Mental capacity to decline health monitoring

[okthought]

My 95 year-old father has a justified fear of hospitalisation, because during his last stay the combination of disruption and dementia produced quite severe paranoia, although he doesn't understand that that's what it was. Unfortunately, he still seems to suffer from lower-level paranoia that I and the world in general are conspiring against him, so mistakenly believes that I would allow him to be taken to hospital unnecessarily for a relatively minor fall or illness, which is far from the truth. He (or perhaps the voice of dementia) has threatened to kill himself if his PA were to tell me that he was unwell or had had a fall, though she makes a best interests decision and tells me anyway. He may now also see routine contact with healthcare professionals as presenting a risk of hospitalisation.

He has hypertension which is generally stable but his BP can still drift dangerously high if not monitored regularly, which used to be done by Community Nurses.

Despite having diagnosed vascular dementia, during the past few months, without my knowledge, the Community Nurses and his GP practice have both assumed, without actually assessing my father's mental capacity, that he retains sufficient capacity to be able to decide to agree to the CNs' suggestion that they should discharge him (to reduce demand on their services) and decline his invitation to attend the GP practice (not that he can travel there independently anyway) for an annual check-up.

As a result, no one will routinely monitoring his BP anymore unless he changes his mind and agrees to annual check-ups.

Does anyone else have similar experience of healthcare professionals assuming that a patient with dementia has mental capacity unless they are told otherwise, rather than actually performing an assessment of the patient's mental capacity?

Although my father can express his wishes very forcefully, I don't think that with poor reasoning (including the tendency to paranoia) and failing memory he can retain sufficient relevant facts for long enough and process them reliably enough to be deemed capable of making properly informed decisions about his own healthcare. My reasoning would be that agreeing not to be monitored would, if anything, be more likely to land him in hospital than keep him out of one.

I don't want to antagonise his generally sympathetic GP, but feel that I should challenge this convenient assumption of mental capacity without proper assessment. I would be interested to hear how others have approached similar situations.

 

[canary]

Its a tricky one. Legally you have to assume capacity until informed otherwise and lots of health workers dont know how to assess capacity - I think you have to trained to do it.
Could you get him to go to the doctor for checking (oh, we are just going to pop in here now and then go for coffee and cake)?
Would someone be willing to come to the house to check his blood pressure regularly?
Could you get someone to check his capacity?

 

[Bod]

Could his PA, or yourself check his blood pressure, with a wrist type monitor, on a regular basis? (weekly)
This is a different type of monitor to ones used in Dr's or hospital. They will give a very good indication of changes in BP, with out the "hospital" look.

Hopefully this would be enough, to keep him happy, and out of the clutchs of the medical world for now.

Bod

 

[okthought]

Thanks, Canary & Bod.

Yes, I'll work out some way of monitoring his BP.

My frustration is with the illogicality of the healthcare professional assuming that a patient with dementia has mental capacity unless they are told otherwise.

Is anyone necessarily going to be aware that a healthcare professional is about to ask the person with dementia to make a decision? A Community Nurse used to visit my father when I wasn't present, partly because I live 200 miles away and partly because they didn't stick to a particular day, let alone a particular time of day. One day, without any warning or notification to me, they invited him to discharge himself from their care.

What would someone be able to tell the healthcare professional? Losing mental capacity isn't a once-and-for-all event for all types of decision. The Mental Capacity Act requires mental capacity to be assessed on a decision-by-decision basis, because even though dementia is a progressive deterioration, mental capacity can still fluctuate from day to day and depends on the complexity of the decision. So, in theory, only someone who is present with my father at the same time as the healthcare professional can say anything relevant. And even if I had been able to be present, I wouldn't have been in a position to tell the nurse categorically that my father lacked capacity. No one is qualified to tell anyone else, since each person dealing with a person who may not have mental capacity has to make their own assessment. All I could have done was to express my considered opinion and present evidence to that effect. Obviously, I might be prepared to defer to the judgement of someone particularly well qualified to make such an assessment such as a mental health professional.

Similarly, bringing in a highly-qualified professional may be appropriate for assessing a person's mental capacity to make a particularly important decision on a particular day, but it's not a once-and-for-all assessment. That assessment is largely irrelevant the next day or for a different type of decision. All you can say is that if a person with dementia lacked capacity to make a certain type of decision six months ago, it's very likely that they lack capacity to make the same type of decision now.