The Mental Capacity Act (MCA) 2005 provides a framework in the United Kingdom for making decisions on behalf of individuals who lack the capacity to make specific decisions themselves.
One of the critical components in this framework is the “Best Interest Assessment.” This process ensures decisions made for those who lack capacity are both appropriate and respectful of their rights and desires. Let’s break down what a Best Interest Assessment entails and why it’s crucial.
Understanding Mental Capacity
To fully comprehend a Best Interest Assessment, we first need to clarify what “mental capacity” means. Mental capacity is the ability to understand, retain, and weigh up information relevant to a decision and communicate the decision. Factors affecting mental capacity include:
- Dementia
- Learning disabilities
- Mental health problems
- Stroke or brain injury
- Substance misuse
Notably, mental capacity can vary over time and with different decisions.
What is a Best Interest Assessment?
A Best Interest Assessment is a formal evaluation conducted to determine what actions or decisions would be in the ‘best interests’ of an individual judged to lack the mental capacity to make those decisions themselves. This assessment ensures that any decision made honours the individual’s rights and preferences as closely as possible.
The Legal Framework
The Five Principles of the MCA
The MCA is based on five key principles:
- Presumption of Capacity: Assume a person has capacity unless proven otherwise.
- Support to Make Decisions: Take all practicable steps to help the person make their own decisions.
- Unwise Decisions: Do not assume a person lacks capacity because they make an unwise decision.
- Best Interests: Any act or decision made on behalf of a person must be done in their best interests.
- Less Restrictive Option: Consider whether the purpose can be achieved in a way that is less restrictive of the person’s rights.
A Best Interest Assessment specifically adheres to the fourth principle but is conducted with the other principles in mind to ensure comprehensive care and respect for the individual.
Steps in Conducting a Best Interest Assessment
Gathering Information
- Understanding the Person’s Wishes: Collect any advance statements or wishes expressed by the individual when they had capacity. This might include verbal statements or written documents.
- Consultation: Speak with people who know the individual well, such as family members, carers, or friends. Their insights into the person’s values and preferences are invaluable.
- Medical and Social Background: Review medical records, previous care plans, and any formal assessments of capacity.
Applying the Best Interests Checklist
The MCA introduces a checklist to guide decision-makers:
- Consider All Relevant Circumstances: Take into account all factors relevant to the decision.
- Regard Past and Present Wishes: Understand any past decisions or preferences and respect them.
- Avoid Discriminatory Bias: Do not base decisions purely on age, appearance, condition, or behaviour.
- Delay in Decision-Making Where Possible: If the individual might regain capacity, delay the decision if it all possible.
- Encourage Participation: Assist the individual to participate in the decision-making process as much as they can.
- Consider the Person’s Well-being: Weigh the pros and cons of each option, considering the individual’s welfare.
- Involve Others: Consult with those involved in the person’s care or who have a legitimate interest in their welfare.
Roles and Responsibilities
Decision-Makers
Decision-makers might include healthcare professionals, social workers, or family members. Their role is crucial, and they should:
- Understand the individual’s condition and likely progression.
- Be aware of the MCA and its principles.
- Keep thorough records of the assessment and decision-making process to show that the Act’s principles have been followed.
Independent Mental Capacity Advocates (IMCAs)
An IMCA may be appointed if the individual does not have family or friends to represent them. The IMCA ensures that the person’s rights are protected and provides an independent voice in the decision-making process.
Special Considerations
Life-Sustaining Treatment Decisions
Decisions about life-sustaining treatment carry particular weight. The MCA stipulates that such decisions must not be motivated by a desire to bring about the individual’s death. The decision must be clinically justified and in the person’s best interests, with thorough documentation to support it.
Deprivation of Liberty Safeguards (DoLS)
If the Best Interest Assessment involves decisions that might deprive the person of their liberty (such as being confined in a hospital or care home for treatment), DoLS come into play. They require additional scrutiny and legal authorisations to ensure the individual’s rights are upheld.
Record-Keeping and Review
Documentation of the Best Interest Assessment is paramount. Records should include:
- A detailed account of the two-stage capacity test.
- Evidence of efforts to support the person in making their own decision.
- The reasons for the decision, including how the person’s wishes and feelings were considered.
- Consultations with family, friends, and professionals.
Regular reviews ensure that decisions remain in the individual’s best interests, particularly if their condition changes.
Case Study: Mrs. Smith
To illustrate, consider the case of Mrs. Smith, an elderly woman with advanced dementia.
- Assessment: Mrs. Smith’s capacity to consent to a medical procedure is assessed. It’s determined she lacks capacity.
- Best Interest Meeting: A meeting is held with Mrs. Smith’s family, her GP, and a social worker.
- Gathering Wishes: Mrs. Smith had previously expressed a preference for non-invasive treatments.
- Decision: The team decides against a surgical procedure, opting for a less invasive alternative, aligned with her past wishes.
- Documentation: The decision, the consultative process, and the rationale are documented thoroughly.
Conclusion
A Best Interest Assessment is a cornerstone in safeguarding the rights of individuals who lack the capacity to make specific decisions themselves. It is a methodical process that places the individual’s welfare, rights, and previously expressed wishes at the forefront of decision-making. By adhering to the MCA principles, involving relevant parties, and thorough documentation, caregivers and professionals can ensure they act in the true best interests of those they support.
If you are part of a decision-making process under the MCA and feel unsure, always consult the relevant codes of practice. Your local council or healthcare trust can provide additional support and training to ensure compliance and the best possible care for those who depend on your decisions.
