Supported decision-making in practice

A capacity assessment should not begin with a test and end with a label. The first task is to make the decision as accessible as reasonably possible. That means checking communication, hearing, vision, language, pain, breathlessness, fatigue, distress, medication effects and the environment.

A person who cannot follow a hurried conversation in a noisy ward at 02:00 may be able to decide after sleep, analgesia, hearing aids and a calm explanation. Support is part of the assessment, not an optional courtesy after it.

Information should be presented in a form the person can use. Short sentences, plain language, pictures, demonstrations, written summaries and teach-back can all help. The aim is not to reduce information below what is material to the decision, but to communicate that information in a way the person can understand.

Do not confuse limited literacy, aphasia, dysarthria, sensory impairment or English as an additional language with inability to decide. These conditions may require adapted communication or specialist input.

Where language is a barrier, a professional interpreter is usually safer than relying on a relative for significant decisions, particularly where confidentiality, accuracy or family pressure may matter. Communication aids and speech-and-language support can be essential when the person’s expressive ability is impaired.

The person does not need to speak in conventional sentences to communicate a decision. The relevant question is whether a reliable method of communication can be established.

Decision-making ability can be affected by acute illness, hypoxia, infection, medication, intoxication, withdrawal, pain, anxiety, sleep deprivation or fatigue. If a decision is not urgent, treat reversible factors and choose a better time. If it is urgent, document why delay is unsafe and use the applicable legal framework.

Support must be proportionate. A minor routine choice may require little adjustment; a high-stakes irreversible intervention may justify more time, senior input and repeated explanation.

A trusted relative, friend, advocate or carer can help the person feel safe, recall values or communicate preferences. Their role is to support the person, not to answer in their place unless they have verified legal authority and that authority applies to the decision.

Ask the person whether they want someone involved. If a supporter dominates the conversation, redirect questions to the person and consider speaking privately where pressure or coercion is possible.

Supported decision-making is not a rule that every decision must wait for ideal conditions. The clinical team must balance the value of improved participation against the harm of delay. In an emergency, life-saving action may need to proceed under the relevant emergency or incapacity framework. In a non-urgent decision, waiting for delirium to improve may be the most autonomy-preserving option.

Use the search box in this module to jump to these terms and related concepts.

• supported decision-making
• interpreter
• hearing
• vision
• communication aid
• fatigue
• pain
• delirium
• trusted person
• reasonable support

Write a support plan listing the practical adjustments attempted before concluding that a person could not make the decision.

Use current official sources for further reading. Links open the issuing organisation.

• MC-EW-01 — Mental Capacity Act 2005
• MC-EW-02 — Mental Capacity Act Code of Practice
• MC-S-03 — Adults with incapacity: code of practice for medical practitioners
• MC-NI-02 — Mental Capacity Act - Department of Health NI
• CON-UK-01 — GMC - Decision making and consent
• CON-UK-02 — GMC - The seven principles of decision making and consent
• CON-UK-04 — NICE NG197 - Shared decision making recommendations

Sources checked through 17 September 2026. High-volatility legal topics must be rechecked before patient-specific decisions.