a Mini Mental State Exam (MMSE) (Folstein et al 1975) and Executive Clock Drawing Task (CLOX) (Royall et al 1998) showed that Patient A’s cognitive functioning had decreased since her last assessment. Patient A’s cognitive decline raised concern surrounding her difficulty in managing her home environment and accidental medication overdose due to mixing-up of times and days. As such, the CPN and I carried out a capacity assessment that resulted in the request for a best interest meeting.

Considerations in the decision making process.

The implementation of evidence-based care in clinical practice has greatly increased the need to understand the decision-making process in nursing (Cader et al 2005). Capacity is a pivotal ethical issue when attempting to balance the autonomous right of a person to make decisions and the right to protection from harm (Letts 2010).

Central to the decision-making process surrounding the best interest of Patient A was the application of the MCA (2005) assessment of capacity. The MCA (2005) is defined as:

A legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for themselves.

Department of Constitutional Affairs (DCA) 2007:15.

Lack of capacity provides the cornerstone of the MCA; it is the ‘gateway’ step, without which health professionals are not able to intervene (Georgantzi 2012). The MCA reinforces the right to autonomy, individual values, beliefs and attitudes to risk. In order for the team to make a decision, concerning the best interests of Patient A, it first needed to give careful consideration as to whether she had capacity to understand and make specific decisions for herself; at the time, she needed to make them (Letts 2010, GB 2005).

The MCA states that in order to assess Patient A’s capacity and make decisions on her behalf, staff should follow five core principles. Patient A must be assumed to have capacity to make autonomous decisions, all steps to help Patient A make her own decisions must be taken and Patient A’s should not be considered incapable of making decisions simply due her hoarding posing risks (GB 2005). Should Patient A be deemed to lack capacity to make decisions then any decisions made must be in her best interest and be the least restrictive option available under the circumstances must be employed (GB 2005).

When applying the MCA two-stage test to Patient A, consideration was given to time and location of the assessment (DCA 2007). In collaboration with patient A, we decided to meet at her home at a time when she was most comfortable with and in order to both put her at ease, thus avoiding stress (GB 2005) and avoid her having to travel across the city to meet with us.

Where Patient A’s Diagnosis of dementia fulfils stage one of the MCA, in that she has an impairment of the brain or mind, this does not necessarily signify her incapacity to make decisions. Any impairment must "affect their ability to make the specific decision when they need to" (DCA 2007:45). Therefore, it was imperative for us to ensure that Patient A received all the relevant information surrounding the risks posed in her home in a way that she understood them. As with most nursing care nursing care, effective and collaborative decision-making revolves around open and clear communication (Thompson & Dowding 2009). The way information concerning risks are framed, will directly affect the decisions that patient’s make. As such, we have a duty to ensure that patients are informed about the decisions they face as well as ensuring that we do not overly influence their decisions (GB 2005, DCA 2007, Aston et al 2010). However, as in the case of Patient A, if the person is unable to understand the information, retain and weigh the information as part of the decision-making process and communicate that decision, they it can be assumed that they lack capacity at that time (GB 2005, DCA 2007).

Information-processing theory explains that we have developed ways of processing information and that many different processes in making effective judgements and decisions (Thompson & Dowding 2009).

The decision surrounding Patients A’s lack of capacity can be seen from a hypothetico-deductive view. Firstly, the cue acquisition stage involved the gathering of clinical information such as Patient A’s diagnosis, past MMSE assessments, medication compliance history and prior evidence of falls. This information will help to inform us of the possible current situation (Ryrie & Norman 2009, Elstein et al 1978 cited in Thompson & Dowding 2009).

Evidence suggests that hoarding is a common behaviour in dementia. Reasons include hoarding things for safekeeping (Keady & Ashton 2009), isolation (Wang et al 2012), memories of the past such as living through a war (Better Health 2013) and feelings of loss (Keady & Ashton 2009, Wang et al 2012). Similarly, people with dementia often have issues surrounding medication compliance. Evidence suggests that up to 50% of patients over 65 may not be concordant with their medication regimes (Social Care Institute for Excellence (SCIE) 2005). This is generally due to forgetfulness without prompting or a lack of awareness of the importance of the medication (Stapleton 2010).

By applying this evidence-base to the cue acquisition stage, we can begin to generate hypotheses surrounding Patient A’s behaviours. We hypothesised that Patient A’s hoarding behaviour related directly to her dementia and that Patient A’s dementia was affecting her memory, thus causing sporadic medication adherence (Elstein et al 1978 cited in Thompson & Dowding 2009).

The next stage involved the interpretation of the cues in an attempt to either confirm or refute our hypotheses. For this we looked at whether Patient A’s past history of falls was related to her hoarding behaviour or whether there was an alternative explanation (Postural drop, medication, physical frailty etc) and whether the change to dossett box medication regime was confusing Patient A, thus explaining the medication non-compliance as an educational issue as opposed to forgetfulness.

Finally, we began to evaluate each hypothesis and chose the one that favoured the majority of the evidence (Elstein et al 1978 cited in Thompson & Dowding 2009). The results of the MMSE assessment, the capacity assessment process, hypothesis generation and evaluation helped us conclude that a decline in cognition since Patient A’s previous MMSE indicated that she did not have the capacity at that time to understand the risks associated with her behaviours.

Different modes of reasoning are involved within information processing when making decisions. As a student nurse, my experience of decision-making is primarily evidence and analysis based however, the CPN not only relied on the analysis of evidence but also relied on her intuition and previous knowledge of the patient. Hammond’s (1996) Cognitive Continuum states that "human cognition is clearly capable of both intuition and analysis and that each has value" (Hammond 1996:89). Hammond (1996) suggests six modes of decision-making, ranging from intuition to analysis. He defined analysis as having high cognitive control, slow data processing, task specific and having high confidence in the evidence (Cader et al 2005). Intuition involves low cognitive control, rapid data processing, low cognitive awareness and a low evidence base. Cader et al (2005) explains that Quasi-rationality (Hammond 1996, Dhami & Thompson 2012) lies centrally within the continuum and includes elements of both intuition and analysis (Figure One) and appears to be at the core of the decision making process used by the CPN.

Figure One: The Cognitive Continuum (Dhami & Thompson 2012 after Hammond 1996).

Hamm (1998) (Figure Two) introduced minor changes to the terms used in the Cognitive Continuum (Cader et al 2005) and used terminology that brought it closer to nursing practice.

Figure Two: The Cognitive Continuum (after Ham 1998:87).

Both Hammond (1992) and Ham (1998) clearly recognise that intuition holds some value in healthcare. However, it should not outweigh evidence-based decision-making skills (Thompson & Dowding 2009, Aston et al 2010). If professionals draw on intuitive decisions alone and mistakes occur, due to a lack of insight into what informed the decision, it would be difficult to pinpoint where the decision-making process broke down (Thompson & Dowding 2009).

Due to the decision that Patient A lacked capacity, the team decided that a best interest was required. After an appropriate assessment, a person is deemed as not having the capacity to make decisions for themselves there needs to be an appropriate and ethical framework in place to ensure that the person’s own interest are paramount (British Psychological Society (BPS) 2007). They explain that the three main models of decision-making for others are:

Advanced Decisions: decision makers take information about a person’s wishes and feelings into consideration when they are making best interests decisions.

Substituted Judgement: a method for making decisions that tries to make the choice that the person would have made, if they had the capacity to do so.

Best Interest: a method for making decisions that is more objective than that of substituted judgement. It requires the decision maker to think what the ‘best course of action’ is for the person.

The MCA framework allows for of all of the above, however it is very clear in stating that the over-riding model of decision-making is that of best interest (GB 2005, DCA 2007). The MCA sets out a checklist of factors that we needed to consider before making decisions on behalf of Patient A by considering both current and future interests of the person, weighing them up and deciding which course of action is preferable (Letts 2010). This involved working in collaboration with family and other professionals to attain the common goal of what is best for Patient A.

Professional’s involved in the best interest meeting included Patient A’s CPN and me, her consultant and her family members. The decisions concentrated on whether Patient A was safe in her home or whether she should be relocated to residential care and whether she had the capacity to manage her medication regime safely or whether a package of care needed to be put in place in order to ensure medication compliance.

The professional view from the psychiatrist was that Patient A could communicate her decisions eloquently however; she did not have the capacity to retain and understand the information concerning the severity of the risks of her current situation. Therefore could not weigh up the information in order to make a rational decision (DCA 2007).

Through previous discussions with Patient A, it was clear that she felt safe in her home and did not feel the need for any further interventions. However her ex-husband, Mr B, who lived in the flat below and was considered as her primary carer, stated that he felt Patient A was frail and posed some significant risks to her health and wellbeing. His concerns surrounded not only Patient A’s health but also his own by explaining that he was finding it difficult to manage her care on a daily basis. His opinion was that it would be preferable for Patient A to have some form of convalescent care until the flat to facilitate the cleaning of the flat and put a care package put in place.

Patient A had two children, one son who could not attend the meeting and a daughter, Mrs C, who attended to present the views and wishes of both children. Mrs C stated that she felt the same way as the ex-husband in that a period of convalescent care would not only provide the opportunity to clean the flat but also allow for the assessment of Patient A’s physical health. However, she did not agree that her mother lacked capacity; simply acknowledging that, her mother could be stoic and difficult to manage at times. In comparison to this, the son’s view was that his mother’s capacity fluctuated on a regular basis. He felt that, should the sister be able to look after her mother for a two-week period, he would be willing to organise a clean up and redecoration of the flat. After discussing this option, Mrs C agreed that this would be a good alternative to placing the mother in temporary care.

The consultation and gaining of views, of people close to Patient A, helped to gain their opinions (DCA 2007, Adams 2009). This allowed for information on the known wishes, feelings and beliefs of Patient A to be taken into account and consideration of the least restrictive options available (GB 2005, DCA 2007 Letts 2010), which aided greatly with the decision-making process.

The best interest meeting arrived at its decisions by analysing value-based judgements such as professional, relative and carer views, comparison with the current evidence base, clarification of key concepts in the care approach and the development of a logical action plan (Tullett 2007, Aston et al 2010). In Patients A’s case we agreed that her current risks were falls due to her hoarding behaviour and further cognitive decline due to medication non-concordance, both of which are familiar scenario’s for people suffering with dementia (SCIE 2005, Keady & Ashton 2009).

In terms of her safety due to hoarding, the meeting decided that the least restrictive option would be to follow the plan put forward by the son. The MCA states that sometimes there is no alternative other than depriving somebody of his or her liberty (GB 2005). However, this could be an infringement of Article 5(1) of the European Convention on Human rights (ECHR) (Council of Europe (CoE) 2010) unless authorised by the court of protection or in accordance with the Deprivation of Liberty Safeguards (Ministry of Justice (MoJ) 2008).

In recent years, the concept of recovery has gained impetus in mental health (Schrank & Slade 2007). Recovery involves overcoming the effects mental illness, with all its implications, and regaining control (Davidson et al 2005) in order to experience "a new sense of self and of purpose within and beyond the limits of the disability" (Repper & Perkins 2003:45). In order to promote the concept of recovery for Patient A, it was imperative that we ensured that any actions we took produced the least restrictive option available. The consideration of placing Patient A temporarily within care was rejected as it would have restricted and undermined her sense of control, self and purpose by going against her known wishes.

Keeping Patient A at home ensured that we could help her to maintain her identity and keep her within her community. This allowed her to take control over certain aspects of her life and maintain her rights and autonomy (GB 2005, MoJ 2008). Therefore, the recovery approach aided the decision-making process by guiding us towards the concepts of recovery, autonomy and inclusion.

In terms of the medication non-compliance, the meeting decided that no change in medication would be beneficial until compliance was reached. This would allow the CPN to visit and assess medication efficacy before making any changes. The meeting agreed that Patient A would be benefit from a care package consisting of a carer coming in to help her with her medication on a twice-daily basis, supported by increased visits by the CPN for the foreseeable future.

As the best interest meeting was within the last days of my placement, my final role within this case was to contact Patient A’s son, discuss the decisions of the meeting and agree a date in which to action the plan. I arranged a date for the son and CPN to visit Patient A and begin sorting and boxing up the property, after which the CPN would liaise with patient A, family and professionals in arranging the care package.

Conclusion.

The decision-making process can be seen as a three-stage process. Firstly we need to ensure that we collect relevant information, we then assess that information using a number of modes of reasoning and ethical criteria and lastly we need to be able to do something with the information that contributes to the holistic care of the patient. This makes decision-making continuous process that should be placed at the centre of all nursing activities.

The ability to make good, effective and ethical decisions is not something we all possess. Making the right choices at the right time requires a good knowledge and skills base which, in combination, help us to make good quality choices for our patients. Decision-making should predominantly be evidence-based however, there remains a place for intuitive knowledge. Nursing is a complex profession where the importance of a good evidence base is paramount. This makes decision-making an ongoing learning process that should evolve in line with current practice.

One of the most relevant legal instruments surrounding capacity is undoubtedly the MCA, which has achieved a paradigm shift in terms of autonomy, legal capacity and decision-making. Nurses have to ensure that they balance a number of elements such as the patient’s best interest, family and carer views, professional opinions and resources. However pleasing all parties is not always possible. Therefore, it is imperative that nurses are able to justify their decisions. The above case example demonstrated that clinical decision-making involves weighing up the positive and negative points associated with each available choice, using a variety of decision-making tools and information, before deciding on an action.