Over many years of professional practice I have come across a number cases where certain vulnerable individuals have found themselves unable to make a decision, most frequently when they are confronted with a ‘big decision’ of lasting consequence.
While in some cases it can be sensible to put off a decision until more information becomes available, this ‘decision paralysis’ can sometimes have lasting and quite damaging consequences. This is especially true where decision paralysis can lead to delays in treatment or reduce the quality of life of the individual while they mull over their decision.
This raises an important question: does a person experiencing decision paralysis lack mental capacity?
Mr A is an adult approximately 35 years old who had his left leg amputated above the knee following a traumatic accident. Mr A has had over 5 years of treatment and interventions provided to support rehabilitation and pain management. Mr A has nerve damage, that to date has not been successfully managed by the specialist teams. Mr A has been told there is no further options available to manage his pain.
However, Mr A is then offered a trial treatment that he is given limited information about, recalling only that there is a 50:50 chance of success. On this matter, Mr is unable to decide, voicing that he has never experienced this degree of uncertainty before.
Pain, and associated medication to manage pain, is reported to be the diagnostic criteria on Mr A’s mental capacity assessment for entering into trial treatment. Mr A was acutely aware of being assessed at the time and did not want to be determined to have a lack of capacity, having a fear of repercussions for his health and care support moving forward. This added to his decision paralysis.
Ms B is a neurodiverse adult approximately 55 years old who has always functioned independently within the community and has no care support in place. Ms B has been given notice to leave her rented accommodation where she has lived for two years. Notice was given due to a change in the landlord’s personal circumstances.
The decision being considered was if Ms B could independently manage a change of accommodation. Ms B’s presentation was changeable during interactions, quickly transitioning from positive, energetic greetings to tearful anxieties. Ms B shared how she was actively seeking information around properties to rent and alternate options, consulting friends and directly to lettings agents. Ms B was then unsure of how to apply this knowledge into practical next steps, or how to weigh up each person’s advice, demonstrating difficulties with processing information. Ms B identified her options as renting a property, living in a caravan, renting a room or relocating across the country to live with an acquaintance.
Ms B was unable to make a choice, seeking another person to decide or take action on her behalf, thus presenting a classic case of decision paralysis.
Broadly speaking, decision paralysis is recognised within society, but is under-represented in terms of Mental Capacity.
In the first instance we must come to what the five underlying principles of the Mental Capacity Act (2005), focusing upon a presumption of capacity and a responsibility to support independent decision making. Therefore, all reasonable adjustments should be made to provide necessary decision-specific information to the client in an accessible format.
From this point, I would then consider if the decision being addressed needs to be answered in and of that moment or can it be delayed to allow time to process. Then, if it is deemed necessary and appropriate to assess mental capacity, careful questioning should support a natural analysis of pros and cons around options from the individual’s perspective, enabling them to come to a place of decision.
In both instances described above, the clients had capacity to make the decisions in question. In the case of Mr A, he clearly needed time to process his options, identify questions he would like answered to support decision-making, and a second consultant’s opinion on his case, weighing up with known alternatives.
Meanwhile, in second case study, Ms B was observed to be unintentionally influenced by others, as she would often confuse a personal opinion with an active instruction, feeling as though she would be disappointing others if she were to chose an alternative. In this case, client B required support to clarify and simplify information to aid processing, with adapted visual options to aid the decision-making process. Client B then required step-by-step support by Next of Kin to promote independent property searches and selections.
Issues with assessments
Case study 1 should hopefully give readers some cause for concern, as it seems that there was no clear explanation given for Mr A’s original mental capacity assessment, leaving him feeling scrutinised and scared for lasting impacts on care and treatment. As such, he was not aware of the Mental Capacity Act’s safeguarding nature, protective principles, or the fact each assessment is decision-specific. This is a vital reminder to us all in explaining and reassuring a client prior to assessment. As without this, we risk further influencing a client’s engagement and answers, leaving them feeling there is a ‘right’ way to respond.
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