The Mental Capacity Act in Dentistry

I remember having to write an essay about the Mental Capacity Act (MCA) during my undergraduate years; yet it took me over a year in practice to fully understand it's relevance and how to use it...

Since working within the community dental setting and treating special care patient groups, I find myself referring to the Act almost every day!

What is the Mental Capacity Act?

The Act, passed into law in 2005 and all health professionals have to follow its Code of Practice when treating patients - in particular this could be in those who may have a cognitive impairment or learning disability, I find most commonly I use the act when treating patients who suffer from dementia. 

5 Principles:

  1. A person must be assumed to have capacity unless it is established that he lacks capacity
  2. A person is not treated as unable to make a decision unless all practicable steps to help him do so have been undertaken without success
  3. A person is not treated as unable to make a decision because he makes an unwise one
  4. A decision made under this act must be done or made in his best interests
  5. Least restrictive measures must be undertaken if possible e.g. a patient may not able to consent for a general anaesthetic, but they may be able to consent for treatment under local

Who lacks capacity?

According to the act, someone who lacks capacity to consent cannot:
  1. Understand the information relevant to the decision
  2. Retain that information for sufficient amount of time
  3. Weigh up that information as part of making the decision
  4. Communicate this decision

How do you use the MCA in practice?

If you work in a trust or other hospital or community environment, it's likely they will have their own trust policy on MCA that you should follow. We also have additional paperwork to fill in (a template framework) which is very useful, as well as additional consent forms for those who lack capacity to consent for themselves. If you work in practice, this may not be available to you. In these cases here are some of my tops tips.

Top Tips:

  • Do not assume someone lacks capacity. This can be tempting if a patient attends with their carers or family, but try to engage them in the decision making process
  • Break things down into simple stages and reintroduce these at the beginning of appointments (this can be particularly useful for dementia patients or those with learning disabilities). Don't overwhelm them with information in a short space of time
  • Information may have to be delivered in several formats, especially if there are sensory difficulties. For example, verbal, written (large print or with illustrations) or the use of an advocate/interpreter
  • The environment you are in may affect the ability for a patient to have capacity e.g. familiar settings, the same surgery or staff, or even treatment in the domiciliary setting may help 
  • Take into consideration time of the day; early morning appointments may mean a patient is less disorientated
  • You may need to take opinions of other individuals into account when making a best interest decision e.g. carers, family members, other professionals, Powers of Attorney (POA)
  • There are 2 different POAs: Health and Financial. Even if the patient has a health POA, they still cannot consent on a patient's behalf but can input their opinion when making decisions 
  • In our service, if things are relatively simple e.g. an unrestorable and symptomatic tooth requires extracting, 2 dentists will sign the appropriate consent form
  • If things are a little more complex, a best interests meeting will be set up with the patient, more than one dentist, if there are available the patient's carers/family members/POAs and if necessary an Independent Mental Capacity Advocate (IMCA).
  • Record keeping is key in this case and always be mindful of any safeguarding issues. 

If you are still unsure or don't feel confident in these cases, consider referring these patients onto the your local community dental services as we are experienced in managing these cases. 

For more information, see the Mental Capacity Act.

I hope this clarifies things! Do you find yourself using the MCA in practice? What do you find challenging? Let me know in the comments below!

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