Understanding Mental Capacity: A Guide for Patients and Families

When someone we love makes a decision that we disagree with, it can be worrying. Perhaps they want to live independently despite difficulties with mobility, refuse help at home, decline treatment, or choose to do something that their family feels is unsafe.

It is natural to want to protect someone, especially when we can see the risks they may be facing. But an important question arises: does making a decision that others disagree with mean someone lacks mental capacity?

The answer is no. In England and Wales, the Mental Capacity Act 2005 protects a person's right to make their own decisions, including decisions that other people consider unwise. This guide explains what mental capacity means, how it is assessed, and what families can do if they are concerned.

What is mental capacity?

Mental capacity is a person's ability to make a particular decision at the time it needs to be made.

It is not a general judgement about whether someone is sensible, responsible or able to manage every aspect of their life. A person may be able to make some decisions independently but need support with others.

For example, someone might be able to decide what to eat, what to wear and who to spend time with, but have difficulty understanding a complicated financial decision. Someone with dementia, a learning disability, a brain injury or a mental health condition may still have capacity to make many decisions.

Capacity can also change over time. A person may have difficulty making a decision when they are unwell, confused or exhausted but be able to make it when they feel better.

The starting point is always to assume that an adult has capacity unless there is evidence that they lack it for the specific decision in question. A diagnosis, disability, age or unusual behaviour does not automatically mean someone lacks capacity. NHS guidance

The four areas of mental capacity

When assessing whether someone can make a particular decision, four abilities are considered.

1. Can the person understand the information?

The person needs to understand the information relevant to the decision, including the main options and the reasonably foreseeable consequences.

For example, if someone wants to return home after a hospital stay, they may need to understand what support they require, what difficulties they might encounter and what could happen if they do not have enough help.

Information should be explained in a way the person can understand, using straightforward language, pictures or other communication support where helpful.

2. Can the person retain the information?

The person needs to be able to hold on to the relevant information long enough to make the decision.

They do not need to remember every detail indefinitely. They may need reminders or an explanation more than once. Being forgetful does not automatically mean someone lacks capacity.

3. Can the person use and weigh up the information?

The person needs to be able to consider the relevant information, think about the options and weigh up the likely benefits and disadvantages as part of reaching their decision.

This can be the most difficult area to understand. Someone may understand that living alone carries risks but still feel that independence, privacy and being in their own home are more important to them.

That does not automatically mean they lack capacity. They are allowed to place different values on different things from their family or healthcare professionals.

The question is whether they can consider the relevant information as part of making their decision, not whether they reach the choice other people would prefer.

4. Can the person communicate their decision?

The person must be able to communicate their choice in some way. This does not have to be through speech. They may communicate by writing, using communication aids, gestures or other means.

If someone has difficulties with speech, hearing, language or communication, reasonable efforts should be made to support them before concluding that they cannot make the decision.

A person should not be considered to lack capacity simply because communicating their wishes is difficult.

Under the Mental Capacity Act, a person may lack capacity for a particular decision if they cannot do one or more of these things because of an impairment or disturbance in the functioning of their mind or brain. GOV.UK guidance

What if someone makes an unwise decision?

This is one of the most important principles to understand.

A decision is not evidence of a lack of capacity simply because it seems unwise, risky or wrong to someone else.

We all have different priorities. One person may value safety and reassurance above everything else, while another may value independence, freedom and control over their own life.

Consider these examples.

Example 1: Wanting to remain at home

An older person has difficulty walking and has fallen previously. Their family would prefer them to move into residential care, but the person wants to remain at home.

If they can understand and weigh up the relevant risks and available support, they may have capacity to make that decision, even if their family remains worried.

Example 2: Refusing help

A person declines a care package because they value their privacy and do not want strangers coming into their home. Their family believes the support is essential.

The person may understand that refusing help could increase the risk of falls or make daily tasks harder. They are still entitled to make that choice if they have capacity for the decision.

Example 3: Wanting to do something physically risky

Someone with reduced mobility wants to walk to the local shop rather than accept a lift. Their family is concerned that they might fall.

The risks should be discussed and practical ways to make the activity safer explored. However, wanting to take a risk does not, by itself, establish that the person lacks capacity.

In each example, the person may make a different choice if they are given clear information, time and support. But if they understand the risks and can weigh up the options, their decision should generally be respected.

This does not mean that risks should be ignored. It means that concern about risk and a finding of incapacity are two different things.

What should families do if they are worried?

It can be distressing to watch someone make choices that you believe could harm them. Families often have valuable knowledge of the person's usual behaviour, preferences and abilities.

Rather than immediately assuming the person lacks capacity, try to:

• Listen to their reasons. Ask what matters most to them and why they prefer one option over another.

• Explain the risks calmly. Make sure they have the information they need without overwhelming or pressuring them.

• Explore alternatives together. Could equipment, adaptations, a different care arrangement or some additional support help them achieve what they want more safely?

• Allow time. Important decisions are often easier to make when someone is rested, comfortable and not under pressure.

• Share your concerns with professionals. A GP, social worker, occupational therapist, physiotherapist or another appropriate professional may be able to help.

Family members do not have to agree with the decision. Their concerns can be taken seriously while still respecting the person's right to make their own choices.

When might a capacity assessment be needed?

A capacity assessment may be appropriate when there is a genuine reason to believe that a person cannot make a particular decision because the functioning of their mind or brain is affected.

For example, they may be unable to understand important information about a decision, repeatedly lose the information before they can use it, or be unable to weigh up the relevant options because of an impairment affecting their thinking.

The assessment should focus on the specific decision, at the time it needs to be made. It should also take account of any practical steps that could help the person decide for themselves.

If someone is suddenly confused or their thinking changes unexpectedly, seek prompt medical advice, as there may be an underlying illness or other cause that needs assessment.

A capacity assessment should not be used simply to obtain the outcome that a family member or professional wants.

What happens if someone lacks capacity?

If a person is assessed as lacking capacity for a particular decision, a decision may need to be made on their behalf. Under the Mental Capacity Act, this must be in their best interests and should take account of their wishes, feelings, values and beliefs, alongside other relevant circumstances.

The least restrictive appropriate option should be considered. In other words, any action should interfere with the person's rights and freedom as little as possible while addressing the decision that needs to be made.

Lacking capacity for one decision does not mean someone lacks capacity for every decision. Nor does it mean that their wishes no longer matter.

Family members can provide important information about the person's preferences and what matters to them, but being a relative does not automatically give someone authority to make every decision on another adult's behalf.

The most important thing to remember

When someone makes a decision that worries us, it is natural to want to step in and protect them.

But protecting someone also means respecting their rights, values and individuality.

Mental capacity is not about making the decision that someone else considers best. It is about whether the person can make that particular decision for themselves, with appropriate support.

People have the right to make their own decisions, including decisions that others consider unwise, provided they have the capacity to make them.

At Physio at Home, we recognise that balancing independence, safety and family concerns can be challenging. Open conversations, practical support and a person-centred approach can often help families and professionals find a way forward that respects the individual's wishes while addressing genuine risks.

This article provides general information about mental capacity in England and Wales. It is not a substitute for an individual assessment or legal advice.

Further information: GOV.UK – Assessing mental capacity | SCIE – Assessing capacity