Synopsis
Assess decision-specific capacity with all practicable support, identify the correct legal authority, apply valid advance refusals, and make transparent best-interests decisions that centre the person's rights, values and least restrictive clinically beneficial option.
- Presume capacity and assess the actual decision at the time it must be made, not the person's diagnosis or global cognitive status.
- First-line practice is supported decision making: optimise pain, oxygenation and attention, treat delirium, use hearing aids, interpreter, simple language, visual material and sufficient time.
- In England and Wales, ask whether an impairment or disturbance affects mind or brain and whether it causes inability to understand, retain, use or weigh, or communicate the decision.
Key red flags
Age, diagnosis, detention, intoxication, communication disability or an apparently unwise choice cannot alone establish lack of capacity.
Conflict about validity, proxy powers, restraint or life-sustaining treatment requires senior review and may need urgent legal resolution.
Investigation priorities
State the exact choice, options, material benefits, burdens, consequences of no action and time by which a decision is required.
Management branches
There is a reasonable concern that the patient may not be able to make a specific healthcare decision.
- Define the decision and urgency, identify potential impairment and correct reversible clinical or communication barriers as far as practicable.
- Explain material information accessibly and assess understanding, retention, use or weighing and communication, recording the person's actual responses.