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What is ‘understanding’?

Insight and understanding: Elderly woman smiling as she looks into the distance

At its most basic level, ‘understanding’ refers to ‘comprehension’ or ‘insight’ – the ability to apply knowledge to a specific topic or situation. However, in terms of the criteria for Mental Capacity Assessments, these definitions are perhaps a little broad. This is because when we test for capacity, we are not looking for an in-depth understanding of a specific topic, but rather an ability to ‘grasp’ the concept within the context of the individual’s own situation.

Understanding the decision

In order to establish what needs to be ‘understood’ in a Mental Capacity Assessment, and to what degree, it is first vital to have a clearly directed decision that needs to be addressed. This may be the individual’s decision to consent to photographs for the purpose of care and medical records; or the individual’s decision to consent to the use of bed rails to prevent falls.

Once the directed decision has been established, the assessor can then identify core concepts surrounding the decision. In the case of the photography example, ‘understanding’ here would include an appreciation of what a photograph is and how a photograph is stored. The individual would also need some degree of insight into how their data might be used, including who would have access to the photos and for what purpose

A graded approach

Of course, an assessor can always provide information in order to support the individual being assessed. However, a graded approach is advised.

For example, you may start with open-ended questions to begin with, providing time for the individual to process and respond. Then, if the individual is unsure of anything, to rephrase the question or perhaps use visual aids and provide additional information about the concepts as needed.

If any information is shared, it is good practice to ask the person being assessed to repeat the information back to you, or even to ask them the question again in order to check their comprehension.

Whether the outcome, all steps of graded support should be recorded in the final assessment.

The threshold of understanding

Clearly, the term ‘understanding’ is really very broad, and can be applied in many different contexts. In the case of Mental Capacity, the individual being assessed needs to have enough insight and understanding of information relevant to the decision in order to make an informed choice.

In order to assess how much understanding is really needed, a balance of probabilities may be required. This means comparing the individual’s insight to the average population. So, for example: what do the average 10 people understand about the decision being made? Does the person being assessed have a level of understanding similar to the average 10 people?

If they do, then as far as Mental Capacity goes, they are deemed to ‘understand’. In which case, the threshold of capacity is often lower than one might think.

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