The College of Optometrists

Capacity to consent – adults

C43
To make a decision about care the patient should be able to:
  • understand and remember the information provided
  • weigh up the information provided, and
  • tell you their decision.
C44
A patient’s capacity may vary from one day to the next or depend on the decision they are being asked to make. You should not assume that just because the patient does not have capacity on one occasion, they lack the capacity to make all decisions.
C45
Making decisions about treatment and care for patients who lack capacity is governed in:
  1. England and Wales by the Mental Capacity Act 2005.201 The Act is supported by a Code of Practice for healthcare workers which you should refer to.205  A person lacks capacity if, at the time the decision needs to be made, they are unable to make or communicate the decision because of an ‘impairment or disturbance’ that affects the way their mind or brain works. Further information for those practising in England is available from the Department of Health.206
  2. Scotland by the Adults with Incapacity (Scotland) Act 2000.207 The Act is supported by Codes of Practice for healthcare professionals which you should refer to.208 A person lacks capacity if they cannot make decisions or communicate them, or understand or remember their decision, because of a mental disorder or a physical inability to communicate in any form.
  3. Northern Ireland by the Mental Capacity Act (Northern Ireland) 2016 (not yet in force).209 The Act will be supported by a Code of Practice for healthcare workers which you should refer to. A person lacks capacity if, at the time the decision needs to be made, they are unable to understand information, retain information, appreciate the relevance of the information or communicate their decision because of an impairment of, or a disturbance in, the function of the mind or brain. The timescales for implementing certain parts of the Act are as yet unclear, so you should seek legal advice if you have concerns about a person’s capacity to make decisions.
C46
No one can make a decision on behalf of an adult who has capacity. If a patient asks you, or a relative or carer, to make decisions for them you should explain:
  1. that it is still important that they understand the options, and
  2. what the treatment or investigation will involve.
C47
You must work on the presumption that every adult patient (over the age of 18) has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment.
C48
You must regard a patient as lacking capacity only once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes.
C49
You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), beliefs, apparent inability to communicate, or the fact that they make a decision with which you disagree.
C50
A patient’s ability to make decisions may depend on the nature and severity of their condition, or the difficulty or complexity of the decision.
C51
You must assess the patient’s capacity to make an informed decision about the treatment and then assess if they are able to decide whether to have the treatment.
C52
If the patient does not have capacity, the Mental Capacity Act 2005 in England and Wales, and the Mental Capacity Act (Northern Ireland) 2016, enables the patient to authorise someone who is over 18 years of age to make decisions for them under a Lasting Power of Attorney (LPA). Alternatively, someone who has authority to make treatment decisions for that person, as a court appointed deputy, can give consent.210, 211 In Scotland the Adults with Incapacity (Scotland) Act 2000 enables someone to hold Power of Attorney (PoA). The phrase ‘next of kin’ has no legal definition or status, and such a person cannot give or withhold consent on behalf of the patient.
C53
There are two types of LPA. One that enables the attorney to make decisions regarding the patient’s property and one that enables the attorney to make decisions regarding the patient’s care or welfare. The care and welfare attorneys are called personal welfare LPAs in England and Wales, welfare PoAs in Scotland, and care, treatment and personal welfare LPAs in Northern Ireland. The attorney powers relating to the patient’s property are valid if the patient has capacity. However, the attorney powers relating to care or welfare only come into play if the patient lacks capacity, or the attorney reasonably believes the patient lacks capacity. If you are relying on someone who has an LPA or a PoA to give consent on behalf of your patient you should keep a copy of the LPA or PoA document.
C54
You must take account of the advice on assessing capacity in the Codes of Practice that accompany the Mental Capacity Act 2005, the Adults with Incapacity (Scotland) Act 2000, the Mental Capacity Act (Northern Ireland) 2016, and other relevant guidance. If your assessment is that the patient’s capacity is borderline, you must be able to show that it is more likely than not that they lack capacity.
C55
The decision or action taken on behalf of the patient who lacks capacity must be in their best interests.
C56
You should record in the patient notes your reasons for deciding that:
  1. the treatment is in the patient’s best interests, and
  2. the patient lacks capacity.
C57
You should offer patients who are likely to have difficulty retaining information a written record of your discussions and the decisions that were made.

References

201 Mental Capacity Act 2005.
205 Department for Constitutional Affairs (2007) Mental Capacity Act 2005, Code of Practice [Accessed 4 Nov 2017]
206 Department of Health (2009) Reference guide to consent for examination or treatment. 2nd ed [Accessed 4 Nov 2017]
207 Adults with Incapacity (Scotland) Act 2000.
208 The Scottish Government. Adults with Incapacity [Accessed 6 Nov 2017]
209 The Mental Capacity Act (Northern Ireland) 2016
210 Office of the Public Guardian Make a lasting power of attorney [Accessed 6 Oct 2017]
211 Lasting Powers of Attorney, Enduring Powers of Attorney and Public Guardian (Amendment) Regulations 2007 SI 2161.

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