Capacity is the ability of a person to make an informed and balanced decision. In other words, this is a combination of a patient’s ability to understand the information presented to them, the ability to weigh pros and cons and come up with a reasonable decision based on that.
All healthy adults are presumed to have capacity. However, if there are signs that a patient may be lacking capacity, then their capacity should be formally assessed by doctors and nurses.
Checking if a patient has capacity may involve checking if they:
In practice, this may involve asking the patient to explain their reasoning.
Since children are still in the process of brain development, we cannot assume by default that patients below the age of 16 have the same capacity as adults. In principle, parents are involved in the care of patients under the age of 16, and usually, the parents have the autonomy to consent to or object to treatment in the name of their child.
Nonetheless, some patients under 16 may be deemed to have the capacity to consent if they are judged to be mature enough to understand the procedure and the implications of their actions. In such a situation, they are claimed to be Gillick competent (an important buzzword for your medicine interviews!).
Since there are no fixed rules for Gillick competence assessment, it has to be based on the professional judgement of the healthcare professional. Importantly, the assessment has to be done in relation to a specific procedure or treatment (for instance, a 10-year old may be competent and mature enough to understand the implications of taking a blood sample, but not necessarily those of an appendicectomy).
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All patients above the age of 16 are deemed to have capacity unless they have a condition affecting their brain or mind at the time of making a medically relevant decision. This can include everything from mental disorders (e.g. bipolar disorder), through neurological conditions (e.g. Alzheimer's disease) to coma or intoxication.
But what if the patient is unable to decide (for instance, if they are unconscious but require an urgent medical intervention)? There are a few possible outcomes:
Advance Directive: The patient may have previously signed a legal document, called the advance directive, in which they have specified what treatments they may not wish to receive in certain situations (remember patients have the right to decline, but not to demand specific treatments). A most common example of an advance directive is a DNAR form (short for Do Not Attempt Resuscitation), in which patients object to resuscitation in advance if they were to suffer sudden cardiac arrest.
LPA (Lasting Power of Attorney): In the UK, if a patient is above 18 and is deemed to have mental capacity, they may nominate a person to take responsibility for their care if they were to lose capacity in the future. In case the patient is unable to decide for themselves at some point, the person with the LPA is granted the authority to make a decision in the patient’s name Nonetheless, even in the above situation, doctors have to ensure the wishes of the LPA and in line with the patient's best interests and previously expressed wishes or opinions.
If not stated by the patient, then the decision will belong to the doctor in charge, who is duty-bound to act in line with the patient's best interests. Additionally, the doctor has the responsibility to inquire about the patient's potential wishes (for instance, from their relatives or by considering the religious and cultural background of the patient), but in case of uncertainty, they mustn't take them into consideration.
Involving parents in case of danger: Even if a child (patient under the age of 16) is deemed to have the capacity, their parents must be involved in their care if the patient is in danger. While the involvement of a child's parents may be against their wishes and be a breach of confidentiality when the child's life is at risk of harm (for instance, suicide), it is common practice to inform the parents about the situation (as justified by the best interests of the patient).
Remember about the Advance Directive and LPA: In your medicine interview, if a patient in the scenario cannot decide for themselves, consider if they have an Advance Directive or an LPA to show off your knowledge and stand out.
Forgetting that different rules apply to children. You don’t need to know the specifics at this stage, just make sure to mention that patients under the age of 16 don’t fall in the same ethical category.
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