Advance Decisions, Mental Health, and Surgical Practice: A Practical Overview
Surgeons frequently encounter complex scenarios where patients’ capacity and wishes must be carefully navigated. Advance Decisions and Advance Statements are important tools that help ensure a patient’s preferences are respected, especially if they later become unable to decide for themselves. Understanding how these apply when mental health conditions are involved is crucial for delivering patient centred, lawful, and ethical care.
Mental Capacity and Its Impact on Treatment Decisions
- Capacity refers to a patient’s ability to understand, retain, and use information to make a particular decision.
- Crucially, capacity can fluctuate; a patient may have capacity one day and not the next.
- Surgeons must assume a patient has capacity unless there is evidence to the contrary.
- A history of mental illness, or even previous detention under the Mental Health Act (MHA), does not automatically negate capacity.
Advance Decisions: Key Principles for Surgeons
An Advance Decision (also known as an Advance Decision to Refuse Treatment) allows an adult with capacity to refuse specific treatments in the future.
If valid and applicable, it is legally binding. This can help guide a surgeon’s decision-making when the patient cannot communicate.
However, if a patient is sectioned under the MHA, an Advance Decision refusing treatment for their mental illness does not have to be followed. The exception is a refusal of electroconvulsive therapy (ECT), which must be respected unless there’s an emergency. Conversely, if the Advance Decision pertains to a separate physical condition unrelated to their mental illness, it remains binding, even if the patient is detained under the MHA.
Interaction with the Mental Health Act (MHA) and Mental Capacity Act (MCA)
The MHA permits treatment of a detained patient’s mental illness without consent. However, the MCA provides a framework for making best-interest decisions when a patient lacks capacity for treatments unrelated to their mental illness. Surgeons must be aware of both, as they may operate on patients who have Advance Decisions in place. Confirming validity (patient over 18, with capacity when made, and no subsequent actions negating it) and applicability (treatment and circumstances match those described in the Advance Decision) is vital. If valid and applicable, the Advance Decision must be followed.
Advance Statements: Adding Context to Patient Preferences
While Advance Decisions refuse treatments, Advance Statements allow patients to express preferences, values, or requests about their care. These are not legally binding but provide invaluable insight into a patient’s wishes. For a surgeon, an Advance Statement can guide patient-centered care—such as preferred supportive measures, communication styles, or comfort measures—if the patient later loses capacity.
Why Surgeons Should Understand This
Surgical practice often intersects with psychiatric considerations, especially when treating patients with fluctuating mental health status. Knowing how to navigate Advance Decisions can prevent conflicts, legal challenges, and ethical dilemmas. If you encounter uncertainty—such as doubts about capacity when the Advance Decision was made or whether the scenario truly fits the document’s stipulations—seek advice from legal teams, mental health professionals, or ethics committees. Ensure documentation is robust, and where possible, involve the patient’s GP or mental health team to confirm capacity assessments at the time the Advance Decision was created.
In short, Advance Decisions and Statements empower patients to shape their future care. By understanding these tools, surgeons can better honour patient autonomy, maintain compliance with the law, and uphold the highest ethical standards.