Capacity assessment — the patient who insists on going home
PLAB 2 & PRES 3 · ethics / elderly medicine · hard · 10 minutes
Candidate brief
You are an FY2 doctor on an elderly care ward. Mr Ernest Boateng, 82, was admitted five days ago after a fall at home (no fracture; a urinary infection was treated and has resolved). He is now medically fit. The occupational therapy assessment concludes he is not safe to manage his stairs at home yet and recommends two weeks in an intermediate-care rehabilitation bed before going home. Mr Boateng is adamant: "I am going home today. It is my house and my decision." The ward nurse tells you he "clearly hasn't got capacity — he doesn't understand he'll fall again." Please assess Mr Boateng's capacity to make this decision and manage the situation.
What examiners look for
Capacity is a process test, not an outcome test. The law (Mental Capacity Act 2005) presumes capacity, and the four functional abilities — understand, retain, use and weigh, communicate — are assessed against THIS decision at THIS time. A conclusion of incapacity requires an impairment of mind or brain AND a functional failure caused by it; "he'll fall again" is a risk statement, not a capacity assessment. The most common professional error in this scenario is smuggling disagreement into the weighing limb: the patient who recites your risks back accurately and still chooses home has weighed them — he has weighed them DIFFERENTLY. Your values about acceptable risk do not outrank his in his own life; the statute protects unwise decisions deliberately, because the alternative is that agreement becomes the test. Support before judgement is a legal duty, not a courtesy: the right time of day, his hearing aid, plain language, correcting the factual misunderstanding (rehab ≠ permanent home), a family member present if he wishes. An assessment done in poor conditions measures the conditions. Many "incapacity" findings evaporate at 10 a.m. with the hearing aid in. When a capacitous patient refuses the safe plan, the professional task changes, it does not end: build the safest version of HIS plan (downstairs bed, commode, carers, alarm, GP review, a named route back), document the assessment and the discussion meticulously, tell the GP, and keep the relationship warm. Discharge against advice, done properly, is still discharge planning. And document like a lawyer is reading it next year — because one may be: the decision, the information given, the support offered, each functional element with his own words as evidence, the conclusion and the conditions. In capacity disputes, the record IS the assessment.
Guideline references
- https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice
- https://www.hacw.nhs.uk/mental-capacity-act---patient-information
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