Deprivation of Liberty Safeguards Assessment

Introduction

The Deprivation of Liberty Safeguards (DoLS) ensures protection of liberty to the patients who are unable to provide consent regarding their care management in care home if freedom is compromised in the care environment (Callaghan and Illsley, 2020). It allows making arrangement to assess for examining if the mentioned care is necessary and in best interest of the person (Griffith, 2017). In this assignment, the DoLS assessment is to be used for Mr X who is 80-years old and shifted to care home for permanent placement after hospital admission due to fall at the home. For this purpose, the case is to be explained and six key assessment of the DoLS is to be performed to critically discuss their consideration in shadowing the care experience for Mr X. The best interest requirement for Mr X is to be critically discussed. Moreover, the outcome of the six assessment for Mr X is to be critically presented. Thereafter, the reflection of the role and professional practise from the mentioned care is to be discussed.

DoLS Schedule

Deprivation of Liberty Safeguards (DoLS) leads the adult to have some nature of freedom in making choice or movement because they do not have the capacity for making own decision independently (Baharlo et al., 2018). The DoLS assessment schedule is to be applied to Mr. X while permanently moving him from the hospital following a fall to the care home to ensure the protection of his liberty. Mr. X who is 80 years old has medical history of advanced dementia due to which he has very limited cognitive ability in managing everyday activities, remembering facts or make enhanced communication. He is also suffering from Type-2 diabetes, arthritis and has experienced stroke. In recent condition, he experienced fall at home due to which Mr X was required to be immediately hospitalised in supporting and caring for him.

DoLS Assessment

In Deprivation of Liberty Safeguards (DoLS) assessment, six key assessment are involved which is divided between two assessors to be performed. The two assessors that are best interest assessor and mental health assessor execute the assessments to determine and decide whether the person they considered for care meets the criteria for authorisation (mind.org.uk, 2021). There are six parts for the DoLS assessment which includes age, mental health, mental capacity, best interest, eligibility and no refusal assessment (leedssafeguardingadults.org.uk, 2021). The age assessment is to determine if the person to be care is 18 years or above age. This is because people below 18 years have different nature of assessment to be implemented and involve parents in decision making (alzheimers.org.uk, 2021). As argued by Crooks et al (2021), deprivation of liberty is highly seen in patient who are elderly. This is because they often lack physical and mental capability in raising voice against their independence being deprived. Moreover, the elderly is cared and controlled by care support which leads the elderly avoid making decision (Akintade and Pierres, 2019). Thus, failure to make effective age assessment would lead patients to be inappropriately involved in DoLS assessment and led them to hindered healthcare support. In case of Mr X, his birth date is verified and assessed he is 80 years old indicating his age makes him eligible to receive support through DoLS while being moved to the care home.

The mental health assessment in DoLS is determining if the person or patient has mental disorder (ageuk.org.uk, 2021). In case of Mr X, it is already mentioned in the medical history that he has advanced dementia and is expressing symptoms of increased forgetfulness, lack of behaviour and physical health control and reduced mobility. Dementia is mental disorder in which the individual develops cognitive decline resulting the person to develop forgetfulness, communication issues, hindered thinking ability and others (Hanson et al., 2017). As argued by Roberto and Deater-Deckard (2018), patients with dementia face deprivation of liberty as they are unable to understand the nature of care been provided and when their independence is compromised. This is because cognitive decline and lack of reasoning ability make them fails to raise voice against their deprivation. In case of Mr X, the mental health assessor used DSM-V to examine and confirm the advanced stage of dementia in the individual to ensure he is eligible for DoLS assessment as he is suffering from mental disorder. This is evident as according to Mental Health Act 1983 dementia is a key mental disorder affecting people (mind.org.uk, 2021).

The study by Bennett et al. (2018) mentions that people with mental disorder have reduced capability in reasoning and evaluating information to take the right decision. This is because mentally ill individual lack analysis capability due to hindered functioning of the brain. In case of Mr X, the health capacity assessment is performed to determine to the extent the individual has mental capability in taking decision regarding care. In assessing the mental health capacity of Mr X, the mental health assessor used DoLS Form 4 which is developed in relation to the review of the Part 8 of Schedule A1 of the Mental Capacity Act 2005. The form allows making mental health capacity assessment in three stages (adass.org.uk, 2021). The stage one mentions identifying the impairment considered to disturb the functioning of the brain (scie.org.uk, 2020). In case of Mr X, his impairment of dementia is seen to hinder his brain functioning. The second stage is the functional test in which ability of the person to understand, retain and weight the information in decision making process is determined (scie.org.uk, 2020). Mr X was explained in simple verbal way regarding the information relevant in supporting his care, but he was unable to understand them in any way. He was also seen unable to retain information provided regarding need of shifting to the care home even for a long time and failed to use the data in making any constructive decision that may support his care.

In performing second stage of mental capacity assessment in DoLS, the principle 1 and 3 of the Mental Capacity Act 2005 is involved. The principle 1 of the Act mentions all the individuals are presumed to have the capacity in making decision (legislation.gov.uk, 2005). Thus, the assessor considering Mr X to have enhanced mental capacity initially provided information in simple way without making any judgement. The principle 3 of Mental Capacity Act 2005 indicates individuals are not to be judged for their unwise decision as each person has different beliefs, values and preferences (legislation.gov.uk, 2005). Thus, Mr X's unwise decisions are ignored and his capacity to weight and understand information is valued to determine mental ability in making decision. The reduced mental capacity is experienced by Mr X as he is suffering from dementia in which the imbalance in the neurotrophins and neurotransmitters in the brain that support signal transfer in healthy brain functioning to retain cognitive ability occurs. Moreover, the disorder led to neurogenesis dysfunction and creates change in brain volume (Brzezińska et al., 2020).

The eligibility assessment is to determine whether the person considered for DoLS are liable for detention under the Mental Health Act 1983 (ageuk.org.uk, 2021). The Mental Health Act 1983 mentions that hospital authorities are liable to detain an individual and provide care against the person’s wishes if they consider the person is at health risk or may cause harm to others (legislation.gov.uk, 1983). Mr X is seen to be incapable in taking own care as he lives alone and suffering from dementia along with recently suffered fall which led to his head injury which make him capable to be detained as per the Act. It also indicates that no deprivation of liberty is been executed for Mr X as it is for him own good. According to Dolatabadi et al. (2018), the elderly with dementia shows increased ability to experience fall. This is because of their reduced physical mobility and confusion created out of frailty with age and presence of the disease. Thus, Mr X is vulnerable to further fall and may cause harm to self, out of the current mental situation. The no refusal assessment is done to ensure whether the care authorised poses any conflict or contradictions for the decision made by the patient (alzheimers.org.uk, 2021). In case of Mr X, he is seen to refuse for shifting him to the care home permanently. Thus, deprivation of liberty is been experienced to be considered in this aspect as he is forcibly been tried to be transferred to care home against his wish.

Best Interests Requirement

The NMC Code of Practise mentions that any care is to be provided in best interest of the patient (NMC, 2018). This because it makes them valued and ensures their enhanced health and well-being. The best interest requirement assessment in regard to DoLS for Mr X is to be made by comparing the assessed components to the elements mentioned in the Strock v Germany (2005) case for deprivation of liberty in patients. According to the Strock v Germany (2005), the components of liberty deprivation for patients in hospital are confinement in a restricted place for non-negligible amount of time, lack of valid consent and attribution of responsibility to the state (mentalhealthlaw.co.uk, 2005). In case of Mr X, it is seen that he is considered to be permanently replaced to the care home instead of own home after the hospital release. The tenure considered for stay at the care home for Mr X is non-negligible as it is considered permanent and may be an act of violation of his liberty. This is because he can no longer return home and spend time in the familiar environment he used to live.

The lack of valid consent from patient leads to violation of liberty as the care provided is considered to be forcefully provided (Robillard and Feng, 2017). As argued by Featherstone et al. (2019), forceful care without consent leads to makes people feel undervalued and develop low self-esteem. This is because the forceful care makes the patients feel deprived of their preferences which support valued feeling and they feel lack of power to control their life which is their basic human right. In case of Mr X, it is seen that no valid consent regarding his permanent movement to the care home is been received from him. He is considered not ever been provided any guardianship who can take decision on behalf of him. The guardianship to take decision on behalf of patient with dementia is important as the patient personally cannot make legible decision out of cognitive decline, but the guardian by understand the person’s preference can make enhanced decision on their behalf to ensure their care in best interest (Mills, 2017). Thus, the second component of Storck v Germany is also seen to be faced in best interest requirement assessment of Mr X.

The third component that is the attribution of responsibility of the state which indicates that any care decision made are required to be made as per the legal obligation mentioned by the state (, 2020). In regard to taking decision regarding moving to care home by the dementia patient, the NHS mentions it is responsibility of the carer to ask the person about the preference even though the person is unable to provide any decision (NHS, 2021). In case of Mr X, it is already mentioned that his consent for moving to the care home in permanent manner is not taken. This is violation of the policy made by the NHS for Mr X which indicates that liberty deprivation may been caused to the patient. The Acid Test in relation to DoLS states that a person is considered to be deprived of liberty if they are been subjected to continuous supervision and are not allowed freedom to leave on their own (gwentsafeguarding.org.uk, 2015). This is because such action indicates the person is always under control by another individuals. As argued by He et al. (2019), patients being controlled entirely by the carer feel their preference and demands are been violated that makes them received unsatisfied care. This is because the carer controlling the support for the patient provide assistance as per the carer's judgement and not the preferences of the patient, in turn, making the individual unsatisfied with the care. In case of Mr X, the acid test is met as he was entirely supervised without freedom to leave after being admitted to the hospital which informs that his liberty may be deprived.

The decision for care if taken to prevent harm for the patient in regard to DoLS is considered is made in the best interest (mind.org.uk, 2021). In case of Mr X, no personal harm is been identified that may be caused by him. However, his report of fall for which he is admitted to the hospital makes him vulnerable to further fall which may be harmful for his health. This is because repeated fall leads elderly to develop fracture and injury that compromises their mobilisation ability (Green et al., 2019). According to principle 5 of Mental Capacity Act 2005, less restrictive option of care that could interfere less with violation of rights of the patient is to be chosen at first (legislation.gov.uk, 2005). In case of Mr X, the less restrictive option present were arrangement of social support at home and fall proof environment installation at home compared to being permanently moved in the care home. This is because receiving social care at home makes the dementia patient retain freedom and remain in the familiar environment with enhanced protection for their health and well-being (Mondor et al., 2017). However, movement to the care home leads the dementia patients to be placed in unfamiliar environment where they may react inappropriately out of fear of being vulnerable and confusion in the new situation (Surr et al., 2020). Thus, the decision made for Mr X is not in his best interest as less restrictive care are available which are not considered for him.

Outcome of six assessment

The Deprivation of Liberty Safeguards (DoLS) is applicable on patients who are in hospital or care home. The care home or the hospital is known as the managing authority in DoLS where they are required to access permission from supervisory body to be able to deprive an individual of their liberty (scie.org.uk, 2020). The supervisory body is the local authority in which the patient lives as a resident (scie.org.uk, 2020). As argued by Ward et al. (2018), local authorities play the role of evaluating the need for detention in the care of a mentally ill person from their locality instead of the management authorities at the hospital. This is because they are authorised personals who have detailed information for people living in their locality and inform if they are required to detained in care. The managing authority of the care home or hospital is required to fulfil a DoLS form and sent it to the supervisory body to decide within 21 days if the person is required to be deprived of their liberty (scie.org.uk, 2020). Thus, the DoLS assessment form for Mr X is to be fulfilled by the hospital authority and send to the supervisory body where the person is resident to determine if his liberty is to be deprived by shifting him permanently to a care home.

The DoLS cannot be implemented in case the patients in the hospital and fulfil the detention criteria mentioned under the Mental health Act 1983 (scie.org.uk, 2020). In case of Mr X, it is seen that the person fulfils criteria for detention as per the Act as the individual is suffering from advanced and worsened dementia. However, the presence of less restrictive option for patient management makes DoLS avoided to be implemented (scie.org.uk, 2020). This is at par with the principle 5 of Mental Capacity Act 2005 which mentions less restrictive options for care are to be considered in a way so that it ensures lesser interference with their rights and freedom to act (legislation.gov.uk, 2005). In case of Mr X, the less restrictive option of care is social support at home for the current condition.

In the case of AJ vs Local Authority (2015), it was mentioned that relevant Person’s representative (RPR) is required to be present to support in making decision on behalf of the patient’s benefit who are unable to make their own decision due to hindered mental health condition (mentalhealthlaw.co.uk, 2015). The person able to be RPR is an immediate family member or friend who acts as representative for protecting the rights and liberty of the person (alzheimers.org.uk, 2018). However, if no family member or friend are present, paid RPR is been appointed who need to have qualifications such as 18 years and over age, able to remain in continuous contact with the patient and willingness to be appointed as representative (scie.org.uk, 2020). This indicates that a friend of Mr X as RPR willing to volunteered is to be appointed in taking decision regarding his care. In case of Mr X, the Court of Protection may be required. This is because Court of Protection is applied when welfare of the person with disabled mental state is compromised by others or to restrict visit of any particular person (scie.org.uk, 2020). In case of Mr X, it is seen that the hospital authorities without accessing consent from him is trying to shift him to a care home which is approved by them only for which the expenses are to be gathered by selling his property. Thus, to protect Mr X’s property, the Court of Protection is to be immediately applied as the action tried to be performed is not consented by the patient.

Reflection on the role of nursing in the DoLS assessment

The wider knolwdege gained through the DoLS assessment has led me create better safeguarding of rights of the patients who are mentally ill and unable to make own decision. This is because the DoLS assessment led me to learn regarding the different aspects of a mentally ill patient is to be focussed to identify way their liberty or freedom is been compromised which are to be protected. Moreover, the DoLS assessment helped me learn the importance of RPR in case of mentally ill people. It assisted in supporting better safeguarding of the patients because it led me to understand way appropriate decision for care regarding mentally-ill patients is to be received where their preferences and needs are met. The assessment informed regarding different legalisation and policies present in safeguarding improvement of mentally ill people. It helps in better protection of the mentally ill patient as legally approved actions could be taken for better health management of the people. This assessment helped me to improve my role of acting in best interest of the patient which is one of my responsibility as a nurse as per the NMC Code of conduct. This is because it educated me regarding the way best interest in care are to be assessed to ensure its successful implementation.

Conclusion

The above discussion informs that Mr X has advanced dementia due to which he is facing hindrance in making own care decision and has recently experienced fall for which on hospitalisation the authorises decided to transfer him permanently to a care home. The DoLS assessment in aspect of age, mental health, mental capacity and eligibility indicate Mr X’s health approves of his liberty to be deprived but analysis on aspect of best interest and no refusal indicate the act to be avoided. The Mental Health Act 1983 and Mental Capacity Act 2005 are referred to determine the reason behind the deprivation of liberty for Mr X is to be avoided. Moreover, case law example of AJ vs Local authority and Strock v Germany informs that Mr X’s deprivation are to be avoided as it is executing against his consent without approval of RPR.

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