Mental Capacity Act Scenario Questions

The Mental Capacity Act 2005 covers decisions for people aged 16 and over who may not be able to make a particular decision for themselves. It is one of the most heavily tested topics in Part B1, because it is where nurses most often get the reasoning wrong.

Five principles hold the whole Act together:

• Assume the person has capacity unless it is shown otherwise.
• Take all practicable steps to help them decide before concluding they cannot.
• An unwise decision does not, on its own, mean a lack of capacity.
• Anything done for someone who lacks capacity must be in their best interests.
• Choose the option that least restricts their rights and freedom.

Capacity is specific, not a label

The most common error, and the most common wrong answer, is treating capacity as a fixed status. It is not. Capacity is assessed for one decision at one moment. A person can lack capacity to consent to major surgery yet keep capacity to decide what to wear or eat. It can also come and go with illness, medication or time of day. A diagnosis of dementia, learning disability or mental illness never removes capacity by itself.

The two-stage test

To conclude that someone lacks capacity for a decision, both stages must be met. First, is there an impairment or disturbance in the functioning of the mind or brain? Second, does that impairment stop them doing any one of four things: understanding the information, retaining it long enough to decide, using and weighing it, or communicating their choice? Fail one of those four, because of the impairment, and the person lacks capacity for that decision.

Best interests is a process

When a person genuinely lacks capacity, care is given in their best interests. That is not the same as doing what staff think is clinically ideal. The decision-maker weighs the person’s past and present wishes, their beliefs and values, and consults those close to them, then chooses the least restrictive option that meets the need. Relatives are part of that conversation but do not hold the decision, unless they are an attorney under a registered health and welfare LPA or a court deputy.

One exception overrides all of this: a valid and applicable advance decision to refuse treatment is binding, just as a capacitous refusal would be. Next: confidentiality and disclosure. Five capacity scenarios first.