Adults with Incapacity

who is Awi applicable to

mental health

dementia

people who cannot consent

what are the gdc standards if valid consent

3.1

3.1.4

3.2

what is valid consent

consent has to be;

informed

given freely and voluntarily

capable patient !

how do u check if a patient is capable or incapable in understanding

ask open questions instead of closed questions to ensure they understand

unless patients cannot physically answer etc

make sure responses are matching with the information/questions you are giving

what is incapacity

in the capacity act 2000 ,incapacity means incapable of;

acting - act on basis of information eg app letters muddled up times / areas / cancel if needed

making a decision - eg take info and weigh up options to make a decision on their tx

communicating decision - law requires they have to communicate it but does not have to be spoken, as long as u can understand eg makaton and interpretor

understand their decision - ask open qs, chunk and check, teach back, dont use closed qs, power imbalance/scared of offending clinician might mean that pt doesnt want to admit they dont understand

retain their decision - even if they might forget, if relaying the options again and the pt chooses the same option then the law states that is enough

these must be in relation to a mental disorder or inability to communicate, if there is not a formal diagnosis this can not be applied to the person

why is giving pt an option of doing nothing important

because it is the law

what is AMCUR

acting

making decision

communicating

understanding

retaining information

use to remember

how do you assess capacity

know defiiniton / amcur

apply it to the pt

use the definition as a framework

what is chunk and check

give info as a whole and then check with the patient what they understand before continuing

what is teach back in pt understanding

similar style to teaching in ddh,

' before you leave, what do you expect next visit '

gives u undertsanding of what pt undertsands in their own words

colloquial terms such as jag for injection helps confirm understand

avoid assumptions

allow time

document pt understanding

what as the healthcare professional is out responsobility when communicating

making sure that pts have resources to understand fully such as;

organising interpretor

extra time

bring laptop if that is how u communicate

what do we do when a pt cant consent

if a pt lacks capacity to consent to dental tx, the adults with incapacity act 2000 applies

what is scotlands adults with incapacity act 2000

safeguards the welfare and manages the finances of people aged 16 plus who lack capacity

in scotland, there is a presumption in favour of capacity - even if there is a diagnosis of something doesnt mean consent is gone yet, u have to assess the individual first and they have to demonstrate incapacity in relation to the deciison being made

what are the 5 key principles of section 47

benefit - has to directly benefit pt otherwise u cant do it

least restrictive to freedom - how each tx decision is carried and what it means for the pt

take in past and present wishes of pt into account

consult relevant others eg family

statutory requirement to encourage residual capacity ie a timer to brush teeth for 2 mins

what is a proxy

umberella term for a substitute decision maker

lots of different types

someone who is authorised to act on behalf of someone with incapacity

is legally recognised

relatives who arent proxies cannot consent to treatment

what is power of attorney

type of proxy

there are different types of poa

similar to making to a will

must be in writing

must be registered with Office of the Public Guardian

powers are dormant until needed - except financial, the proxy can be activated eg if

they dont have expiry date

activated by pt who have chosen who they avt for if need be

what are the types of power of attorney and what are they responsible for

welfare - medical / dentistry, diet, etc

continuing - money, property, businesses but not consent to med/dent

joint or combined - have power to welfare and and financial etc

up to the pt to choose who and what powers the poa have access to, powers can be to multiple ppl

in terms of seperation/ poa is incapable before the person, the person can resign

why are there diff types of poa

because it is pts choice to who and what they choose

how do we check the poa document and why

ask to see the original or lawyer endorsed copy of the poa

electronic ones dont have embossed seal

need to read the body of the document

must check inside what powers have been granted

can check with opg

this is because the document can be easily altered to chnage who/what poa are there and who is responsible for consent

what does the documentation for poa need to have before it is accepted

the power to consent or withold consent to medical and dental treatment

can check with office public guardian

what can welfare of poa do and not do

cannot have more power than a capable pty

cannot authorise use of force

cannot demand specific treatment

what are key points of welfare poa

poa are granted while pt is still capable

they can choose whoever they wish

must be in writing and register with office of public guardian

poa dont have expiry date

not all the same

you must check the whole doc for what powers have been granted

can photocopy relevant info and front page once have seen to put in pts notes

what is a guardian

type of proxy

granted when adults either;

no longer have capacity to choose who they wish to make decisions for them eg very advanced dementia

or

the adults have never been able to make their own decisions eg born with illness

guardianships do expire typically 3 years but can be longer

can use more than 1 guardian

can also appoint a substitute

can consent for use of force

how does a person get a guardianship

apply through the court and the sheriff assesses and social worker investigates the

what types of guardians

financial

welfare

both

what is on a guardianship document

see original or lawyer endorsed copy

electronic dont have embossed seal

need to read the body of the document

need to have

'the power to consent or withold consent to medical and dental treatment

exam

what types of proxy

what is an intervenor

sheriff court appointed and are usually for a one off manner

not common and relevant to dentistry

how do we check proxy status

can confirm proxy in place

can confirm welfare powers exist

not confirm what they are tho

cant give contact details so best is gmp

who can consent for dental tx

patients with capacity

welfare poa

welfare guardians

all doctors and specialty dentists who are trained can auhtorse tx under section 47 of AWI act

dentist can only authroise dental tx

what happens if there is a proxy

if pt is not deemed to have capacity for the particular decision and there is a proxy with relevant welfare powers ;

then follow the 5 key principles of the AWI act

get consent from the proxy - gives idea of what the pt would like

have an AWI issued

what types of consent do we need for different txs

not for a scale filling or extraction

if it was like GA then written

if u het verbal for pt, get verbal from proxy

if written form pt, then written from proxy

what happens if there is no proxy/ no welfare poa etc

follow the 5 key principles with AWI

then get section 47 certificate issued

this then authorises the tx to go ahead

who is able to complete an AWI certificate

all doctors

dentists with specialty training

opticians with training

nurse practiitoners with training

all these for each relevant field

not dental therapists

what do we do if there is a dispute of tx plan within awi

talk and have a convo and document it and send a letter

invite the disagreeing person to an appointment

then refer for local senior second opinion

escalate further to an onward referral to specialist or consultant

what is mental welfare commission for scotland

for if you have concerns about people misusing poa guardianship etc