McWilliams Andrew, Ariyo Kevin, David Anthony S, Owen Gareth S
Mental Health, Ethics and Law Research Group, Department of Psychological Medicine, King's College London, London, SE5 8AF, UK.
Metacognition Group, Wellcome Centre for Human Neuroimaging, University College London, 12 Queen Square, London, WC1N 3BG, UK.
Wellcome Open Res. 2024 Apr 24;9:221. doi: 10.12688/wellcomeopenres.20952.1. eCollection 2024.
The Mental Capacity Act 2005 of England and Wales is a ground-breaking piece of legislation with reach into healthcare, social care and legal settings. Professionals have needed to develop skills to assess mental capacity and handle malign influence, but it is unclear how assessments are implemented in real world settings. Our previously reported survey found professionals juggling competing resources in complex systems, often struggling to stay up to date with law.The current follow-up study uses one-to-one interviews of professionals to characterise in detail six areas of uncertainty faced when assessing mental capacity, whilst suggesting ways to make improvements.
Forty-four healthcare, social care and legal professionals were interviewed, using a semi-structured topic guide. Transcripts were analysed using framework analysis: a qualitative technique built to investigate healthcare policy.
Our topic guide generated 21 themes. In relation to the six areas of uncertainty: 1) Many participants stressed the importance of capturing a holistic view, adding that their own profession was best-placed for this - although a medical diagnosis was often needed. 2) The presumption of capacity was a laudable aim, though not always easy to operationalise and occasionally being open to abuse. 3) There was cautious interest in psychometric testing, providing a cognitive context for decisions. 4) Undue influence was infrequent, but remained under-emphasised in training. 5) Multi-professional assessments were common, despite doubts about fitting these within local resources and the law. 6) Remote assessment was generally acceptable, if inadequate for identifying coercion.
Practical constraints and competing demands were reported by professionals working within real world systems. Assessment processes must be versatile, equally applicable in routine and emergency settings, across diverse decisional types, for both generalist and specialist assessors, and able to handle coercion. Recognising these challenges will guide development of best practices in assessment and associated policy.
英格兰和威尔士2005年的《精神能力法案》是一项具有开创性的立法，其影响涉及医疗保健、社会护理和法律领域。专业人员需要培养评估精神能力和应对恶意影响的技能，但尚不清楚这些评估在现实环境中是如何实施的。我们之前报告的调查发现，专业人员在复杂系统中应对相互冲突的资源，往往难以跟上法律的更新。当前的后续研究通过对专业人员进行一对一访谈，详细描述了评估精神能力时面临的六个不确定领域，同时提出了改进方法。
使用半结构化主题指南对44名医疗保健、社会护理和法律专业人员进行了访谈。使用框架分析法对访谈记录进行分析：这是一种用于调查医疗政策的定性技术。
我们的主题指南产生了21个主题。关于六个不确定领域：1）许多参与者强调全面了解情况的重要性，并补充说他们自己的专业最适合做到这一点——尽管通常需要进行医学诊断。2）能力推定是一个值得称赞的目标，但并不总是易于实施，偶尔还容易被滥用。3）对心理测试存在谨慎的兴趣，可为决策提供认知背景。4）不当影响很少见，但在培训中仍未得到充分重视。5）多专业评估很常见，尽管有人怀疑能否在当地资源和法律范围内进行。6）远程评估总体上是可以接受的，但对于识别胁迫来说并不充分。
在现实世界系统中工作的专业人员报告了实际限制和相互冲突的需求。评估过程必须具有通用性，同样适用于常规和紧急情况，适用于各种决策类型，适用于通才和专科评估人员，并且能够应对胁迫。认识到这些挑战将指导评估最佳实践和相关政策的制定。
