S Ramsey West of Scotland Basic Surgical Trainee
Correspondence to: Dr Sara Ramsey, 12B Burnbank Gardens, Glasgow
Email: sara_l_ramsey@hotmail.com
SMJ 2005 50(1): 20-23
Abstract:
The Adults with Incapacity (Scotland) Act 2000 provides new guidelines on obtaining consent for adults who are incapable of providing informed consent. This article surveys current practice of health workers when obtaining consent from such individuals, and the results are compared to the Incapacity Act and local guidelines. The survey results suggest that practice of the guidelines is variable and often legally inadequate Aims: To quantify awareness and practical application of the Adults with Incapacity (Scotland) Act in surgical wards in a central Glasgow teaching hospital, 2 years after the Act’s introduction. Methods: An interviewer led anonymous questionnaire was presented to all degree educated staff encountered on random visits to acute and elective surgical and orthopaedic wards in a split site teaching hospital. Results: 17 out of 50 staff approached (34%) had not heard of the Adults with Incapacity Act. There was a significantly higher level of awareness amongst staff based on acute wards (85%) when compared with those from elective wards (54%) (p<0.05, chi-square) There was a complete absence of formal training in using the Act and knowledge was sometimes inaccurate or incorrect. Most staff that had heard of the Act could suggest causes of incapacity, but some included physical disability. There was a persistence of the belief that a relative can consent for an incapable adult patient, and this was expressed by some of the staff despite knowledge of the Act. Conclusions: This study shows that a significant number of ward staff have no knowledge of the Act; and understanding is variable amongst staff who have heard of it. The Adults with Incapacity (Scotland) Act 2000 is a unique piece of legislation to protect the interests of incapable patients, and doctors treating them; but is of no use if medical and nursing staff are unaware of its existence.
Keywords: Consent, incapacity, Scotland
Introduction
Devolution and the new Scottish parliament provided new legislation to protect the welfare of adults with incapacity. As the first act passed, the Adults with Incapacity (Scotland) Act 2000 provides a legal framework for decision making on behalf of incapable adults.1 It simplifies financial and property issues, and gives doctors a general authority to treat patients with incapacity. It is based on the principles of beneficence, minimal intervention, and respect for the patient’s wishes pre-dating incapacity. Prior to the introduction of the Act, relatives were asked to sign a consent form if the patient was incapable and required invasive treatment. This practice never held legal credence, and the Act disposes of this practice in Scotland. However, English law is still deficient in formal provision for the incapable adult, despite the early draft mental incapacity bill. The Act has been in place for over two years at the time of the study; but the author’s subjective experience at ward level suggests there are variations in understanding and use of the Act. This study aims to quantify awareness, and practical application of the Adults with Incapacity Act in various surgical wards in Glasgow.
Methods
The selected surgical wards in a split-site teaching hospital In Glasgow were visited on randomly chosen days and times, two years and six months after the introduction of the Act. All trained junior medical and nursing personnel encountered at these times were invited to participate in an anonymous interviewer-led questionnaire. Consultants were excluded from the study due to concerns over potential legal implications if results were incorrect. No agency or locum staff were encountered, but would have been approached if encountered, on the rationale that all staff working in Scotland should be familiar with relevant legislation and practice. Responses were noted down by a single observer and coded for job title and ward base. The study was carried out prior to the first rotation of the PRHO’s to allow them to have worked in only one ward base. All participants were asked two general questions on the practice of obtaining consent in a patient deemed incompetent. All interviewees that had heard of the Act were questioned as to what they understood by the Act, their confidence in using the act, and details of any training or information provided. These questions attempted to differentiate between simple awareness and practical understanding and application of the Act. (Copies of the questionnaire are available from the author.)
Results
There were 50 individuals questioned in total. Of these, 26 were staff nurses, six charge nurses or equivalent, 12 pre-registration house officers, and seven middle graders – senior house officers of various grades and specialist registrars. No individual approached declined to complete the survey. Of these 50 individuals, 17 had not heard of the Adults with Incapacity Act in any aspect of practice. (Table 1, and dialogue box 1) Awareness of the Incapacity Act was higher amongst staff working in acute surgical and acute orthopaedic wards in comparison with elective wards. In the acute wards, 17 staff out of 20 (85%) had heard of the Act, compared with 16 out of 30 (54%) in elective wards, which is significant. (p < 0.05, chi-square) The staff who had heard of the Act (n=33) were asked to explain what they understood by it. Their answers demonstrated varied levels of understanding and some rogue concepts. (Dialogue box 2) Of particular concern were two members of staff who confused the concept of physical disability and mental incapacity. Most staff who were aware of the Act could cite several criteria for the diagnosis of incapability; such as dementia, learning difficulties, and acute confusion.
The answers regarding the sources of information about the Act were more vague, and participants were often unsure of any formal source. The majority of the participants (n=14) had heard of the Act solely through ward experience. Thirteen participants had received information whilst at university or college, two from a professional journal and only one person had received information from the Trust. The remaining individuals were unsure of the information source. (Dialogue box 3) None of the participants had undergone formal training in using the Act, but 41% (n=13) expressed confidence in using it. Unfortunately, confidence did not always correlate with accuracy of understanding. (Dialogue box 4) All participants (n=50) were asked who would sign the consent form if a patient was incompetent and required surgery. Sixty four percent of staff questioned (n=32) thought a relative could consent in this instance, despite local Trust policy2 on the contrary. A number of staff who were aware of the Act still thought a relative could consent for an incapable patient. Only three members of staff (6%) were aware of the role of the Welfare Attorney in making decisions for an adult with incapacity, and expressing the patient’s wishes from prior to their incapacity.
Discussion
This study shows that a significant number of Scottish health care professionals in this two centre trust have not heard of the Adults with Incapacity Act. Knowledge and understanding amongst those who have heard of the Act is varied, and frequently inaccurate. Acute surgical and orthopaedic wards undoubtedly see more incapable patients who require treatment, and hence should have greater exposure to the Act. The majority of staff questioned cited their knowledge came from direct experience of patients with incapacity in their care, and probably explains the greater incidence of understanding on these wards. This knowledge has been shown to be of questionable accuracy, and no a substitute for formal training. The absence of formal instruction in the use of the Act is concerning for medical and nursing staff alike. Consenting practice has altered over the last few years, with an emphasis on consent being obtained by the operator rather than junior medical staff. However, it is vitally important for all medical and nursing staff to keep up to date with changing practice; junior staff may often be called upon to “gain consent from relatives” during visiting time by misguided but well-meaning nursing staff.
All health care professionals should be aware of the Adults with Incapacity Act and its implications for care of the incapable patient. This is after all the primary piece of legislation governing the field of consent, and has been in place for over two years. Trusts must act to ensure their staff are capable of applying legislation, and may need to provide compulsory training if these figures are replicated in other localities.
Strengths and weakness of this study
Use of the single observer gave consistent presentation of the questionnaire, and consistent documentation of responses. The immediate approach prevented staff discussing answers or checking reference books. Anonymity was important as staff were concerned they might be criticised for admitting uncertainty or ignorance. Wards were visited at various times of day, and days of the week; with all staff approached to minimise selection bias. Questions were designed to differentiate simple awareness of the Act, and understanding of its principles. This was to assess real life application of the Act. The overall numbers were small and limited to one centre in Scotland. Progression to a multi-centre study would be needed to give proper assessment of knowledge and use of the Act throughout Scotland. The classification between elective and acute work loses its validity in doctors above PRHO level as they often work between both settings.
Literature review
A review of the literature shows no previous published work on the practical application of the Act. Articles discussing definition of the incapable patient are extensive, but have no specific reference to the changing law in Scotland.3 The few articles that refer to the Adults with Incapacity Act are of a speculative nature, and discuss the changes that the Act may bring.4,5 At the time of writing this is the only study aiming to quantify understanding and use of the Act since its instigation.
Conclusion
The Adults with Incapacity (Scotland) Act 2000 provides a unique piece of legislation to protect the interests of vulnerable adults and the medical staff providing their care. This legislation is of no practical value if medical and nursing staff are unaware of its existence, or of how to apply it.
REFERENCES
1 www.scotland.gov.uk/justice/incapacity
2 http://ngtweb/gppfiles/gpp gppresults.asp?Category=Consent
3 Gunn M. The meaning of incapacity. Med Law Rev 1994;2:8-29
4 Scots will protect the mentally incapacitated; excerpts from the Scottish Executive white paper. Bull Med Ethics 1999; 151:5-6.
5 Lyons D. Adults with Incapacity (Scotland) Act 2000: implications for medical practice. Health Bull(Edinb) 2001;59:146-9