BrainInjuryFrontalLobeDamage

andMentalCapacity

DrNeilBrooksRehabWithoutWalls

PresentaAontoABILmeeAnginLondonon19.3.19

Structure

•  MHA(1983)

•  The“frontal”paAent•  BacktobasicsreMCA(2005)(assumpAonofcapacity,

minimallyrestricAve,righttomakefoolishdecisionsetc.)

•  Caselaw(LoughlinvSingh,2013;EXBvFDZ,2018)–  Effectsoffrontalbraindamage

–  Capacitouswithsupport(ornot)–  Judge’suseoflayevidence

•  Somecases

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MHA(1983)

•  Beinga“PaAent”•  DiscussedextensivelyinMasterman-ListervBru\on&Co

(1989)

•  A"paAent",withinthemeaningofsecAon94(2)oftheMentalHealthAct1983,isapersonwho"isincapablebyreasonofmentaldisorderofmanagingandadministeringhispropertyandaffairs."

•  Itwasallornone

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The“frontal”paAent

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FrontalLobeDamage

Changesin:–  MoAvaAon–  EmoAon–  Behaviour–  CogniAon

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FrontalLobeSyndrome1

CogniAveimpairments:

•  Planning•  Problem-solving•  IniAaAve•  Strategyshicing•  Judgement•  Abstractreasoning•  A\enAon•  IQandmostmemoryfuncAonsUSUALLYPRESERVED

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FrontalLobeSyndrome2

MoAvaAonalandBehaviouralChanges

•  Apathy,IniAaAve,MoAvaAon•  (Usedtobecalled“pseudo-depression”)•  DisinhibiAon•  ImpulsiveBehaviour •  EmoAonallability•  Euphoria•  IrritabilityandAggression•  Indifference•  Lackofinsight March25,19 DrNeilBrooks,RehabWithoutWalls 10

FrontalLobeSyndrome3

PersonalityChanges

•  Selfcentred•  Unfeeling•  Inabilitytoseeandunderstandtheneedsofotherpeople•  SociallybluntandinsensiAve•  (Usedtobecalled“pseudo-psychopathic”)

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FrontalLobeParadox

•  ExecuAvefuncAonpreservedintheoffice,butimpairedinreallife

•  Theneuropsychexamisconductedatameasuredpace,withfewexternaldistracAons

•  Ocen,intellectisunimpaired,butisnotusedflexiblyandadapAvely

•  Theabilitytosay,butnottodo•  Forexample,seeLoughlinvSingh;EXBvFDZ

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Impactofthesechangesondailylife

•  Socialandfamily

•  Work•  MentalCapacity

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GeneralPrinciples-s.1MCA2005

Apersonmustbeassumedtohavecapacityunlessitisestablishedthathelackscapacity.

ApersonisnottobetreatedasunabletomakeadecisionunlessallpracAcablestepstohelphimtodosohavebeentakenwithoutsuccess.

Apersonisnottobetreatedasunabletomakeadecisionmerelybecausehemakesanunwisedecision.

Anactdone,ordecisionmade,underthisActfororonbehalfofapersonwholackscapacitymustbedone,ormade,inhisbestinterests.

Beforetheactisdone,ordecisionismade,regardmustbehadtowhetherthepurposeforwhichitisneededcanbeaseffecAvelyachievedinawaythatislessrestricAveoftheperson’srightsandfreedomofacAon.

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LackofCapacityFuncAonalandDiagnosAcTest

•  S.2(1)ApersonlackscapacityinrelaAontoama\erifatthematerialAmeheisunabletomakeadecisionforhimselfinrelaAontothema\erbecauseofanimpairmentof,ordisturbanceinthefuncAoningofthemindorbrain

–  Func:onal:unabletomakeadecisionforhimself…

–  Diagnos:c:becauseofanimpairment…–  Test:

•  Isthereanimpairmentordisturbance?Ifso;•  Isthepersonunabletomakeadecision?Ifso;

•  IsthisinabilitybecauseoftheidenAfiedimpairmentordisturbance(the“causaAvenexus”)

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FuncAonalTestWhatismeantby“lackofcapacity”?

•  S.3(1)ofMCA92005)statesthatPisunabletomakeadecisionforhimselfifatthematerialAme;

•  heisunable:–  Tounderstandissue-relevantinformaAon;or

–  ToretainthatinformaAon;or–  TouseorweighthatinformaAonaspartoftheprocessofmakingthedecision;or

–  Tocommunicatethedecision(whetherbytalking,usingsignlanguage,oranyothermeans)

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7

02 0

58

1

Fig. 2. Distribution of functional inabilities cited by judge for P’s lack of capacity

Inability to understand

Inability to retain

Inability to use or weigh

Inability to communicate n=0

Ruck Keene et al. Int J of Law & Psychiatry, 2019

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Caselaw

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LoughlinvSingh2013

•  SevereTBIinRTAatage12•  Damagetothelecfrontallobeofthebrain•  MoAvaAon,iniAaAonandorganisaAongreatlyreduced

•  IQwellpreservedbutoutsideastructuredsernghestrugglestouAlisehisintelligence

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LoughlinvSingh2013

•  “…dysexecuAvesyndromemanifestbypoororganisaAonandplanninganddifficultysustaininga\enAon…

•  …impulsivity,disinhibiAon,poorjudgmentandlackofmoAvaAon…

•  …parAculardifficultyinweighinguptheconsequencesofhisdecision…appearstooperateverymuchinthepresent…doesn’tseemabletoanAcipatetheconsequencesofhisacAons…”

DrKieranO’Driscoll,ConsultantNeuropsychiatrist

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•  TheMCAcriteriaarecogniAve-understand,retain,use/weigh

•  EmoAonplaysahugepartindecisionmaking.•  KristopherLoughlinhadanimpairedemoAonalunderstanding

oftheworld

•  Hecan’tunderstandhowpeoplefuncAon•  Hecan’treadsocialcues•  “Kristopher–andagainit’sthenatureoftheinjurythathe

hastoknowwhenadviceisappropriate…myconcernisthathemaynotknow…becauseheneedstheinsighttoknowthat…doesn’tappeartoknowwhenheneedstoknow…”

DrKieranO’Driscoll,ConsultantNeuropsychiatrist

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“…he’sverymuchdisadvantagedintermsofhisdecision-makingprocessesastowhattheshort,mediumor,certainly,longtermconsequencesofhisdecisionwouldbe.Theotherproblemis–anditgoesbacktotheemoAonalaspect–thewaytheMentalCapacityActisconstructedgivestheimpressionthatthecogniAveorintellectualsideofthingsisthemostimportant,intermsoflanguage,memoryandraAonalisingyourdecision.But,infact,emoAonplaysaverypowerfulpartinourdecision-making.AndmyimpressionisthatMrLoughlin’semoAonalunderstandingoftheworldandpeoplehasbeenimpaired…”DrKO’Driscoll,ConsultantNeuropsychiatrist

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•  “…theconsulAngroom…isanarAficialenvironment…ifyouaskanindividualhowtheywouldbehave,forexample,weretheytoreceivemoneyandtheytellyoutheywouldinvestitinahouse,youhavetotakethatintocontextoftherestofthebehavioursintherealworld…

•  …verywellrecognisedthatfolkwithfrontallobebraininjurieswillsayonethinganddoanother…withallthebestintenAons,hemayhavewishedtodosomething,but…couldeasilydotheopposite…”

DrKieranO’Driscoll,ConsultantNeuropsychiatrist

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•  Theexpertsweredividedoncapacity•  Claimant’sexpertssaidnotcapacitousevenwithsupport•  Defendant’sexpertssaidcapacitouswithsupport

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•  Thejudgereliedinpartuponlayevidence,parAcularlyaboutdecisionmakingindailylife,withandwithoutsupport

•  Thejudgequotedextensivelyfromevidencefromfamilymembers(motherandsister)andcareprofessionals(supportworkerandcasemanager)–  “However,Ihavetobearinmindthatthoseworkingincloseand

frequentcontactwiththeClaimantarelikelytohavea“feel”forhiscapacitytomanagehisaffairs…Therefore,Iconclude,notwithstandingthelegalpresumpPoninfavourofcapacity,thattheClaimantdoesnothavecapacitywithintherelevantlegaldefiniPon.”

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EXBvFDZ(2018)

•  SevereTBIaged26•  “PermanentdifficulAesinexecuAvefuncAoningandin

aspectsofhisbehaviour”

•  Lackedcapacitytomanagepropertyandaffairs

•  AnissueofwhetherEXBshouldbetoldthesizeofhiscompensaAonaward

•  Thejudgeconcluded,“TheClaimantlackscapacitytodecidewhetherornotheshouldknowtheamountoftheSe\lement”

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EXBvFDZ(2018)

•  “…basicappreciaAonthatsomeofhiscompensaAonisintendedtopayforhissupportandfutureneeds…

•  …whencalm…withintheconfinesofanoffice…andwithsupport,inthatmomenthewouldrecognisepointssuchasthenecessityofanawardlasAngalifeAme…

•  …evenifhecouldbesupportedtounderstandsuchconceptsinthecontextofaquietoffice,hesAllwouldnotapplysuchconceptstohiseverydaythinkinganddecisionmaking…”

DrGemmaWall,TreaAngNeuropsychologist

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SomeCases

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DMVeryseverephysicalandcogniAveimpairment

Veryli\leinsight

AskedtoassessCapacity:

–  ToliAgate– Makedecisionsregardingwhatcareandsupportarrangements,includingrelevantcarepackagesherequires

– Makeadecisionwhereheresides– Makedecisionsastocontactwithothers

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CapacitytoliAgate

•  IdonotknowhowcomplexanyliAgaAonmightbe…

•  Nevertheless,giventhenatureandseverityofDM’scogniAveimpairments,coupledwithanextremelackofinsight,IhavetoadvisethecourtthathelackscapacitytoliAgate,evenrathersimpleliAgaAoninvolvingfewandsimpledecisions,andevenwithsupportandadvice

•  Ithinkthattheamountofsupportandadvicewouldbesuchthat…decisionswouldbemadeforhim…

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Capacitytomakedecisionsregardingcare…

•  DM’scogniAveimpairmentsaresosevere,sopervasive,andwithsuchsignificantdaytodayconsequences,thatIadvisethecourtthatDMlackbothaspectsofcapacity(careandresidence)

•  Hecangivesuperficiallyappropriateanswers,butthesearesimple,simplisAc,concreteandoffthepoint…unabletounderstand,retain,anduseorweighinformaAonaboutcare,support,andresidence

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JH

Capacity:

–  Tomarry–  ToconsenttosexualrelaAonships–  ToliAgateproceedingsinrelaAontocapacity

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JH

•  Alonghistoryofalcoholabuse,withalcoholicliverdisease•  SeveretraumaAcbraininjuryasaresultoffallingoutofbed

whileinalcoholicdetox

•  VeryseverecogniAveimpairmentincludingaphasia,andimpairedunderstanding,memory,andproblemsolving

•  CurrentlylivinginaLAcarehome•  WishestomarryheronandoffalcoholicpartnerPD,who

hasphysicallyabusedherinthepast,abusedstaffinthecarehome,andbroughtalcoholintothecarehome

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JH

•  ObviouslylackedcapacitytoliAgate•  Hascapacitytomarry(just!)inthecurrentcarehomewhere

decisionmakingissupported,sheiswelllookedacer,andsober,andhasnocontactwithPD

•  “…onbalance,JHcurrentlyjustpassesthethresholdforcapacitytomarry…hassomeappreciaAonofthefactthatmarriageisacontractandthatthereare…somemutualreciprocalobligaAonsa\achedtomarriage”

•  “…wereJHtoresidewithPDthenthe…supportwouldalmostcertainlynotonlynotbeavailable,butshewouldbeexposedtoundueinfluencefromPD,shewouldconsumelargeamountsofalcohol,and…mentalcapacityinmanyaspectsoflifewoulddiminish,including…capacitytoconsenttomarriage”

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JH

•  “…So,onbalance,JHcurrentlyhascapacitytomarry,butwereshetolivewiththepersonshewantstomarry(PD),manyaspectsofmentalcapacity,includingthecapacitytomarrywould,inmyopinion,almostcertainlydisappear,andtherewouldbemajorconcernsaboutJH’sconAnuingwellbeing…”

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Conclusions

•  ExecuAvedysfuncAoncanhaveamajordestabilisingimpactondailylife–includingdecisionmaking,andaspectsofmentalcapacity

•  IwelcomedtheMCA(2005)buthavetoconstantlyremindmyselftogobacktothebasicsoftheActandCodeofPracAce

•  And,nottoconflatecapacity,vulnerability,andbestinterests•  ANDtostartwiththepresumpAonofcapacity

•  TheprotecAonimperaAveisever-present

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