Dementia Gateway: Making decisions

Capacity: Can the person make the decision?

Key messages

Decisions cannot be made for a person with dementia unless there is evidence that they can't make the decision themselves. This is called a mental capacity assessment.
Knowing a person has dementia is not enough to say they can't make a decision. You need to be clear about the reasons why the person can't make the specific decision under consideration.
Care staff must have a 'reasonable belief' that a person can't make a decision before doing anything in their best interests.
It is good practice to write down the reasons why a person with dementia can't make a particular decision.

Always start from the assumption that the person has the capacity to make the decision in question.
First principle of Mental Capacity Act

Explore the links below now to read more about this topic:

1. The two-stage mental capacity assessment Open
Decisions cannot be made for a person with dementia unless there is evidence that they can't make the decision themselves. But how can we assess a person's capacity to make a decision? The Mental Capacity Act sets out two things that have to be checked before it can be decided that a person cannot make a decision for themselves:
- There is some reason why the person's ability to make decisions is affected. If the person has a diagnosis of dementia, this would be true. Other examples are the effects of a stroke, some mental health problems or having a learning disability.
- The person is unable to make the specific decision under consideration. The person would need to be unable to understand, remember or weigh up relevant information. This would also be the case if they could not communicate the decision because of lack of control over their body.
This is called the two-stage mental capacity assessment.
2. Who decides whether a person can make their own decisions? Open
The person who is expected to do the mental capacity assessment is the person who might have to do something in the person's best interests (for more on this, see the feature on 'Making decisions in a person's best interests' in this section). Here are some examples:
- Care workers may need to decide if the person is able to choose whether they have a bath or not, or what food they have.
- Family members may need to decide if the person is able to choose to go out with them.
- Doctors will need to decide if the person can make their own treatment decisions.
- A social worker may need to decide if the person can make a decision about staying at home or moving to a care home.
As you can see, any member of the care team may have to make an assessment about a person's mental capacity.
3. What is expected of care workers? Open
Care workers don't have to be experts in working out whether a person with dementia can make a particular decision. It is OK to have a 'reasonable belief' (more on this below).

But how do you establish what is a reasonable belief? If you know a person has dementia, you need to think about whether they can understand what the risks are. For example, if the person wants to leave the home, can they understand the risks of traffic? Or if a person wants to make a cup of tea, are they able to understand the risk of getting burnt?

If there is no or little risk – say, deciding between tea and coffee or what music to listen to – then the person should be able to make their own decision.

If you think a person with dementia is unable to make a particular decision, you should be able to give reasons for this. It is good practice to write these in their care plan. Here are some examples to show what this would look like:
- Mrs Sing is unable to make decisions about having a wash. This is because her dementia means she doesn't understand the risks of not washing when doubly incontinent.
- Mr Charles has dementia and diabetes. He is unable to make decisions about what he eats. This is because he does not understand the risks of poor sugar control.
4. A capacity dilemma: helping with medication Open

Often care workers are expected to help people with dementia to take their medication. As a care worker, you need to know if the person is making their own decisions about taking the medication or if it is being given to them in their 'best interests' (for more on this, see the feature 'Making decisions in a person's best interests' in this section).

The doctor prescribing the medication should have decided this already and let the staff supporting the person know. This should be written in the care plan.

If care staff know that a doctor has decided that a person with dementia can't make their own decisions about taking the medication, this would be a reasonable belief. The care staff wouldn't need to do a capacity assessment each time they supported the person.

Where this is the case, it would be OK to encourage the person to take their medication if they are resisting it. But it wouldn't allow the staff member to hide the medication in food or to use a form of restraint so the person takes the medication. These can only happen if it is written in the care plan and agreed by a doctor as being in the person's best interests.

If a care worker thinks that person with dementia is able to make their own decisions about medication they should make sure the doctor knows this.

Over to you!

Click here to do a quick activity that will deepen your understanding of this topic. The activity can be done alone or with colleagues and you can also download a copy. Trainer's notes have also been provided.