This will often be a relatively informal, straightforward process (for example for relatives and carers), in which a ‘ reasonable belief’ of lack of capacity when acting for someone is enough to provide statutory protection. All those taking some action on behalf of those in their care will be expected to be able to assess capacity. If a properly supported process does not enable the person to make the particular decision, a ‘capacity assessment’ is required. Finally, it is noted that careful attention should also be given to written materials such as consent forms, which can be improved by use of structure and uniformity, shorter sentences and words, and simplified or illustrated formats ( Reference Dunn and JesteDunn & Jeste, 2001). In line with this research, there is scope for ward-based procedures to be developed to both support and evaluate level of independence in specific decision-making areas when preparing for discharge, for example a graded self-medication procedure for in-patients receiving stroke rehabilitation. Research has identified a number of ways for enhancing capacity including: education ( Reference Lapid, Rumman and PankratzLapid et al, 2004) multiple learning trials with corrected feedback ( Reference Wirshing, Wirshing and MarderWirshing et al, 1998) and enhanced structure using computer-based presentations ( Reference Dunn, Lindamer and PalmerDunn et al, 2002).
#FLOWSTATE CHART CODE#
The main areas mentioned in the Code of Practice include: providing all relevant information (including simplifying information, outlining benefits and risks, considering effects on others) enhancing communication and making the person feel at ease (considering, for example, location, timing and support from others). Therefore, clinicians are required to take ‘all practicable steps’ to support decision-making. Within the Mental Capacity Act 2005, if a ‘properly supported process’ is sufficient to enable the person to make the particular decision, they are assumed to retain capacity (although vulnerable). Properly supported process enables person to make the decision in question Palmer et al ( Reference Palmer, Dunn and Applebaum2005) have shown such an approach to be effective for screening for capacity to consent to research. With this in mind, clinicians should consider routinely using simple open-ended screening questions to detect reduced capacity, for example ‘why might it be difficult for you to manage safely at home?’ for placement decisions, and ‘what is this treatment about?’ for treatment decisions. There is considerable heterogeneity within diagnostic groups, and factors (such as cognitive impairment) that have the most significant association with impaired capacity explain no more than 25% of the variance ( Reference Jeste and SaksJeste & Saks, 2006). Thus, certain factors are more predictive of lack of capacity than others, for example the presence and severity of cognitive impairment (including lower scores on the Mini-Mental State Examination MMSE Reference Folstein, Folstein and McHughFolstein et al, 1975), diagnoses such as psychosis and bipolar disorder, and presence of delusions other factors, such as degree of psychopathology and age show a less consistent relationship ( Reference Cairns, Maddock and BuchananCairns et al, 2005 Reference Jeste and SaksJeste & Saks, 2006).
Once an impairment or disturbance of mental functioning is detected, a clinician should be aware of the likely impact on capacity. Doubts raised about the capacity to make particular decisions
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