Assessment Process
When conducting a Mental Capacity Assessment, an assessor should test for four functional elements, these include: understanding, remembering, weighing up the decision, and communicating the decision.
Understanding
Assessing client's understanding of the information relevant to the decision, by identifying the specific decision being assessed (define the question in clear terms). Clients should be able to demonstrate awareness that a choice must be made, identify what that choice is and its consequences.
Assess the examinee's understanding of the relevant information such as
Reasons for the decision to be made.
Consequences that come from making choices related to the decision, or choosing not to decide.
If your client has little exposure to the information relevant to the decision, please provide information relevant to the decision (in basic terms if necessary).
If the client has communication needs, the assessor will be responsible for providing information in ways that can support understanding (e.g. use of drawings, photographs).
Alternate forms of communication may also be necessary (e.g. AAC, gestures, signs or symbols).
It will also be important to understand your client's preferred language, and seek support to provide information in the language of their preference.
Clients are not to be regarded as unable to understand the information relevant to a decision if they are able to understand explanations of it given to them in a way that are appropriate to their circumstances (using simple language, visual aids or any other means).
Remembering
Assess whether the client is able to retain the information long enough to make a decision.
MCA Section 3(3) states that people who can only retain information for a short while must not automatically be assumed to lack the capacity to decide. It depends on what is necessary for the decision in question.
Weighing up the Decision
Assess whether the client can identify, use, and weigh risks and benefits for the specific issue of concern.
Can the client weigh information in regard to reasonably foreseeable consequences?
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Appreciation of the wider consequences of the decision on themselves and others (degree of insight and awareness may influence this);
Assessing the client's ability to take on the perspective of others (who might be affected by their decision-making).
Does the client offer a rational and coherent explanation as to why they agree/disagree?
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Ability to weigh the risks and benefits of different options - compare the risks and benefits of the available options
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Using a recognisable logic to arrive at a final decision;
Comparative: Can the client differentiate between choice A and B? E.g. “Choice A makes me stay longer in hospital than choice B.”
Consequential: Does the client understand how either choice will affect their life? E.g. “I have to make a lot of changes in my diet if I pick choice A.”
Consider the client's ability to integrate different facets of decision-relevant information, to arrive at a reasonable decision.
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Client must make and state a clear choice and not make multiple reversals of choice.
There should be consistency between expressed beliefs and decision reached
• The possible influence of pressure from others should be considered.
The impact of the client’s religious and cultural beliefs on their decisions.
Can the client apply understanding of the situation/decision, and understand the impact of their decision?
Food for thought:
How would you differentiate an unwise decision, versus an inability to make a decision?
Communicating the Decision
Can the client communicate a consistent decision clearly and coherently?
Take all practicable steps to help the client communicate their choice.
Decisions can be communicated by any means possible (e.g. verbal or sign language, gesture, drawing, writing, etc.).
If necessary, repeat assessment over multiple sessions and in different settings to test the consistency of responses.
Where do you get the information?
In some situations, gathering information from various sources may be needed for a comprehensive assessment. Information about your client can be gathered through clinical interviews with your client, their caregiver(s) / applicant(s), or other relevant individuals involved in their care.
Throughout the assessment, take note of the four functional elements. You may use the “5-2-4” diagram to help you keep track of your clients’ answers
Daily life requires us to navigate multiple decisions. Some of these decisions may be minor and may be less likely to have lasting impact of our lives, while others may have a bigger impact on our lives. To balance the need for an individual's rights and freedom while offering safeguards, the decisions covered in ADAP are limited to those mentioned below.
In the next two sections, we will further unpack our understanding of the decisions covered in ADAP, and areas to explore in an assessment. As mental capacity assessments are about personal decisions, the assessments often need to be contextualised to the life of an individual.
While exploring topics, it will be essential to keep the four functions of mental capacity in mind as you conduct and reflect on the assessment.