Mental capacity assessment: a descriptive, cross-sectional study of what doctors think, know and do

BACKGROUND: The Mental Capacity Act (MCA) (2005) was enacted in 2007 in England and Wales, but the assessment of mental capacity still remains an area of professional concern. Doctors' compliance with legal and professional standards is inconsistent, but the reasons for poor compliance are not well understood. This preliminary study investigates doctors' experiences of and attitudes toward mental capacity assessment (MCAx). METHODS: This is a descriptive, cross-sectional study where a two-domain, study-specific structured questionnaire was developed, piloted and digitally disseminated to doctors at differing career stages employed in a large, multi-site National Health Service Trust in London over 4 months in 2018. Descriptive statistics and frequency tables adjusted for missing data were generated and secondary analysis was conducted. RESULTS: Participants (n=92) were predominantly UK trained (82%), female (58%) and between the ages of 30 and 44 years (45%). Less than half (45%) of the participants reported receiving formal MCAx training. Only one-third (32%) of the participants self-rated themselves as very competent (29%) or extremely competent (4%). Self-reported MCA confidence was significantly affected by career stage with Consultants with over 10 years of experience reporting lowest confidence (p=0.001). CONCLUSIONS: This study describes significant variation in practice by doctors and low self-confidence in the practice of MCAx. These results raise concerns that MCAx continues to be inconsistently performed by doctors despite appropriate awareness of the law and professional guidance on best practice

Adjusting the frequency of mammography screening on the basis of genetic risk: Attitudes among women in the UK.

Purpose To explore public attitudes towards modifying frequency of mammography screening based on genetic risk. Methods Home-based interviews were carried out with a population-based sample of 942 women aged 18–74 years in the UK. Demographic characteristics and perceived breast cancer (BC) risk were examined as predictors of support for risk-stratified BC screening and of the acceptability of raised or lowered screening frequency based on genetic risk, using multivariate logistic regression. Results Over two-thirds of respondents (65.8%) supported the idea of varying screening frequency on the basis of genetic risk. The majority (85.4%) were willing to have more frequent breast screening if they were found to be at higher risk, but fewer (58.8%) were willing to have less frequent screening if at lower risk (t (956) = 15.6, p < 0.001). Ethnic minority status was associated with less acceptability of more frequent screening (OR = 0.40, 95% CI = 0.21–0.74), but there were no other significant demographic correlates. Higher perceived risk of BC was associated with greater acceptability of more frequent screening (OR = 1.71, 95%CI = 1.27–2.30). Conclusion Women were positive about adjusting the frequency of mammography screening in line with personal genetic risk, but it will be important to develop effective communication materials to minimise resistance to reducing screening frequency for those at lower genetic risk

Consent in pregnancy - an observational study of ante-natal care in the context of Montgomery: all about risk?

Background How to best support pregnant women in making truly autonomous decisions which accord with current consent law is poorly understood and problematic for them and their healthcare professionals. This observational study examined a range of ante-natal consultations where consent for an intervention took place to determine key themes during the encounter. Methods Qualitative research in a large urban teaching hospital in London. Sixteen consultations between pregnant women and their healthcare professionals (nine obstetricians and three midwives) where ante-natal interventions were discussed and consent was documented were directly observed. Data were collectively analysed to identify key themes characterising the consent process. Results Four themes were identified: 1) Clinical framing - by framing the consultation in terms of the clinical decision to be made HCPs miss the opportunity to assess what really matters to a pregnant woman. For many women the opportunity to feel that their previous experiences had been ‘heard’ was an important but sometimes neglected prelude to the ensuing consultation; 2) Clinical risk dominated narrative - all consultations were dominated by information related to risk; discussion of reasonable alternatives was not always observed and women’s understanding of information was seldom verified making compliance with current law questionable; 3) Parallel narrative - woman-centred experience – for pregnant women social factors such as the place of birth and partner influences were as or more important than considerations of clinical risk yet were often missed by HCPs; 4) Cross cutting narrative - genuine dialogue - we observed variably effective interaction between the clinical (2) and patient (3) narratives influenced by trust and empathy and explicit empowering language by HCPs. Conclusion We found that ante-natal consultations that include consent for interventions are dominated by clinical framing and risk, and explore the woman-centred narrative less well. Current UK law requires consent consultations to include explicit effort to gauge a woman’s preferences and values, yet consultations seem to fail to achieve such understanding. At the very least, consultations may be improved by the addition of opening questions along the lines of ‘what matters to you most?

The narrative paradox of the BRCA gene: An ethnographic study in the clinical encounters of ovarian cancer patients

In this era of personalisation a patient’s molecular profile plays an increasingly central role in development and delivery of personalised medicine. This paper sets out to explore the sociocultural implications of mainstreaming BRCA genetic testing in the treatment of advanced ovarian cancer patients, who carry a BRCA1 or BRCA2 gene mutation. It draws on ethnographic research conducted by between April-June 2016 in a large tertiary London hospital. Participant observation was conducted across two sites. For the first two weeks participant observation was conducted in the traditional genetic testing setting in two separate clinics. From thereon, participant observation was conducted in the clinical encounters of treating patients in the ovarian cancer clinic. In addition, face-to-face interviews were conducted with medical oncologists who worked in the clinic. Contributing to the fields of cancer genetics, personalised medicine and medical material culture studies in medical anthropology the paper seeks to further discussions about the interactions and relationships unfolding between medical objects and subjects across the landscape of cancer care. It highlights the importance of clinic-based ethnography to examine the complexities of identities and technologies as they intersect with the themes of suffering and hope in new and contradictory ways for BRCA-positive patients with late-stage disease. The paper argues that a BRCA mutation is not only central to the political economy of hope but takes on a more materialist nature as it becomes an embodied practice that moves in and beyond the clinic

Tackling the psychological impact of ovarian cancer

Ovarian cancer is the sixth most common cancer in women in the UK and the most lethal of gynaecological cancers. The only proven method of prevention is removal of the ovaries and fallopian tubes before cancer develops. This strategy is not recommended for the general population, but is available for women who are known to be at increased risk because of a genetic predisposition. Ovarian cancer screening with the aim of reducing mortality through early detection is not available on the NHS, due to the lack of a convincing evidence base. The generic term ‘ovarian cancer’ encompasses a group of cancers that includes the ovaries, along with primary cancers of the fallopian tube and peritoneum. It is not a single disease entity but different diseases with different risk factors, precursor lesions, patterns of spread, response to chemotherapy and prognosis. Most patients (80%) present with aggressive high-grade serous carcinoma at an advanced stage and overall five-year survival is less than 35%. This poor outcome reflects the high risk of recurrence after initial treatment. The psychological impact of this disease can be profound

Inviting end-of-life talk in initial CALM therapy sessions: A conversation analytic study

OBJECTIVE: To examine how end-of-life talk is initiated in CALM therapy sessions with advanced cancer patients. METHODS: Conversation analysis was used to systematically examine the sequences where talk about death was raised in the first sessions of ten patients. RESULTS: Open questions about the patients' experiences, feelings or understanding in the context of talk about their troubles, were found to regularly elicit talk concerning end-of-life. These questions were designed in ways that invite patients to discuss troubling aspects of their cancer journey, without making discussion of this topic an interactional requirement. That is, the interactional work required to not engage in such talk is minimised. This choice is provided through the open question design, the degree to which negative feeling descriptors are specified, and the sequential context of the question. CONCLUSION: The analysis shows that therapists provide patients with the opportunity to talk about end-of-life in a way that is supportive of the therapeutic relationship. The readiness of patients to engage in end-of-life talk displays the salience of this topic, as well as the reflective space provided by CALM therapy. PRACTICE IMPLICATIONS: The results provide important insight into the process of CALM therapy, which can be used to guide training

Recruitment, adherence, and retention of endometrial cancer survivors in a behavioural lifestyle programme: the Diet and Exercise in Uterine Cancer Survivors (DEUS) parallel randomised pilot trial

Objective: Healthy eating and physical activity may help endometrial cancer survivors (ECS) improve their quality of life. However, most ECS do not meet the relevant guidelines. This pilot trial aimed to test the study feasibility procedures for a definitive trial of a behavioural lifestyle programme. Design and setting: This 24-week parallel two-arm randomised pilot trial took place in two hospitals in London, UK (April 2015–June 2016). Participants: Sixty disease-free ECS within 3 years of diagnosis. Interventions: Participants were randomised using minimisation to receive the intervention or care as usual. The ‘Shape-Up following cancer treatment’ programme used self-monitoring, goal-setting, self-incentives, problem-solving and group social support for 12 hours over 8 weeks to help survivors improve their eating and physical activity. Outcome measures: The main outcome measures were recruitment, adherence, and retention rates. Further outcomes included barriers to participation and feedback on programme satisfaction. Results: Of the 296 potentially eligible ECS, 20% (n=60) were randomly allocated to the active intervention (n=29) or control group (n=31). Three participants in each arm were deemed ineligible after randomisation and excluded from analysis. Twenty participants (77%; 95% CI 61% to 93%) adhered to the intervention and provided generally favourable feedback. At 24 weeks, 25/26 (96%; 95% CI 89% to 100%) intervention and 24/28 (86%; 95% CI 73% to 99%) control participants completed their assessment. No intervention-related adverse events were reported. Among eligible survivors who declined study participation (n=83), inconvenience (78%; 95% CI 69% to 87%) was the most common barrier. Conclusions: The trial was feasible to deliver based on the a priori feasibility criteria. Enhancing recruitment and adherence in a definitive trial will require designs that promote convenience and consider ECS-reported barriers. Trial registration number: NCT02433080; Pre-results. Trial funding: University College London, St. Bartholomew’s Hospital Nurses League, and NIHR University College London Hospitals Biomedical Research Centre

All change: job rotations as a workplace learning tool in the Flinders University Library Graduate Trainee Program

This paper examines the place of job rotations as a workplace learning tool in the Graduate Trainee Librarian Program at Flinders University Library, Australia. Specifically, it asks two questions: whether job rotation is an effective workplace learning tool for new librarians; and, whether the trainee experience contributed to the retention in the Library and career progression of those in the program. These questions are examined using Kirkpatrick's Evaluation Framework. The findings indicate that while participants rate the trainee program very positively overall, their satisfaction with workplace learning in their placements was lower. The majority of former trainees have remained with the Library and have progressed in their careers