Vicky is a 38-year-old woman who has a moderate learning disability. She can communicate verbally, but she can only understand short sentences and requires time to process information. She has a body mass index (BMI) of 43 and uncontrolled diabetes type 1 (her blood glucose reading range is 20–33.3 mmol/l). Her diabetes is currently managed through oral medication as she is refusing insulin injections. Vicky has a long-standing history of poor diet and has been known to hoard food. She often becomes distressed if staff try to encourage her to dispose of food because it may threaten her health. Vicky enjoys shopping and will often seek out foods with a high sugar content. However, she is often very fatigued and frequently dozing when out. Vicky has poor impulse control, and she does not like talking about her health conditions. There have been episodes of Police contact due to aggression, some of which has related to discussing her health needs; this is putting her placement at risk. Incidents of aggression have been linked to high blood sugar readings.
You are the community learning disability (CLD) nurse. You have been asked to complete a mental capacity assessment to ascertain whether Vicky understands her diabetes and the impact of her diet.
-
1. What does the Mental Capacity Act say about Vicky's capacity to manage her diabetes?
Show Answer
Correct answer: The Mental Capacity Act (MCA) states that a person must be assumed to have capacity unless it is proven otherwise. Therefore, you would need to assess her capacity before this question can be answered.
-
2. How would you assess whether Vicky has capacity?
Show Answer
Correct answer: This would depend on the individual. The MCA states that all reasonable measures must be taken to support someone to make a decision. This would include utilising all communication methods used by the person, education programmes and desensitisation approaches. To demonstrate capacity, the individual must be able to understand the information presented to them, retain the information long enough to make the decision, be able to weigh the information as part of the decision making process and must be able to communicate the decision back to those involved.
With regards to Vicky, you could consider supporting Vicky to gain an understanding of what her diabetes means by using simple sentence structure with picture aids or social stories to aid education. You may also consider attending the diabetes clinic using graded exposure to support her monitoring and understanding of her diabetes.
This might mean that she does not have capacity at this moment in time. However through working with those close to Vicky and through supporting her education, she may be able to gain capacity to make an informed decision regarding managing her diabetes at a later date.
-
3. What would you do to document the assessment and evidence?
Show Answer
Correct answer: As there is evidence to suggest that Vicky may not have capacity, a mental capacity assessment would need to be completed. This should detail all of the strategies used to support Vicky to make this decision and any evidence to suggest that she either does or does not have capacity.
-
4. It has been assessed that Vicky does not have capacity, what happens next?
Show Answer
Correct answer: There should be a best interest meeting with the key stakeholders. At this meeting, it should be determined what would be in the person's best interests and what would be the least restrictive process.
Vicky clearly enjoys shopping and food is an important part of her daily activity. Therefore, it would be too restrictive to remove all food options or shopping opportunities. Staff could look at offering suitable options for Vicky to choose from. Vicky could be supported to purchase planned items, or be given a token amount, for example £1.00 to purchase her choice of food. Regardless of food purchased, this would be a great improvement on her previous health and therefore may support Vicky to comply with the programme as she may feel that she has some independence.
-
5. Who would need to be involved in making the best interest decision?
Show Answer
Correct answer: It is ultimately the decision maker. However, it is best practice to involve all stakeholders (key persons) in the individual's life. This would include staff/carers, family, advocate and involved professionals. In cases where an individual does not have family, or the decision is at conflict with the family beliefs, an independent mental capacity advocate must be involved.
-
6. Who would the decision maker be for this assessment?
Show Answer
Correct answer: There can only be one decision maker. However in the person's best interest, it would be best practice to consider the opinions of all stakeholders. The ultimate decision and accountability remains with the decision maker.
In Vicky's case, it would be the CLD nurse as you are the lead professional involved in this case.
If the decision involved a medical intervention (e.g. dental treatment/hospital investigation/wound care from a district nurse), the decision maker would be the professional leading on this intervention and the community LD nurse may facilitate the capacity assessment to provide information to the decision maker.
