Adults with incapacity: guide to assessing capacity

Chapter 4: Assessing capacity interview - personal care

This chapter provides an outline for conducting an interview to assess the capacity of a person with mental disorder or inability to communicate in relation to his/her personal care.

Steps to take

Step 1:
Explore the factual understanding of current personal care circumstances

Talk to the person about his/her

• current living arrangements;
• own view of their health; and
• recollection of informal help and formal services received.

If the person does not mention relevant facts, bring these to his/her attention. If acknowledged, inquire at a later stage to see if these have been retained. Probe for the reasons behind any significant discrepancies between self reporting and third party reporting. It is presumed that you will know in advance where the person lives and if they live alone/with someone, and the availability and acceptance of supports.

Points to consider

• Is there a substantial discrepancy between the person's description of his/her daily routine or current living arrangements and that known or reported by others?
• Is the person aware of his/her responsibilities or obligations to dependants? (if appropriate).
• Is the person aware of the important decision-making demands faced in meeting personal care needs?

Step 2:
Identify areas of unmet need in each personal care domain being investigated

Talk with the person about self care, i.e. ask what he/she does to look after themselves and how well the person thinks he/she manages. The aim is to explore whether the person has the skills and knowledge to meet his/her personal care needs. If not, does the person recognise his/her limitations and seek appropriate assistance?

It will then be helpful to compare the person's self assessment with reports from others on how he/she manages on a day-to-day basis. If it is not possible to form an opinion about how well the person is functioning in essential areas, it is advisable to arrange for an additional occupational therapy assessment.

Points to consider

• Does the person admit to any problems in meeting personal care needs? If so, does he/she seek appropriate assistance?
• Is there evidence of recent change in the person's ability to self-manage? For example, has there been a deterioration in his/her appearance, self care, living environment - house less clean and tidy than before, lack of food in the cupboard, etc.
• Can the person recognise risky situations and respond accordingly?
• Could the person ask others for help in an emergency?
• Does the person encounter safety or physical health risks because of memory problems?

Step 3:
Explore decision-making within critical areas of unmet need

Areas of unmet need in terms of the person's personal care will be identified through the assessment and review process. The next stage will be to explore the person's ability to make decisions in relation to how these might best be met.

• First, ask questions designed to uncover the degree of insight the person has in relation to his/her self-care limitations. Begin by asking the person about any concerns raised by others who know the person well.
• Secondly, ask the person specific questions to test their 'understanding and appreciation' of the choices available. You may need to probe to assess: how far the person is able to weigh up the advantages and disadvantages of one option over another; whether or not the person can anticipate the consequences, both in terms of likelihood and severity. If the issue is refusal of services, explore fully the person's appreciation of the foreseeable consequences.
• Thirdly, look for evidence of reasoned choice. Examine the chain of reasoning for logical consistency. This is especially important where the person seems to be making an irrational or illogical decision that may have an adverse impact on his or her personal care, physical safety or well-being. You may need to probe his/her choices that seem to be predicated on delusional beliefs or hallucinatory experiences. A review of previous actions, prior wishes or history of choice under similar circumstances may provide information that either justifies or challenges the present choice or preference being expressed.

Points to consider:

• Is the person able to understand crucial information relevant to making decisions about his or her particular personal care needs?
• Is the person able to remember crucial information and/or is there evidence of consistency of choice over time?
• Can the person say what is likely to happen if his/her personal care needs are not met? Is the person's assessment realistic? Is he/she focussing on possible minor consequences and overlooking major ones?
• Are the person's stated reasons for his/her choice relevant to the decisions in hand?
• Are the persons actions or choices consistent with his/her expressed goals and priorities?
• Even if the person is unable or refuses to articulate the reasons for his/her personal care choices, are actions consistent with his/her expressed values or beliefs?