Making Decisions ( Mental Capacity)

Examples of people who may lack capacity include those with:

• dementia
• a severe learning disability
• a brain injury
• a mental health illness
• a stroke
• unconsciousness caused by an anaesthetic or sudden accident

But just because a person has one of these health conditions doesn’t necessarily mean they lack the capacity to make a specific decision.

Someone can lack capacity to make some decisions (for example, to decide on complex financial issues) but still have the capacity to make other decisions (for example, to decide what items to buy at the local shop).

The MCA says:

• assume a person has the capacity to make a decision themselves, unless it’s proved otherwise
• wherever possible, help people to make their own decisions
• don’t treat a person as lacking the capacity to make a decision just because they make an unwise decision
• if you make a decision for someone who doesn’t have capacity, it must be in their best interests
• treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms

The MCA also allows people to express their preferences for care and treatment, and to appoint a trusted person to make a decision on their behalf should they lack capacity in the future.

People should also be provided with an independent advocate, who will support them to make decisions in certain situations, such as serious treatment or where the individual might have significant restrictions placed on their freedom and rights in their best interests.

How is mental capacity assessed?

The MCA sets out a 2-stage test of capacity:

1) Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?

2) Does the impairment mean the person is unable to make a specific decision when they need to? People can lack capacity to make some decisions, but have capacity to make others. Mental capacity can also fluctuate with time – someone may lack capacity at one point in time, but may be able to make the same decision at a later point in time.

Where appropriate, people should be allowed the time to make a decision themselves.

The MCA says a person is unable to make a decision if they can’t:

• understand the information relevant to the decision
• retain that information
• use or weigh up that information as part of the process of making the decision

Helping people make their own decisions:

Before deciding a person lacks capacity, it’s important to take steps to enable them to try to make the decision themselves.

For example:

• does the person have all the relevant information they need?
• have they been given information on any alternatives?
• could information be explained or presented in a way that’s easier for them to understand (for example, by using simple language or visual aids)?
• have different methods of communication been explored, such as non-verbal communication?
• could anyone else help with communication, such as a family member, carer or advocate?
• are there particular times of day when the person’s understanding is better?
• are there particular locations where the person may feel more at ease?
• could the decision be delayed until they might be better able to make the decision?

Is the decision in their best interests?

If someone lacks the capacity to make a decision and the decision needs to be made for them, the MCA states the decision must be made in their best interests.

The MCA sets out a checklist to consider when deciding what’s in a person’s best interests.

It says you should:

• encourage participation – do whatever’s possible to permit or encourage the person to take part
• identify all relevant circumstances – try to identify the things the individual lacking capacity would take into account if they were making the decision themselves
• find out the person’s views – including their past and present wishes and feelings, and any beliefs or values
• avoid discrimination – don’t make assumptions on the basis of age, appearance, condition or behaviour
• assess whether the person might regain capacity – if they might, could the decision be postponed?

It’s vital to consult with others for their views about the person’s best interests.

In particular, try to consult:

• anyone previously named by the individual
• anyone engaged in caring for them
• close relatives and friends
• any attorney appointed under a Lasting Power of Attorney or Enduring Power of Attorney
• any deputy appointed by the Court of Protection to make decisions for the person