Capacity Assessment 🧠
On-call guide to assessing decision-making capacity in Ireland under the Assisted Decision-Making (Capacity) Act 2015: functional test, supports, documentation, and when to escalate.
🚨 When capacity matters (escalate early)
- Capacity is decision-specific and time-specific. Assess the decision in front of you (e.g. leave hospital, refuse IV antibiotics, consent to CT), not "global capacity".
- Common on-call triggers: DAMA / leaving against advice, refusing essential treatment or investigations, disputed consent, safeguarding concerns, placement or discharge decisions.
- Escalate to your registrar/consultant early if the decision is high-stakes, capacity is unclear, or there is conflict with family or decision supporters.
- Life-threatening emergency with no time to assess or support decision-making: provide necessary treatment without delay per HSE National Consent Policy emergency provisions and local SOP, then document and review capacity as soon as practicable.
- An unwise or risky decision alone is not a reason to assess capacity. If undue influence or safeguarding concerns exist, escalate via local policy (see Outcomes).
- Do not use MMSE, MoCA, or a diagnosis alone as a capacity test. Cognitive screens inform the picture; they do not determine capacity.
⚖️ Guiding principles (ADM Act 2015)
- The Act sets nine guiding principles for any intervention. On the ward, the ones you use most are below; see the DSS Code of Practice for the full list.
- Presume capacity unless the contrary is shown for this decision at this time. The person questioning capacity must provide the evidence, not the patient.
- Do not treat someone as unable to decide unless all practicable steps to help them decide have been taken without success.
- Do not treat someone as unable to decide merely because their decision seems unwise.
- Intervene only when necessary, in a way that is least restrictive of the person’s rights and freedom of action, and that gives effect to their will and preferences as far as practicable.
- Capacity can fluctuate (delirium, pain, sedation, time of day). Optimise the environment and reassess when appropriate.
🧪 Functional test (understand / retain / use / communicate)
- Per the Assisted Decision-Making (Capacity) Act 2015 and Decision Support Service Code of Practice, a person lacks capacity for a specific decision if they are unable to do one or more of the following:
- Understand the information relevant to the decision (nature, purpose, risks, benefits, and reasonable alternatives, including doing nothing).
- Retain that information long enough to make a voluntary choice.
- Use or weigh that information as part of making the decision.
- Communicate the decision by any means (speech, writing, gesture, assistive technology, or via a third party where needed to implement it).
- Assess only after practicable supports have been offered (interpreter, tailored information, quiet space, treat delirium/pain). If the person can decide with support, they have capacity.
- A pre-existing diagnosis or cognitive screen must not determine capacity. Record which functional element(s) are not met for this decision, with evidence.
📋 How to assess on the ward
- Name the decision clearly (e.g. "capacity to refuse CTPA tonight" or "capacity to leave hospital against medical advice").
- Optimise first: glasses/hearing aids, interpreter, quiet space, pain and nausea control, treat reversible delirium causes, avoid assessing mid-sedation if safe to wait.
- Explain in plain language. Check understanding by asking the person to explain back in their own words (risks of leaving / refusing, benefits of the proposed plan, alternatives).
- Explore values and reasons. An unwise choice with coherent reasoning usually still indicates capacity.
- Who assesses: per DSS Code of Practice, usually the professional with the best understanding of this specific decision (often the clinician proposing treatment). It is not always a doctor. Involve seniors for complex or contested decisions; psychiatry/geriatrics when cognitive, psychiatric, or communication issues dominate.
- Check for existing decision support arrangements via collateral, chart, and Decision Support Service records where relevant (see next section).
🤝 Decision support arrangements & advance planning
- Decision-making assistance agreement: appointed assistant helps the person obtain information and communicate; the person still makes the decision.
- Co-decision-making agreement: relevant decisions are made jointly with a registered co-decision-maker. Confirm scope and registration.
- Decision-making representation order: court-appointed representative may make specified decisions. Act within the order’s scope.
- Enduring power of attorney (EPA): may cover personal welfare and/or property; check whether it is registered with the Decision Support Service and what it authorises.
- Advance healthcare directive (AHD): respect valid, applicable refusals of treatment. Requests for treatment guide care but do not create a right to clinically inappropriate treatment.
- Next of kin do not automatically decide for an adult who lacks capacity. Involve them for will and preferences, and work within formal arrangements and HSE Consent Policy.
💬 Outcomes & next steps
- Has capacity: respect a voluntary, informed decision (including refusal), even if you disagree. Document counselling, risks explained, and the person’s understanding.
- Lacks capacity for this decision: provide all practicable supports first; if still unable, proceed under guiding principles / will and preferences and any valid decision support arrangement or AHD. Involve senior early.
- Unclear or contested: escalate, seek second opinion, involve MSW / psychiatry / legal as per local pathway. Do not coerce.
- If the person wants to leave and has capacity: follow DAMA process. If they lack capacity and leaving is unsafe: escalate immediately; do not simply "let them walk".
- Safeguarding or undue influence concerns: per DSS Code of Practice, treat as safeguarding; escalate same day via local policy (senior, HSE safeguarding team, Gardaí / Tusla as required).
📝 Documentation (write this)
- The specific decision assessed and the date/time.
- Information given (risks, benefits, alternatives) and supports offered (interpreter, quiet room, written info, advocate).
- Evidence for each functional element: understand / retain / use or weigh / communicate, with examples of what the person said or did.
- Conclusion: has / lacks capacity for this decision at this time, and why.
- Who was involved (senior, decision supporter, family) and the agreed plan if capacity is lacking.
- Plan to review if capacity may return (e.g. after treating delirium or when less sedated).
Based on
Note Template
Ready-to-use clinical note structure
🕒 06 / 10 / 2026 — 01:53 ATRP re: Capacity assessment Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [cognitive / psychiatric / neurological / other relevant] Framework: Assisted Decision-Making (Capacity) Act 2015 / HSE National Consent Policy 🧾 Decision assessed (specific, time-bound): • [e.g. capacity to refuse CTPA / leave against medical advice / consent to procedure] • Information given: risks, benefits, alternatives (including doing nothing) 🩺 Context & supports: • Reversible factors addressed: [pain / delirium / sedation / hearing / language / quiet space] • Practicable supports offered before concluding lack of capacity: [interpreter / written info / advocate / decision supporter / time to decide] • Existing arrangements: [DMA / co-decision / representation order / EPA (DSS-registered) / AHD / none known] 🧠 Capacity assessment (Functional test (understand / retain / use or weigh / communicate)): • Understand: [Y/N] — evidence: [...] • Retain: [Y/N] — evidence: [...] • Use / weigh: [Y/N] — evidence: [...] • Communicate: [Y/N] — evidence: [...] 📋 Impression: • [Has / lacks] capacity for this decision at this time • Reasoning: [...] 📌 Plan: • If has capacity: respect decision; document counselling • If lacks capacity: Will and preferences / decision support arrangements / least restrictive option; escalate senior • Review capacity when: [e.g. delirium treated / less sedated] • Senior informed: [ ] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer