11/13/24, 8\:11 PM Guide | Mental capacity assessment

Mental capacity assessment

Table of contents

Introduction

Mental capacity refers to the ability of an individual to use and understand information to make a decision, and then to
communicate the decision made.
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Doctors are often asked to assess whether someone’s decision-making is impaired by illness so that we can ensure decisions
are made in the patient’s best interests.
As part of an OSCE station, you may be required to assess mental capacity or discuss with an examiner how you would
approach capacity assessment in a speci
of an adult patient in an OSCE setting.

De

Patients may lack capacity due to an impairment of the brain or mind. This may be a progressive impairment (e.g. dementia), a
permanent injury (e.g. traumatic brain injury), or a temporary impairment (e.g. delirium, intoxication).
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As mental state can
Capacity should always be discussed in decision-speci
and bene
their dignity.
You should assume capacity unless proven otherwise. You should never assume that an individual lacks capacity because of
their medical or psychiatric history, appearance, behaviour or beliefs.
Individuals are entitled to make decisions that you consider unwise, or di
have the capacity to make this decision.

Preparing for the capacity assessment

Before conducting a capacity assessment, review the patient’s medical notes to understand their functional status, recent
illness progression, and any previous capacity assessments. If able, discuss with the wider multidisciplinary team (e.g. nursing
colleagues) any concerns they may have.
Beforehand, consider whether you are the most appropriate person to conduct the capacity assessment. If the capacity
assessment relates to a speci
Consider when to conduct the assessment. Avoid times when confusion or drowsiness are more likely, such as after a nap or
following the administration of sedating medications.
Consider who should be present for the assessment. The patient may feel more comfortable with familiar sta
present. The family should be informed of the purpose of the assessment and should avoid in

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
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Con
Explain the purpose of the conversation\:
I s n o w a g o o d t i m e ?”
Ensure privacy during the assessment so that you will not be disturbed.
“ I’ d l i k e t o c h a t a b o u t m a k i n g d e c i s i o n s a b o u t y o u r c a r e , s o w e c a n b e s t s u p p o r t y o u .

Conducting the capacity assessment

To have the capacity to make a speci
Understand information
Retain information
Use the information to make a decision
Communicate their decision
Firstly, the patient must understand the situation and the options presented to them\:
“ C o u l d y o u t e l l m e a b i t a b o u t w h y y o u a r e i n h o s p i t a l ?”
“ D o y o u u n d e r s t a n d w h a t t h e o p t i o n s a r e f o r m a n a gi n g y o u r i n f e c t i o n ?”
Additional support may be required, such as visual or hearing aids, or an interpreter. Be aware that using a family member as
an interpreter compromises patient privacy.
Secondly, they must be able to retain this information during the conversation. Do they forget the conversation quickly, or
become too distracted to continue? Memory or concentration may be a
disorder. You may need to come back to conduct your assessment another time.
The patient must then show they can weigh up options and make a decision based on their reasoning. This is often a good
time to explore patient concerns.
Flawed logic does not mean capacity is lacking, so long as the decision is supported by the patient’s own reasoning.
Lastly, this decision must be communicated back to the assessor. Communication can be verbal, written or indicated with sign
language or gestures. Steps should be taken to facilitate communication if required.

Closing the consultation

Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Document the outcome of the mental capacity assessment

Documentation

Document your assessment clearly in the medical notes, including\:
The indication for assessment
The decision this relates to
Date and time
Who was present during the assessment
As capacity can
should be informed.
Complex cases, or inconclusive assessments, should be discussed with senior clinicians who may recommend specialist
assessment by liaison psychiatry.
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Legal considerations

If the patient lacks the capacity to make a decision, you should strive to
allows the patient the most freedom).
A supportive legal framework should be implemented to protect their rights, and copies should be made available in the
patient’s medical notes. In England and Wales, this documentation is the mental capacity act, overseen by the court of
protection.
The deprivation of liberty safeguards (DoLS) should be completed if the decision made infringes on a patient’s ability to leave
or if they are controlled or supervised in any way to which they cannot consent to.
In Scotland, diadults with incapacity act).
Any decisions made regarding the patient should be in accordance with their best interests. This can be determined from
consulting several sources, including the multidisciplinary team, next of kin and any pre-existing legal documentation that
describes their wishes.
The patient may have an advance decision to refuse treatment (ADRT), written and witnessed documentation that details
speci
The patient may have appointed a lasting power of attorney for health and welfare (England and Wales) or welfare power of
attorney (Scotland). This person, often a family member or friend, is legally appointed by the patient in advance of becoming
unwell to make decisions on their behalf if they lack capacity in the future.
3,4
Lasting power of attorney for property and
make healthcare-related decisions.

Special circumstances

In rare circumstances, it may be necessary to act against the wishes of a capacitous patient if there is an immediate threat to
life. A senior clinician must be involved in this situation.
If a patient is detained under the mental health act (MHA), a capacity assessment should still be carried out for all decisions
relating to physical health.
The court of protection is involved in all capacity decisions relating to contraceptive sterilisation, organ donation, and
withdrawal of nutrition and hydration during a permanent vegetative state.

Example scenarios

Example 1

Rashida is an 80-year-old woman admitted with a urinary tract infection. She has been refusing to take oral antibiotics, and the
nursing team is unclear why this is. She has no past medical history and no signs of delirium. Her interpreter explains that the
last time Rashida was prescribed an antibiotic, she experienced severe diarrhoea. She knows this was a di
but does not want to risk this happening again.
Does this patient have the capacity to refuse antibiotics?
Although this decision may seem irrational, Rashida has demonstrated she understands, retains and has decided upon the
information provided and communicates her wishes, which should be respected.

Example 2

John is a 31-year-old man who has presented to the emergency department after taking an overdose of paracetamol with
alcohol. When you approach the bedside to gain consent for cannulation, he opens his eyes to voice but is too drowsy to
engage in conversation. His wife tells you he has always been afraid of needles. He has no power of attorney and no advance
directive.
Does this patient have the capacity to refuse intravenous cannulation?
At present, John does not appear to be able to understand, retain or communicate information due to his intoxication. Although
he has a needle phobia, there is no legal documentation in place to suggest he would not want cannulation in this instance.
Due to his presentation, it is in his best interests to receive medications and
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his next of kin, and his capacity reassessed regularly, as his cognition will likely improve over the coming days.

Reviewer

Dr Emma Leighton
Psychiatry Registrar

References

1. NHS. C o n s e n t t o t r e a t m e n t- a s s e s s i n g c a p a c i t y . Published December 2022. Available from\: [LINK]
2. General Medical Council. M e n t a l c a p a c i t y Available from\: [LINK]
3. Alzheimer’s Society L e g a l a n d LINK]
4. Compassion in Dying. M a k i n g d e c i s i o n s a n d p l a n n i n g y o u r c a r e . Available from\: [LINK]
Source\: geekymedics.com
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