Difficult Capacity Cases—The Experience of Liaison Psychiatrists. An Interview Study Across Three Jurisdictions

The most recent publication from the Mental Health and Justice project is an article published in Frontiers in Psychiatry on 11 July 2022 led on by Dr Nuala Kane, digging into ‘difficult’ capacity cases.  Called Difficult Capacity Cases—The Experience of Liaison Psychiatrists. An Interview Study Across Three Jurisdictions, we[1] explain the motivation for the article in the introduction:

Assessment of capacity for treatment and discharge decisions is common in the general hospital. Liaison psychiatrists are often asked to support the treating medical or surgical team in difficult capacity assessments. However, empirical research on identification and resolution of difficult capacity cases is limited. Some studies have identified certain patient, decisional, and interpersonal factors which cause difficulty, but no study has explored how these issues are resolved in practice. Our study therefore aimed to describe how experienced liaison psychiatrists identify and resolve difficult capacity cases in a general hospital setting.   

Methods: We carried out semi-structured interviews with 26 liaison psychiatrists from England, Scotland, and New Zealand, on their most difficult capacity cases. Thematic analysis was used to examine types of difficulty and how these were resolved in practice. Summaries were prepared and example quotes extracted to illustrate phenomena described.

Results: We identified four types of difficulty in capacity assessment, spanning both clinical and ethical domains: 1) Difficulty determining whether the decision is the patient’s own or driven by illness, 2) Difficulty in applying ethical principles, 3) Difficulty in avoiding personal bias, and 4) Procedural difficulties. The liaison psychiatrists presented as self-reflective and aware of challenges and pitfalls in hard cases. We summarized their creative strategies to resolve difficulty in assessment.

The paper stands alongside the other outputs from the ‘contested capacity’ workstream of Mental Health & Justice, including:

And last, but very much not least, the website established by the team to seek to provide practical, research-based guidance for clinicians and social care professionals on the assessment of capacity.

[1] I say ‘we’ because, whilst Nuala led on the interviews and on drafting the paper, other members of the ‘contested capacity’ workstream contributed to the article, namely Drs Gareth Owen and Scott Kim, and I.

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