7.1. Analyse informed decision making in relation to medication

This guide will help you answer 7.1. Analyse informed decision making in relation to medication.

Informed decision making plays a central part in supporting the safety, rights and wellbeing of people using health and social care services. When medication is involved, this process becomes even more important. Medication can bring health benefits, reduce symptoms and control conditions, but it can also carry risks if not used properly. People need to feel confident that their views, knowledge and preferences are considered.

This guide covers what informed decision making means when medication is involved, the legal and ethical background, the steps in the process, the role of risk assessment, how to support individuals, and the factors that help or block good decision making.

What is Informed Decision Making About Medication?

Informed decision making means that a person is given all the relevant information they need before agreeing to a medication or treatment. They need time, support, and the chance to ask questions. Their decisions are based on a clear understanding of the benefits, risks and options.

With medication, this covers things like:

• What the medication is called
• Why it is being offered
• How it will help
• Possible side effects
• Any alternatives
• How to take or use it

A person who is informed can make choices that match their wishes, beliefs, health needs and lifestyle.

The Legal Framework

In England, several laws relate to medication and decision making. They protect people’s rights and guide care staff.

Key laws include:

• Mental Capacity Act 2005. This law says everyone aged 16 or over must be assumed to have capacity (the ability to make a choice) unless shown otherwise. People should be helped to make their own decisions. If they cannot, staff must act in the “best interests” of the person.
• The Human Medicines Regulations 2012. These rules control how medicines are prescribed, dispensed, and given. Only qualified people can prescribe or supply medication unless it is a legal exception.
• The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This states providers must get consent for treatment, protect rights and keep people safe.
• Data Protection Act 2018 and UK GDPR. These protect personal information, including about medication.

Following the law is not a choice – it is a requirement.

Ethical Principles

Ethics means what is right and fair when caring for another person. In medication, ethical principles make sure people are treated with honesty and respect. These include:

• Autonomy (right to make choices about your own care)
• Beneficence (helping others and doing what is good for them)
• Non-maleficence (not causing harm)
• Justice (treating people fairly)
• Respect for dignity (valuing each person)

Staff should always try to balance what is safe with the person’s wishes.

Steps in the Informed Decision Making Process

Supporting someone with medication decisions requires clear steps. Each step builds a full picture and gives the person the best chance to make a choice that is right for them.

1. Sharing Information

A staff member gives clear, accurate and honest facts about:

• The medication name and purpose
• How it works and its likely benefits
• Possible side effects or reactions
• What happens if the medication is not taken
• How and when to take it
• How to spot a problem or allergy
• What choices are available

Information should be easy to understand. Avoid medical jargon. Use pictures or simple words if needed. Written information can back up spoken explanations.

2. Checking Understanding

Ask the person to repeat back the main details in their own words. This finds out if the information made sense. Offer extra explanation if needed.

3. Discussing Preferences

People may have cultural, religious or personal reasons for accepting or refusing medication. Discuss their views and listen with respect. Never rush this stage.

Examples of influences:

• Previous experience with medicine
• Concerns about side effects
• Religious beliefs against certain ingredients
• Food or alcohol intake restrictions
• Personal values about natural remedies

4. Giving Opportunity to Ask Questions

Staff should allow enough time for questions. Reassure the person that all questions are welcome and valid, no matter how small.

5. Supporting Decision Making

Offer guidance but never force or direct the person’s choice. Help them weigh up the risks and benefits. If appropriate, involve family, friends or advocates.

6. Recording the Decision

Always record what was decided and the main reasons. Documenting this protects the person, you and your employer. If the person refuses medication, write this down and the reason. Record who was involved in the conversation.

7. Reviewing the Decision

People can change their mind about medication. Check in regularly to see if they are still happy with their choice or need further support.

Assessing Capacity

Capacity means having the ability to make a specific choice at a certain time. The Mental Capacity Act guides how to check capacity.

Ask these questions:

• Does the person understand the information?
• Can they remember it long enough to decide?
• Can they weigh it up?
• Can they communicate their decision (by any means)?

If the answer is yes to all, the person has capacity and their wishes stand. If not, decisions must be made in their ‘best interests’, considering their wishes, feelings and views.

The Role of Risk Assessment

Medication always carries some risk. Health and social care staff must help people balance risk and benefit.

Risk assessment means thinking about the possible harm of taking or not taking a medication. Include the risk of:

• Side effects
• Interactions with other medicines
• Health getting worse due to missed doses
• Allergic reactions

Share this risk with the person. Explore ways to reduce harm, like monitoring, adjusted doses, or trying alternatives.

Supporting People Who Lack Capacity

If someone cannot make their own decision about medication, a ‘best interests’ approach is used. The process must:

• Consider all available information
• Take into account the person’s past wishes and feelings
• Involve family, friends, or advocates where possible
• Avoid discrimination or making assumptions

A decision made in this way should still reflect what the person would most likely have wanted.

Person-Centred Approach

Medication decisions are often most effective when the care is person-centred. This means seeing each person as an individual with their own history, preferences and needs.

A person-centred approach links directly to informed decision making:

• Give people choices
• Respect refusal – people may say no, and this must be respected
• Involve the person at every stage
• Make adjustments for communication or sensory needs
• Document every step and discussion

This approach improves trust and helps people feel more in control.

Barriers to Informed Decision Making

Sometimes barriers get in the way of people being truly informed about medication. These need to be identified and removed where possible.

Common barriers include:

• Communication difficulties (hearing, speech, language)
• Learning disabilities or mental health problems
• Lack of accessible information (written, pictorial or audio)
• Pressure from family or staff
• Shortages of time during consultations
• Overuse of jargon or unclear language
• Stress or feeling unwell during discussions
• Cultural or religious misunderstanding

Staff can remove some of these by adapting their method, using interpreters, offering written information in other languages, or giving more time.

Supporting Good Decision Making

There are several ways workers can actively support good decisions about medication:

• Make environments quiet and private so people can focus
• Allow enough time – never rush
• Repeat information in several ways
• Involve trusted friends, family, or advocates if the person wishes
• Adjust for sensory needs – large print materials, hearing loops, simple pictures
• Always respect the person’s pace and preferences
• Check back: “Is there anything you are unsure about?”
• Keep your own knowledge up to date – know where to find accurate guidance

The Role of Advocates and Interpreters

Some people need more assistance to participate fully. Advocates speak up on behalf of people who find it hard to do so themselves. Interpreters help with language barriers.

An advocate might:

• Help a person express views or concerns
• Make sure their interests are put first
• Attend medication reviews or meetings

An interpreter ensures information is understood in the person’s own language. Arrange these services early if needed.

Consent

Consent means agreement. Before giving any medication, staff must get the person’s consent. This can be:

• Verbal (spoken)
• Written (signed form)
• Implied (nodding, holding out an arm)

No consent = no medication, unless giving it is legally justified in an emergency or best interest decision.

Consent must be informed. This means the person knows what they are agreeing to, in a way that makes sense to them. Trickery or pressure is never allowed.

Refusing Medication

People have the right to say no, even if you disagree with their reasons. Refusal must not be seen as a failure or problem. Staff should find out why, discuss the risks and check if the person changes their mind, but never force the issue.

Respecting refusal is part of good care.

Involving Families and Carers

Many people want family or carers to be involved in medication decisions. Always ask the person first who they would like involved. Some may prefer privacy.

Families can provide useful background, spot side effects, or help with remembering to take medication.

Final Thoughts

Informed decision making about medication is not just a process. It is the foundation of safe, respectful and person-centred care. Legal and ethical rules set the standard, but kindness, understanding and clear communication make it real in daily practice.

When you support others to make choices about their medication, you empower them. You promote dignity, safety and trust – three key aims in health and social care.

By following these principles and adapting your approach for each person, you support positive outcomes and a better quality of life.