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Capacity to make decisions is fundamental to patient autonomy

In accorance to ethical principles families should be involved in decision making

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What Professional issues are raised by this case?

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What Professional issues are raised by this case?

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Thinking of professional values what do you think nurses would do in this situation?

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Thinking of professional values what do you think nurses would do in this situation?

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Assess capacity

If an adult lacks the capacity to give consent, a decision about whether to go ahead with the treatment will need to be made by the healthcare professionals treating them.

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There are a few ethical considerations for the nurse to consider in this scenario.
These ethical issues relate to the patients rights and autonomy. Nursing practice has moved from a caring practice to a health promotion and prevention service. It is really important for nurses to involve patients in their own care. Person centred approach.
All nurses must follow the NMC code of practice at all times.
The NMC specifically states in regards to patients rights and autonomy :
1 Treat people as individuals and uphold their dignity   -1.3 avoid making assumptions and recognise diversity and individual choice
-1.5 respect and uphold people’s human rights

2. Listen to people and respond to their preferences and concerns
-2.2 recognise and respect the contribution that people can make to their own health and wellbeing

-2.3 encourage and empower people to share in decisions about their treatment and care
-2.4 respect the level to which people receiving care want to be involved in decisions about their own health, well being and care

-2.5 respect, support and document a person’s right to accept or refuse care and treatment.

https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

Often patients are experts in their own care, however this may not be the case for this patient and this leads onto the Mental Capacity Act 2005.

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Part 3 of the NMC code demonstrates the importance of working in partnership to provide the best possible care for the patient
3 Make sure that people’s physical, social and psychological needs are assessed and responded to

-3.3 act in partnership with those receiving care, helping them to access relevant health and social care, information and support when they need it
-3.4 Act as an advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care

It is important to point the patient in this scenario in the right direction for advice. This links in with the the Mental Health Wales Measure 2010. This is legislation implemented by the Welsh Government in 2012. The Mental Health measure makes provision for those receiving care and treatment in hospital are able to access independent specialist advocacy if they wish to.

Link to advocacy guidelines and Mental Health Measure
https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

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Although the NMC code states the importance of patients rights and autonomy and respecting their wishes in regards to their care, part 4 of the Code is particularly important in this scenario in acting in the patients best interests and possibly proceeding with the treatment regardless of the patient wishing not to.
The code states:

4 act in the best interests of people at all times

-4.1 balance the need to act in the best interests of people at all times with the requirement to respect a person’s right to accept or refuse treatment

-4.3 keep to all relevant laws about mental capacity that apply in the country in which you are practising, and make sure that the rights and best interests of those who lack capacity are still at the centre of the decision-making process

These points are important to consider when making a decision regarding the patients care here, and links in with beneficence  and non malificence. As the patient has been deemed not to have capacity the nurse needs to ensure the treatment is in the patients best interests and do no harm/ least harm.

https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

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A nurse has a duty of care, promoting good and minimising harm, whilst acting on the patient’s best interest.

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It states that a medical practitioner has a duty to do no harm or allow harm to be caused to a patient through neglect. Therefore the nurse is obliged to carry out all necessary procedures to ensure that Jonathan is fully aware of the situation he is in and that he isn't neglected.

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The Mental Health Measure is concerned with the support that people with mental health problems in Wales receive. Part 4 of the measure is particularly relevant in this scenario. It states:
'Part 4 offers every in-patient access to the help of an independent mental health advocate.'
The measure extends from the Mental Health Act, which gave the right to an Independent Mental Health Advocate (IMHA) for those under long term sections or living in the community subject to guardianship, to include all people admitted to psychiatric hospitals in   Wales. This means that patients on short term or emergency sections of the Mental Health Act and those in hospital voluntarily or informally now have the right to an IMHA.

It is important to make the patient aware that he has the right to ask for help and advice from an independent advocate who's key role is helping patients to obtain and understand information about their care and treatment.

'They may help a patient become involved, or more involved, in decisions made about their care and treatment, and/or represent the patient and speak on their behalf (54 to 57).'
http://www.legislation.gov.uk/mwa/2010/7/part/4
https://gov.wales/sites/default/files/publications/2019-03/the-mental-health-wales-measure-2010.pdf

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The Nursing and Midwifery Code states that it is the responsibility of nurses to “act as an advocate for the vulnerable”

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3

Admission for treatment.

(1)

A patient may be admitted to a hospital and detained there for the period allowed by the following provisions of this Act in pursuance of an application (in this Act referred to as “an application for admission for treatment”) made in accordance with this section.

(2)

An application for admission for treatment may be made in respect of a patient on the grounds that—

(a)

he is suffering from [F1mental disorder] of a nature or degree which makes it appropriate for him to receive medical treatment in a hospital; and

(b)

F2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(c)

it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained under this section[F3; and

(d)

appropriate medical treatment is available for him.]

(3)

An application for admission for treatment shall be founded on the written recommendations in the prescribed form of two registered medical practitioners, including in each case a statement that in the opinion of the practitioner the conditions set out in subsection (2) above are complied with; and each such recommendation shall include—

(a)

such particulars as may be prescribed of the grounds for that opinion so far as it relates to the conditions set out in paragraphs (a) and [F4(d)] of that subsection; and

(b)

a statement of the reasons for that opinion so far as it relates to the conditions set out in paragraph (c) of that subsection, specifying whether other methods of dealing with the patient are available and, if so, why they are not appropriate.
http://www.legislation.gov.uk/ukpga/1983/20/section/3

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Capacity, Jonathan and the Best Interests Principle. 

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Capacity, Jonathan and the Best Interests Principle. 

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A person who lacks capacity – “a person who lacks capacity to make a particular decision or take particular action for themselves at the time the decision or action needs to be taken” (Mental Capacity Act, 2005). As Jonathon is extremely depressed it is possible that he’s lost the will to live, he could also find it difficult to make decisions (NHS, 2019).

Considering the current situation, Jonathan would be forced to have the operation under the ‘best interests’ principle. This would be decided after an in-depth discussion with the multi-disciplinary team.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4114162/

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Table - ethical issues mental health act

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The best interests principle in the Mental Capacity Act 2005 (the Act) states that any act done or decision made on behalf of an adult lacking capacity must be in their best interests. This can cover financial, health and social care decisions. The person making the decision is the “decision-maker” and is likely to be the person caring for the patient on a day-to-day basis, the doctor or other member of the healthcare staff responsible for carrying out the particular treatment or procedure, or an LPA or Court of Protection deputy.