How to Ascertain Capacity When Someone Has a Stroke

Determining whether a person has the capacity to make decisions is a crucial part of supporting stroke survivors. Capacity can be affected in subtle ways after a stroke, and understanding how to assess it is key for families, carers, and healthcare professionals.

What is Capacity?

Capacity, in legal and medical terms, refers to a person’s ability to make a specific decision at a specific time. Under the Mental Capacity Act 2005 in England and Wales, a person is presumed to have capacity unless it is established otherwise. Capacity is decision-specific and time-specific—it can fluctuate, especially after a stroke.

Why Capacity Might Be Affected After a Stroke

A stroke can affect the brain in ways that impact decision-making abilities. Common areas affected include:

• Memory and attention: Difficulty recalling information or focusing on key details.

• Language (aphasia): Trouble understanding or expressing words.

• Executive function: Difficulty planning, reasoning, or evaluating options.

• Emotional changes: Anxiety, depression, or impulsivity may affect decisions.

These changes can make it challenging to assess whether someone truly understands the consequences of a decision.

Principles for Assessing Capacity

When assessing capacity, it’s essential to follow the key principles of the Mental Capacity Act:

1. Assume capacity unless proven otherwise – Don’t assume a stroke automatically means incapacity.

2. Support the person to make decisions – Use clear communication, visual aids, or simplified language.

3. Focus on the specific decision – Assess capacity for each decision separately.

4. Respect unwise decisions – People are allowed to make decisions others might consider unwise.

5. Use the least restrictive approach – Any intervention should minimally interfere with the person’s freedom.

Steps to Assess Capacity

1. Explain the decision clearly: Use plain language, short sentences, and visual cues if necessary. Make sure the person knows what the decision is about and why it matters.

2. Check understanding: Ask the person to repeat back the information in their own words. This helps confirm comprehension.

3. Evaluate reasoning: Determine if the person can weigh the options, understand the consequences, and compare alternatives.

4. Assess communication: Consider whether speech difficulties or physical impairments are preventing the person from demonstrating capacity. Alternative methods, like pointing or using communication boards, may help.

5. Document your findings: Keep a detailed record of the assessment, including how the decision was explained, the person’s responses, and your conclusion about their capacity.

When to Involve Professionals

If there is uncertainty, it may be necessary to involve:

• Doctors or stroke specialists – for a clinical perspective on cognitive impairment.

• Speech and language therapists – for communication assessments.

• Occupational therapists – for evaluating functional decision-making abilities.

• Solicitors or legal professionals – if decisions involve finances, property, or lasting powers of attorney.

Supporting Capacity

Even when someone’s capacity is limited, support can help them participate in decisions:

• Provide information in multiple formats (written, verbal, pictorial).

• Break decisions into smaller, manageable steps.

• Allow extra time for processing information.

• Include family or trusted carers to help interpret preferences.

Conclusion

Assessing capacity after a stroke is not always straightforward, but it is essential for protecting the rights and autonomy of the individual. By following structured assessments, using supportive communication, and involving professionals when needed, families and carers can ensure that stroke survivors are empowered to make decisions about their care and life wherever possible.