Keiran Mark Bellis

Paramedic

United Kingdom

Doctorate Title: The Capacious Suicide – A study to determine the effectiveness of a standard mental capacity assessment tool in the assessment of capacity in the suicidal patient.

Doctorate Description: There remains a significant grey area within paramedic practice when considering mental capacity assessment and allaying that with an individual’s intent to harm themselves sufficiently where death by suicide is a potential outcome, the challenges are potentially seen as even greater. This though, should not necessarily be the case, as the underlying principles of any capacity decision remain constant, and the law does not differentiate between the larger, capacious decisions and those made daily when determining appropriate care. Mental capacity assessments are crucial in emergency medical situations to ensure appropriate legal and ethical decision making, allied with this is the need for an effective mental capacity assessment tool, as this is a critical aspect of patient care. This research will add to the current body of literature in a way that has yet to be fully explored, resulting in a decision-making tool to support the current standardised capacity assessment too, which will be both evidence-based and borne from legal, moral and ethical consensus through the application of an initial Delphi Study which will commence after the culmination of a significant element of desk-based research, the outcomes of the Delphi Study will shape a number of semi-structured interviews conducted with key stakeholders. Under the working title “The Capacious Suicide – A study to determine the effectiveness of a standard mental capacity assessment tool in the assessment of capacity in the suicidal patient.” I will seek to review capacity legislation from both key jurisdictions within the United Kingdom mainland and reflect on the key differences in s5 of the Mental Capacity Act 2005 (MCA 05) and s47 of the Adults with Incapacity Act (Scotland) 2000 (AWIA 00) and reflect upon the current provision of the statute and common law which has developed within both legal systems. I will then use this information the critically assess the effectiveness of the typical mental capacity assessment tool utilised by paramedics within the United Kingdom.

When considering the assessment of a patient’s mental capacity there is little consensus within paramedic practice and when you overlay this with a life and death decision the profession typically reverts to a highly paternalistic position, despite there being nothing within the legislation which makes any distinction between capacity assessments for consent and refusal of treatment in adults. There appear to be many confounding variables which lead to conflicting views and opinions, which ultimately leads to a variance in outcomes for patients. These variables include the type of education, length of practice, personal moral and ethical perspectives, and religion to name a few. There is a webbed matrix of investigation which will be addressed during the desk-based literature review this will include a review of the AWIA 00 and its direction of capacity assessment which will be mirrored with the MCA 05 for England and Wales (Compassion in Dying 2018), Mental Capacity and Self Determination (Gregel & Owen 2015) and Capacity and Suicidal Intent (Klonsky, Saffer & Bryan 2018; Litmann 1987 and Allen 2013). This will create a backdrop to commence the primary research.

The process of mental capacity assessment within the paramedic field relies heavily upon the single mental capacity assessment tool which is set out by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC 2022). This is a tripartite tool which supports clinicians in determining a patient’s capacity through the utilisation of a functional test, a diagnostic test, and the determination of a causative nexus. This test is drawn from the MCA 05 which is the primary piece of legislation which governs mental capacity assessment within England and Wales. This poses significant challenges when considering that within Scotland the legislation which supports mental capacity assessment is the AWIA 00. There has been some considerable discussion within the published literature which has analysed the relationship between prehospital capacity assessments and the Mental Capacity Act (Gaisford 2018; Evans 2007 and Amblum-Almer 2014) but this has all been focused on the relationship between the MCA 05 and capacity, highlighting the correct management of a patient, in the eyes of the law once capacity or lack of capacity has been established. This poses a dualistic problem of a lack of published literature discussing the relationship between capacity assessment and the AWIA 00 and a lack of specific focus relating to the actual tool promoted by JRCALC. Both pieces of legislation rely heavily upon supplementary publications (Mental Capacity Act 2005 Code of Practice 2007 & Adults with Incapacity Act (Scotland) 2000: Principles 2019) and it is within these supporting documents there is a wider discussion which ultimately resolves to maintain subjectivity within this area, this includes pre-existing mental health conditions, alcohol and many other aspects of a patient’s life and wellbeing.

Many mental health patients are aware of the phenomenon of being told they “Have the capacity to choose to end their life”, or similar when asking for help while suicidal. This phenomenon has been widely discussed for years, but currently, there is no published research into what this means, or how it affects people and their clinical outcomes (Alves 2022). There is little case law which supports or challenges these perspectives, though capacity and the right to self-determination were discussed by the coroner in an English case back in 2009. The Kerrie Wooltorton case and that of St George Health Care N.H.S. Trust v S (1999), where the capacity and autonomy of the individual were addressed in the refusal to permit medical treatment will be a natural launch point for the piece. When considering other elements and substances which may affect or limit a patient’s capacity to refuse lifesaving treatment, there has been some historical discussion regarding alcohol and suicide (Kendall 1983; Roy & Linnoila 1986 and Sher 2006) there is little contemporary evidence to challenge or support the information published in the supporting documents to the legislation. Interestingly there is a dearth of published information regarding mental capacity assessments within Scotland, and this is even starker when considering assessments completed by paramedic personnel.

Objectives

The main objectives of this study are as follows:

a. Evaluate the effectiveness of the paramedics' mental capacity assessment tool in accurately determining patients' mental capacity.

b. Compare the outcomes of the paramedics' mental capacity assessment tool with other standardized assessment methods.

c. Identify any limitations or areas for improvement in the current mental capacity assessment tool.

Methodology/Research Methods

The use of both a Delphi Study and semi-structured interviews will enable a mixed methods approach with a series of quantitative Likert scale-based questions within the early iterations of the Delphi Study before transitioning to qualitative responses within the latter rounds which will ultimately shape the direction of the semi-structured interview process. The early iterations of the Delphi Study will determine the paramedic’s confidence in using the single assessment tool in a multitude of different clinical situations, ultimately those including a potential life or death decision, their understanding of the legal principles which underpin the tools use and its scope within the specific jurisdiction, for example under the auspices of s47 AWIA 00 and s5 MCA 05. This will feed into and shape the semi-structured interview process where the current legal, moral, ethical jurisprudential, and theological perspectives will be examined alongside practical and profession-based expertise. The specific elements of the process, the literature review, Delphi Study, and Interviews will all have the capacity to become publications within their own right, thus enhancing the overall worth of the project.