This foundation stone of the Mental Capacity Act (MCA) is one of the five statutory principles, the one that says we should never decide that people lack capacity to make a decision for themselves unless we’ve done everything ‘practicable’ to enable them to make that decision for themselves, without success.
Like many of the phrases we use all the time, this is ‘deceptively simple,’ which makes it worth looking at a bit more closely, to see what it means in practice.
For a start, what does ‘practicable’ mean? There’s certainly the element of ‘practical’ in there. In an emergency, it may simply not be possible to, find the right pictures to help explain the options to someone who is confused and probably a bit scared, or find an interpreter. You may try really hard to get hold of someone’s relatives to get their help with communicating, only to find they’re all at work. So, what does ‘practicable’ mean in practice?
Bending over backwards
A charming care provider explained this to me as meaning ‘we must bend over backwards to do everything we can think of’. He was actually rather like Humpty Dumpty in his build, and somehow the picture he conjured up has stayed with me. It’s great advice, though. It does mean doing all you can think of to enable someone to make their own decisions. We should think ahead about any foreseeable ‘emergency’ situations that might well arise – such as, a person for whom English is a second language may forget their English when unwell or stressed – and put your contingency planning into the care plan.
I visited an excellent care home for older people, that planned ahead. They got Josef’s son to record, in Czech, a reminder of why his medication was necessary, and how often it needed to be taken, and why there was sometimes a need for a blood test with this medication – ending up with a joke in Czech, that never failed to make Josef laugh. Then, when Josef got confused and a bit frightened, and his English failed him, they could play him the recording if his family weren’t around. He’d laugh, and relax, and remember his English as well as the reason for his pills.
This meant he didn’t end up being given restraint to have a blood test against his will, or being given his medication covertly. In the language of ethics, his autonomy was respected; in common terms, his dignity was upheld. And in the language of the MCA, he was supported – by a practicable means – to make his own decision about his medication and blood test.
For ideas about supporting decision-making, see the MCA code of practice chapter 3:
And, here’s the challenge: encourage staff to think as creatively as possible about an individual and how to support that person to make more of their own decisions. Let me know how it goes: we’ll share the best ideas!