Healthcare Professionals and Supporting decision-making and assessing capacity

Donal is an older man with poorly controlled type 2 diabetes and is confined to bed due to being morbidly obese. Medical and nursing staff believe that he has very little insight into his diabetes, the need to adhere to dietary advice, or the possible complications of his poor diabetic control. Instead, he continues to eat unhealthy foods.

Donal has developed leg ulcers and kidney disease but reports that, despite his health problems, he has a good quality of life and has no intention of changing his ways as advised by doctors and nurses. On several occasions over many years, the primary care team has discussed this matter with Donal, explaining the issues in ways he understands, responding to his concerns, and providing information in different formats. They have emphasised that Donal’s behaviour is life-threatening, but his position remains unchanged.

The issue of whether Donal’s lack of insight into his diabetes suggests a lack of capacity to make his own decision about changing his ways is raised at a meeting of the primary team. It is decided, however, that this would not be an appropriate avenue to explore because there is no appropriate trigger for an assessment of his capacity to make the decision.

Although Donal’s lifestyle choices are having a serious impact on his health, a decision not to comply with dietary advice is common in people with diabetes. Donal values his current quality of life and those who have known him a long time confirm that he has ‘always been this way’. It is also noted that there is no reasonable, proportionate, or practical intervention that could be made in the circumstances.

Comment: This vignette demonstrates that, in the absence of a valid trigger to assess capacity to make a particular decision, the presumption of capacity remains intact. In this case, it appears that Donal has poor insight into his diabetes and/or has made what doctors and nurses might consider to be an ‘unwise decision’ that will likely hasten his death. Donal’s decision is, however, consistent with his values and, in particular, his assessment of his own quality of life. Given the totality of these circumstances, the primary care team will continue to advise and treat Donal as best as possible but identify no adequate trigger to assess his capacity to make the decision at this time.