Makindo Medical Notes

📚 This chapter covers mental capacity in the UK, based on the Mental Capacity Act 2005 (MCA). Essential for OSCEs, ward practice, and ethical decision-making. Particularly relevant in geriatrics where dementia, delirium, and frailty often complicate decision-making.

⚖️ What is Capacity?

Capacity = a person’s ability to make a specific decision at the time it needs to be made. It is decision-specific and time-specific (not all-or-nothing).

• 💡 A person may lack capacity for some decisions (e.g. finances) but retain capacity for others (e.g. choosing lunch).
• 🔄 Capacity can fluctuate (e.g. delirium, hypoglycaemia, infection).
• ⚖️ In UK law, every adult is presumed to have capacity unless proven otherwise.

📜 The 5 Principles of the MCA (2005)

1. 🧠 Presumption of capacity: Assume capacity unless proven otherwise.
2. 🗣️ Support to decide: Provide help (glasses, hearing aids, communication aids, interpreters, optimal timing).
3. 🙃 Unwise decisions ≠ lack of capacity: Risk-taking ≠ incapacity.
4. 🛡️ Best interests: If lacking capacity, any act/decision must be in their best interests.
5. 🔒 Least restrictive option: Choose the least restrictive intervention.

🧾 The Capacity Test (2-stage)

Stage 1: Impairment of mind or brain

• Dementia, delirium, learning disability, stroke, mental illness, intoxication.
• Temporary or permanent.
• Pathophysiology note: e.g. delirium → impaired attention & memory; dementia → progressive executive dysfunction. These mechanisms explain why “retain” and “weigh” steps often fail.

Stage 2: Functional test (the 4 abilities)

A person lacks capacity if, due to impairment, they cannot:

• 🔎 Understand relevant information.
• 💭 Retain it long enough to decide.
• ⚖️ Weigh the information (balance risks/benefits).
• 🗣️ Communicate their decision (speech, writing, gestures).

📊 Best Interests Decision-Making

• 👥 Involve family, carers, advocates (IMCA if no family).
• 🧠 Consider past wishes, beliefs, values.
• 🏥 Choose option least restrictive of liberty.
• 📝 Document assessment, reasoning, and consultation clearly — vital in exams and practice.

🔒 Deprivation of Liberty Safeguards (DoLS)

• Applies if a person lacking capacity is deprived of freedom in hospital or care home.
• Authorisation must be sought (DoLS or new Liberty Protection Safeguards, LPS).
• Update (2025): LPS rollout is planned but delayed; most trusts still use DoLS.
• Purpose: protect rights, prevent arbitrary detention.

📜 Legal Tools

• 📃 Advance Decisions to Refuse Treatment (ADRT): Legally binding if valid & applicable.
• 👥 Lasting Power of Attorney (LPA): For health/welfare or finance decisions.
• ⚖️ Court of Protection: Decides in disputes/complex cases.
• 🛡️ Independent Mental Capacity Advocate (IMCA): Protects patients with no family during serious decisions.

🧑‍⚕️ Case Examples — Capacity & Decision-Making

• Case 1 (Refusal with capacity): 🧠 An 82-year-old man with mild dementia develops pneumonia but refuses antibiotics. He can understand, retain, weigh information, and communicate his decision. He therefore has capacity, and his refusal must be respected, even if it risks harm. Teaching point: capacity is decision-specific and autonomy must be honoured if capacity is intact.
• Case 2 (Delirium, lacks capacity): 🩺 A 90-year-old woman develops delirium following hip surgery and refuses analgesia. She is disorientated, unable to follow conversation, and cannot process or retain information. She lacks capacity at this time, but capacity may return once delirium resolves. Analgesia is given in her best interests, with family consulted and the decision documented. Teaching point: capacity can fluctuate and should be reassessed as the clinical state improves.
• Case 3 (Advance Decision to Refuse Treatment): 📜 A 76-year-old man with advanced dementia is admitted following a collapse. His records include a valid, applicable ADRT declining CPR. This ADRT is legally binding, so a DNACPR order is completed, family are informed, and documentation updated. Teaching point: advance decisions take precedence when valid and applicable, ensuring prior wishes are respected.

📝 OSCE / Exam Pearls

• Always state: “Capacity is decision-specific and time-specific.”
• Use the 4 abilities: understand, retain, weigh, communicate.
• Best interests = consult family/advocates, document well.
• Unwise ≠ incapacity.
• Know ADRT (binding) vs advance statement (not binding).
• Practical OSCE line: “I would ensure hearing aids and glasses are in place, choose a quiet environment, and use simple language before concluding lack of capacity.”