Makindo Medical Notes

Mental capacity is the ability of a person to make a specific decision at the time it needs to be made. For healthcare professionals, assessing capacity is both a legal obligation and a clinical responsibility. Students and junior doctors must be confident in recognising when to assess capacity and when to escalate concerns.

📜 Legal Framework (UK)

• The Mental Capacity Act (2005) governs decisions for adults in England & Wales.
• Presumption of capacity unless proven otherwise.
• Capacity is decision-specific and time-specific.
• Any intervention for those lacking capacity must be in their best interests.
• Always choose the least restrictive option.

⚖️ The Four-Stage Test of Capacity

Patients must be able to:

• 🗣️ Understand information relevant to the decision.
• 🧩 Retain that information long enough to make a choice.
• 🧮 Weigh the pros and cons of different options.
• 🗨️ Communicate their decision by any means (verbal, written, non-verbal).

🚩 Red Flags – When to Suspect Impaired Capacity

• Patient refusing treatment in a way that doesn’t align with their values or prior beliefs.
• Evidence of confusion, delirium, dementia, severe learning disability, intoxication, or psychosis.
• Rapidly fluctuating mental state (e.g., sepsis, hypoglycaemia, delirium).
• Unrealistic or bizarre explanations for choices.

🩺 Approach for Doctors & Students

• 👂 Listen carefully: Many patients just need clearer explanations or more time.
• 📝 Document thoroughly: Note why capacity was questioned, what information was provided, and how the patient responded.
• 🧑‍⚕️ Escalate early: Involve seniors, psychiatry liaison, safeguarding teams if unsure.
• 📚 For students: Observe assessments, practice structured history-taking, and learn to use simple language when explaining decisions to patients.

💡 Advice for Clinical Practice

• Always assume capacity unless there is clear reason to doubt it.
• Capacity is about the process of decision-making, not whether you agree with the outcome.
• Involve family/carers if appropriate, but remember the decision is ultimately the patient’s (unless lacking capacity).
• If lacking capacity: act in best interests, considering patient’s prior wishes (advance statements, LPA).
• When urgent (e.g. life-saving treatment) → act first, document later.

🧑‍⚕️ Common Clinical Scenarios (Cases)

🎯 Key Takeaways

• Capacity is decision- and time-specific.
• Use the 4-step test for assessment.
• Document everything clearly – protects both patient and clinician.
• Escalate concerns early; students should always involve seniors.
• Ethical tension: autonomy vs best interests – navigate with care and guidance.

📚 References

• Mental Capacity Act 2005
• NHS – Capacity & Consent
• GMC – Decision Making and Consent