Mental Capacity: The balance between choice, support, and restrictions

I was recently involved in a Deprivation of Liberty (DoLS) assessment for an 80-year-old lady with a diagnosis of dementia.

She resided in a care home with locked doors that restricted her from leaving the care home unaccompanied. She was also unable to leave the unit she was in, going into the garden or other units within the care home without supervision from staff or her family.

On assessment, I found that she had fluctuating mental capacity to make decisions about her accommodation in the care home for the purpose of receiving the care and support she required. From the morning until around 4pm, she knew where she resided, why she was in the care home, the support she receives and risks she may encounter if she did not receive such support. Her awareness started to decline however from early evening, and she would at times try to wonder out of the care home. When staff intervene and explain why it was unsafe for her to leave unsupported, she was receptive to this but would forget this information about an hour later and she would again try to leave.

In a mental capacity assessment with someone who has such a presentation, it is advisable to assess her at a time when she is likely to be at her best, rather than a time when she is likely to be confused. This is referred to in the Principles of the Mental capacity act, 2005 as taking practicable steps in supporting someone to be as involved in the decision making process as much as possible.

Having considered all the relevant factors during the mental capacity assessment with her, I was satisfied that she was able to understand, retain and weigh up the relevant factors pertaining to her accommodation in the care home. She decided that her accommodation in the care home was in her best interest and she was happy to continue living there. She was aware that without support, she will struggle with caring for herself and in fact, she was able to recall that she had neglected herself at home before being admitted to the care home. She understood that she had a diagnosis of dementia and she was aware of how this impacted her memory and other functions; in particular, she was aware that she is prone to wandering and she said it was appropriate for care home staff to stop her from leaving the care home. As such, I formed the opinion, on the balance of probability that she had mental capacity to make decisions about her health and welfare.

DoLS was not applicable in this case but, I felt there will be benefit in the care home staff working with the client to revise her care plan so that her capacitous decision on how her care should be managed when her capacity fluctuates, is recorded and followed by care home staff. I also recommended that she should be assisted with going out in the community a lot more as this was important to her.

Sadly, my recommendations were not well received by the care home as this meant extra work for the care staff who were already stretched. Moreover, the care home staff felt placing the lady on DoLS regardless of the fact that she did not meet the criteria was best for them as it gives staff a legal framework to rely on in restricting the lady from leaving the care home or requesting to go out. It was clear here that the focus was on making the process of care provision convenient for staff rather than providing a service aimed at meeting the specific needs of a client and protecting their rights to liberty.

In this instance, educating the care home staff about the rights of vulnerable people and about the mental capacity act was important in shifting their views and understanding that risks can be managed and clients can be supported while encouraging them to make choices about how they would like to be cared for.

In summary, professionals working with vulnerable people need to listen to what is important to clients instead of focusing on what is easier for us as professionals. Providing this lady with the opportunity to leave the care home occasionally with adequate support would have promoted her emotional wellbeing and arguably, her physical health.

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