Abstract
CLINICAL CASE: This case is based on a multidisciplinary team (MDT) discussion about a 77-year-old lady with a background history of hypothyroidism and type-1 diabetes. This patient had a one year history of gradual memory loss, and rapid decline in the previous three weeks leading to hallucinations and forgetting meals and medications. A mental capacity assessment indicated lack of capacity, and the patient’s children had been appointed to be Lasting Power of Attorneys (LPAs). They wanted to arrange residential care for the patient against her will. The GPs referred the patient to Older Adult Mental Health (OAMH) Services for a formal dementia assessment and diagnosis. Diagnostic Evaluation and Mental Health Assessment Blood tests were done at the GP practice as requested by the OAMH team. The only significant abnormal finding was elevated TSH at 57.3 mU/L (normal range 0.4 - 5). Part 1 of the MHA specifies the application of the act to patients with, “any disorders or disability of the mind”. The Community psychiatry nurse deemed that until TSH levels were back to normal the patient’s cognitive changes could not be deemed a mental health issue but instead physically treatable delirium secondary to hypothyroidism and levothyroxine non-compliance. The patient’s care was trapped in a self-reinforcing harmful cycle: forgetfulness contributed to her missing levothyroxine doses and a high TSH measurement, however she could not receive assessment and management for her memory issues due to the high TSH. CONCLUSION: The rejected OAMH referral led to a shift in focus towards the MCA. The patient had undergone a formal capacity assessment based on criteria outlined in Section 3 of the act. Her memory loss rendered her unable to retain information and weigh it up to make decisions, resulting in her being deemed incapable of making long term decisions about her own care. The patient's children, as LPAs wanted the patient to be admitted to full time residential care due to worries about deterioration of health. As outlined by Cheshire West and Chester Council v P [2014] UKSC 19, the case would meet the “acid-test” for DoLS, with the patient being both 1) under continuous supervision and 2) unable to leave The DoLS code of practice outlines six assessments for authorisation for a deprivation of liberty, the only one of which impending being the mental health assessment, declined due to TSH tests. The MDT members took a pre-emptive approach by again coordinating with the mental health team to repeat assessment, on the condition of a decrease in the patient’s TSH levels with help of care from district nurse home visits. This case outlined the interplay of endocrinology, mental health and mental capacity, highlighting importance of pre-planning, a holistic approach and multidisciplinary coordination to maximise quality of care and safe-practice.