This document provides information on assessing mental capacity under the UK's Mental Capacity Act. It discusses the five key principles of the act, including presumption of capacity, best interests, and least restrictive options. It then explains the two-stage functional test for assessing capacity for a specific decision, considering impairment or disturbance and the impact on decision-making abilities. Several case studies are presented and questions assess understanding of applying the act's principles to decisions around capacity.

1. Decisions Around
Capacity

2. Aims of the session
• 5 key principles of MCA
• 2 stage functional test of capacity
• Begin to assess capacity

3. Mental Capacity Act
• Empowers and protect vulnerable people who are
not able to make their own decisions.
• Defines who can take decisions and when
• Enables people to plan ahead for when they may
lose capacity
• The Mental Capacity Act applies to people aged 16
and over.

4. Five Key Principles
1. Presumption of capacity
2. Maximising decision making capacity
3. Right to make unwise decisions
4. Best interests
5. Least restrictive option

5. Two-stage functional test of
capacity for a Specific Decision.
Stage 1.
Is there an Impairment of or Disturbance of the functioning of the mind or
Is there an impairment of brain?
or disturbance in the
functioning of a person’s mind or brain?
YES
Does this affect the persons capacity to make a specific decision?

6. Stage One.
Is there an Impairment of or Disturbance in
the functioning of the mind or brain?
Record the conclusion and no further action
required under Mental Capacity Act 2005

7. Stage two.
Does this affect the person’s capacity to make a particular
decision?
Person Has Capacity

8. Workshop.

9. Case 1
• Mr Jackson is brought into hospital following a traffic accident. He
cannot speak and is clearly in distress, making noises and gestures.
From his behaviour, hospital staff conclude that Mr Jackson currently
lacks the capacity to make decisions about treatment for his injuries,
and they give him urgent treatment.
• Later , one of the nurses thinks she recognises some of his gestures as
sign language, and tries signing to him. Mr Jackson immediately
becomes calmer, and the doctors realise that he can communicate in
sign language.
• He needs a non urgent repair of his fractured ankle.
• Who can consent to this?
Mental Capacity Act 2005 Code of Practice

10. In using sign language which
of the principles is being
followed?
1. Presumption of
capacity
2. Maximising decision
making capacity
3. Right to make
unwise decisions
4. Best interests
5. Least restrictive
option
33%
30%
17%
13%
7%
1
2
3
4
5

11. Case 2
• George has severe learning disability care home.
• He has poor dental hygiene and recurrent infections related to
this which causes him a lot of pain. He will not open his mouth
for teeth cleaning or the dentist. The dentist feels that George
needs a general anaesthetic to clean his teeth and fill any
cavities.
• His mother is worried about the effects of an anaesthetic, but
she hates to see him distressed and suggests instead that he
should be given strong painkillers when needed.
• You as the GP are called to prescribe painkillers repeatedly for
this and repeated courses of antibiotics.
• How should you go about managing this situation long term?
Mental Capacity Act 2005 Code of Practice

12. The team decide he should
have the anaesthetic. Which of
the key principles is most
relevant?
1. Presumption of
2.
3.
4.
5.
capacity
Maximising decision
making capacity
Right to make
unwise decisions
Best interests
Least restrictive
option
23%
23%
10%
20%
23%
1
2
3
4
5

13. Case 3
• Peter is a 60-year-old man who is admitted to hospital for
investigations for abdominal pains. Peter had a stroke two
years ago and is extremely claustrophobic. His speech is
slurred and difficult to understand and he gets a little confused
when he is very tired.
• The medical staff want to do an abdominal CT scan on Peter
but this will require him to lie flat in an enclosed space,
something that Peter will not consider. He refuses to consent
to the procedure. It is clear that he understands what the
doctors have explained.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074624.pdf

14. What aspects of the mental
capacity act are most relevant
1. Presumption of
capacity
2. Maximising decision
making capacity
3. Right to make
unwise decisions
4. Best interests
5. Least restrictive
option
10
0%
1
2
3
4
5

15. Case 4 Alfred Jones aged 82
AJ is admitted following a fall at home. He was diagnosed and
treated for pneumonia. He remained in hospital for three
weeks rehabilitation at which stage he was mobile with a
frame but had fallen three times whilst an inpatient. He was
independent with ADLs and ate reasonably.
His family tried to persuade him to go into a care home as he
was living alone but he was insistent that he would rather die.
He also refused the offer of a package of care but did agree
to a weekly cleaner, meals on wheels and community alarm.
His MOCA was 28/30 and he showed no
evidence of delirium.

16. • Using the two stage approach and thinking about
the key principles of the MCA, does AJ have the
capacity to make the decision to return home
without a package of care?

17. Does he have Capacity?
1. Yes
2. No
0%
0%
10
1
2

18. Case 4 Discussion.
• Using the two stage assessment process, he does
not have a disorder of the mind or brain that might
impair his decision making.
• He is presumed to have capacity
• He has the right to make decisions others may
consider unwise.

19. Case 5 Ethel Davies aged 79
ED is admitted following a fall at home. She was diagnosed
and treated for pneumonia. She sometimes appeared slightly
muddled, and sometimes did not appear to be listening to
what you were saying. On a few occasions at night she was
found sitting in the linen store. Often on the doctors rounds
she was asleep.
After five days of treatment her chest signs had resolved. Her
family visiting from Australia asked for her to be placed in a
care home as they felt she had dementia.
Her MOCA was 24/30.
On questioning Mrs ED about her wishes she told you she was
too tired to talk about these things now.
The social worker is keen for you to make a quick decision
about her capacity so funding for her care home can be
sorted.

20. • Using the two step process does the mental
capacity act apply?
• If so and there may be an impairment of her
capacity what things must you take into account
when planning her ongoing care?

21. Case 5 Discussion
• She is showing signs of delirium which may well
impair her capacity to make a decision about
discharge.
• Given time and adequate treatment it is very
possible she will regain her capacity to make this
decision herself.
• Therefore such an important decision should be
deferred.
• It would certainly not be in her best interests for
such a restrictive decision as care home placement
to be made at this stage.

22. Case 6 Mr Desmond Trent 89
• Mr DT was found by his neighbour who had not
seen him for a week collapsed on the floor of his
bungalow.
• He is known to suffer with dementia with a MOCA
five months ago of 18/30.
• He was living alone with no carers and was usually
seen on his way to the corner shop every morning.
• The ambulance crew noted that the house was in a
squalid state with faeces stained underwear on the
floor. The fridge was full of gone off milk and the
carpet covered in large cigarette burns.

23. Case 8 Mr Desmond Trent 89
• The neighbour who had found him visited the ward
and told you that he was concerned as Mr DT had
on a few occasions been found wandering locally
having forgotten his address.
• Mr DT wants to return home as soon as possible to
be with his wife who died three years ago.

24. • Using the first stage of the process is the Mental
Capacity Act relevant here?
• What aspects of the history might make you
concerned about his ability to decide about
discharge destination for himself?
• What process needs to be followed to assess his
capacity to return home?
Case 8 Mr Desmond Trent 89 questions

25. The consultant asks him.
• Why are we worried about you returning home?
• “You are after my wife”
• What would happen if you fell at home again?
• “I have never fallen”
• We are all worried that you have been eating gone
off food
• “My wife does all the food”
• The consultant returns a few days later and has a similar
conversation, Mr ET does not remember the consultant
or the previous conversation.
Case 8 Mr Desmond Trent 89 ctd

26. • What aspects of the mental Capacity act are being
explored
• On this evidence do you feel Mr DT demonstrates
capacity to decide to go home, if not why not?
• What is the next appropriate step in deciding
ongoing management?

27. Recommended Listening.
• Radio Four Inside the Ethics committee
• Episode two Series four.
• Series in which Vivienne Parry is joined by a panel of experts to
tackle the ethics involved in a real hospital case.
• An 86-year-old man with dementia who has had a bad fall wants to
go home but his son is concerned that he cannot look after himself
and needs to be in residential care. The programme looks at how
medical staff and families work out what is in his best interests and
whether he has the capacity to make decisions about his care, and
how his previous preferences should be included in the decision.

28. Recommended reading
• http://www.bmj.com/content/347/bmj.f5299
• September 2013 BMJ
The Judge as Medical Ethicist.