a wide range of mental capacity assessment instruments is available, but not all fulfil the UK legal requirements. They cannot understand information relevant to the decision. Dr Catherine Pennington is a Senior Clinical Research Fellow at the Centre for Dementia Prevention, University of Edinburgh, and honorary Clinical Lecturer at the University of Bristol ReMemBr Group. Mental Capacity: Dealing with Fluctuating Capacity Fluctuating capacity is when a person’s ability to make a specific decision changes frequently or occasionally. Patients may fail a test of capacity due to fixed, abnormal illness-related beliefs, rather than impaired understanding, recall or communication [9]. Print copy below The content below is reflective of our leaflet. MacArthur competence assessment tool-treatment (MacCAT-T) [, Semi-structured interview. The following keywords were used as search terms: ‘mental capacity’, ‘informed consent’, ‘capacity assessment’. Cognitive abilities, alongside patient emotions, values and experiences are all valid factors that contribute to decision making. This allows decision-specific assessments and simplification of information. It is therefore vital that we are able to accurately assess a person's ability to make informed choices. High inter-rater reliability, but lower test–retest reliability. They cannot retain information for the time required to make the decision. Multiple instruments for assessing capacity exist, but none are universally accepted [8]. An example of a more detailed need for capacity assessment may be in the context of a patient receiving a surgical intervention, where there may be large risks associated with the procedure itself. It seems there is also sometimes little consultation with the person in care or their representative.Many people are confused about what a Mental Capacity Assessment (MCA) actually is – and when it should be used. Development and Application of High-Throughput Single Cell Lipid Profiling: A Study of, The five key principles of the Mental Capacity Act 2005, Assessment of capacity for everyday decision making [. As dementia progresses, there is a concomitant progressive loss of capacity. No current instrument is sufficiently flexible or broad in scope to consider individual and contextual factors in the assessment of capacity and for this reason expert judgement and due attention to patient values and narratives are essential. FAST stage 3, Allen level 5-This stage is not classified as a stage of dementia, but is often named Mild Cognitive Impairment. Decisions must be in their best interests. Publications dealing with capacity assessment and tools for evaluating capacity were selected. Disagreement about capacity (either between professionals, or between staff and the patient or relatives) should prompt a detailed assessment and open discussion. High inter-rater reliability. It can also change in both the short term and the long term. Multiple tools exist to aid in the assessment of decision-making capacity. It is good practice to establish how the person with dementia wants to be addressed. Semi-structured interview using three everyday decision scenarios. The assessment of someone’s mental capacity to make an important decision often requires a specialist expert. However, there are contrasting legal and clinical approaches: clinicians often view capacity as a gradient, whereas the legal approach is more dichotomous. Adaptable to different scenarios. Tools meeting the UK legislative requirements are listed in Table 1. Your comment will be reviewed and published at the journal's discretion. Vignettes around planned treatment. Capacity rating tools typically do not give an overall rating or score, being designed as an adjunct to professional judgement, not a substitute. Evaluating whether an individual can make a decision in the real world is very challenging. Moye J, Karel MJ, Azar AR, Gurrera RJ. Capacity is traditionally evaluated during clinical assessments by psychiatrists and physicians, the reliability of which remains unclear [8]. Internationally, many areas where capacity legislation has been enacted follow a similar model to that of the UK. For everyday purposes (rather than use in research into capacity itself) toolkits that allow tailoring of the information to an individual decision are preferable. Here, we review the UK legal framework for defining mental capacity, and published capacity assessment tools. My Mum had a Mental Capacity Act assessment following a fall at home. have reduced morbidity and/or mortality) residing in an institutional fa… Others are tailored for people with dementia, learning difficulties, or mental health disorders. In contrast, informal capacity estimates by healthcare staff and patient’s relatives are unreliable compared to expert opinion and structured tool use [10]. Prisons and Probation Ombudsman for England and Wales. PART A: CHECKLIST BEFORE CARRYNG OUT FUNCTIONAL MENTAL CAPACITY TEST DIAGNOSTIC TEST Determining whether an individual has the ability to make a specific decision can be very challenging for both clinicians and researchers. Marson D, McInturff B, Hawkins L, Bartolucci A, Harrell L. Oxford University Press is a department of the University of Oxford. There is some reason why the person's ability to make decisions is affected. Decisions about mental capacity should never have a blanket approach, and professionals should tailor their methods to the individual and decision in question. With patient rights’ reliant on judgements of decision-making capacity, it is imperative that such assessments are reliable and valid. Finally, the very act of deciding to carry out a capacity assessment is not, itself, neutral, and the assessment process can, itself, often be (and be seen to be) intrusive. These include: 1. Ways to optimise capacity include approaching an individual on a ‘good day’ (best identified by the patient, relatives or knowledgeable carers) and at a preferred time of day (e.g. simplified information) could achieve capacity. Palmer BW, Dunn LB, Appelbaum PS et al. Multiple different tools have been developed to aid in capacity assessment. Overall, whilst global cognition correlates to some degree with capacity status, there are no definitive rules that can be applied. If a person lacks capacity, any decisions made must be in their best interests. Such superficial assessments are inadequate and will miss both those lacking capacity, and those who with support (e.g. However, clinical judgements made without using a structured tool have lower reliability, particularly regarding people with dementia [29]. This work focuses on methods of assessing capacity meeting the UK legal requirements, and critically appraises current knowledge to identify what may be a gold standard approach towards the assessment of capacity. Papers were screened by title, then abstract. Mental capacity is a functional term that may be defined as: the "mental (or cognitive) ability to understand the nature and effects of one's acts.". Changes in care: capacity and decision making. safeguarding needs, support needs, housing needs etc. Many people with mild or moderate dementia will still have the ability to make informed choices, particularly when information is given in an appropriate format. Marson DC, Earnst KS, Jamil F, Bartolucci A, Harrell LE. The ability to retain information sufficient to make a decision is specified in the UK law: tools which require recapping of information were deemed to have met this standard. Carney M, Neugroschl J, Morrison R, Marin D, Siu A. Gerstenecker A, Niccolai L, Marson D, Triebel KL. Email: Search for other works by this author on: Memory Research Group, School of Clinical Sciences, University of Bristol, Level 1 Learning & Research, Southmead Hospital, Bristol, UK, Centre for Ethics in Medicine, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, UK, Principles of the Mental Capacity Act 2005 [, Criteria determining a lack of capacity (note the presence of any one factor indicates a lack of capacity) [. Mental incapacity and criminal liability: redrawing the fault lines? There are many ways to assess mental capacity. a search of electronic databases was made for articles published between 2000 and 2017 detailing structured tools for the assessment of mental capacity. However, not all patients ne… Decisions must restrict freedom as little as possible while still achieving the desired benefit; and encourage the adult to exercise residual capacity. MacArthur competence assessment tool for clinical research (MacCAT-CR). Complex decision making involves multiple cognitive domains. Published by Oxford University Press on behalf of the British Geriatrics Society. Capacity is decision specific and should be assessed on this basis. There is a risk of serious harm to those who refuse medical or social care, and professionals who fail to conduct adequate and timely capacity assessments may be guilty of wilful neglect. These were evaluated against the UK legal requirements. Health and social care professionals must be vigilant to prevent neglect, particularly when individuals with complex neurodegenerative or neuropsychiatric conditions refuse interventions. 1. ReMemBr Group, School of Clinical Sciences, University of Bristol, Bristol Brain Centre, Southmead Hospital, Bristol, UK, Neurology Department, North Bristol Trust, Southmead Hospital, Bristol, UK, Centre for Dementia Prevention, University of Edinburgh, 9A Bioquarter, 9 Little France Road, Edinburgh, UK. Capacity is particularly relevant in the context of Power of Attorney (PoA), Guardianship, voting, contracts, wills, marriage and criminal responsibility [1–3]. When assessing reasoning, the MacCAT-T and CCTI identified impairments in the dementia group, whilst the HCAI did not. Copyright © 2020 British Geriatrics Society. It has been suggested that in clinical practice, clinicians may equate treatment refusal with lack of capacity and treatment acceptance with competency. Look at possible risk factors for dementia (modifiable and non-modifiable in your patient) 4. This means they may have capacity to make a decision at some times but lack capacity at other times. There may even be scope to develop more standardised and universally agreed approaches to the assessment of capacity. Contract law is typically determined on a case by case basis, and whilst there are protections to guard against unscrupulous sales tactics, people with impaired capacity are vulnerable to financial exploitation. When considering which to use, the clinician or researcher should consider what their question is. The article reviews the pros and cons of the different tools available, alongside cultural and neuropsychological aspects of decision making. It also avoids confusing adults with cognitive impairment by discussing hypothetical situations—a discussion that is arguably more complex than discussing a real-life, personally relevant decision. Deprivation of Liberty Safeguards (DoLS) are an amendment to the Mental Capacity Act (2005) to ensure that any care restricting a person's liberty is appropriate and in their best interests. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. An irrational decision does not equate to the absence of capacity. Tomoda A, Yasumiya R, Sumiyama T et al. This allows us to support the greatest level of autonomy possible, and also identify and protect people who have lost the ability to make or communicate their own decisions. The majority affected are older adults, who experience progressive cognitive decline. It has been suggested that expression of choice is less cognitively demanding than other aspects of decision making [23]. Moye J, Gurrera RJ, Karel MJ, Edelstein B, O’Connell C. Cairns R, Maddock C, Buchanan A et al. What is the Test for Mental Capacity The Two Stage Test – Decision Making Capacity. Mum had a diagnosis of mixed dementia 4 years prior to the fall. Capacity is assessed based on the process of decision making rather than the content of the decision itself, and under UK legislation a decision does not have to be rational, reasonable or logical. Structured interview. Some tools require that decision making be rational, which is not a UK requirement. compared the MacCAT-T, CCTI and the HCAI for the assessment of people with mild to moderate dementia and matched controls [27]. In some cases, judging capacity is straightforward, whilst in others there may be disagreement between different clinicians, assessment tools or between tool and clinician [25]. Some are aimed at specific patient groups or decision, whilst others are culture specific. It affects more than one cognitive domain (for example memory, language, orientation, or judgement) and social behaviour (for example, emotional control or motivation). Give examples of how and why adjustments to care and support might need to be made when a mental health condition, dementia or learning disability is identified. Read the Age and Ageing paper Tools for testing decision-making capacity in dementia, Marjory Warren House Conversely, expression of choice is not emphasised in N.American literature, but is a key component of the UK legislation. When the Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory (SICIATRI) was used by Japanese patients discussing palliative care decisions two components had to be changed [11]. We evaluated published instruments designed to aid in the assessment of capacity, focussing on those meeting the UK legal requirements. If a person is later judged to have already lost capacity when they entered into a business or marriage contract, or made a will, these are deemed void. Defining and judging mental capacity requires a fine balance between patient autonomy and protection of vulnerable adults. From the MCA asset: Mum was identified not to have capacity to make decisions. This does not negate the usefulness of SICIATRI, but it is important to recognise that some tools may require context-specific modification. The perceived ‘safest’ option is usually to discharge to a care home, although it is difficult to know whether someone will really be ‘safer’ (i.e. Summary of literature review findings (Pubmed; all searches limited to English language publications). Information must be vigilant to prevent automated spam submissions clinical trial participants has. Derived from the mca asset: Mum was identified not to abandon the patient their... Staff and their employers have a blanket approach, and to prevent neglect, particularly individuals... Visual aids or other communication means aims to make the decision or haven... 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