Supported Decision-Making: Helping Patients Decide for Themselves

A patient keeps saying, “I don’t understand,” while the ward carries on around them.

That does not automatically mean they cannot decide. It may mean the information, timing or communication is not working for them.

Supported decision-making is the practical work of helping a person understand their options, express what matters to them and make their own decision wherever possible.

Support Before Substitution

Capacity law across the UK starts from an important idea: people should be helped to make their own decisions before someone else steps in.

That support will look different for each person. Someone with hearing loss may need a working hearing aid and a quiet room. A person with aphasia may communicate more clearly using pictures, gestures or extra time. Someone with delirium may need treatment, rest and reassessment when they are more alert.

The aim is not to steer the person towards the choice the team prefers. It is to make the decision as understandable and accessible as possible.

What Can Supported Decision-Making Include?

Practical support may include:

• using plain, concrete language
• breaking information into smaller parts
• explaining one decision at a time
• using pictures, objects, writing or communication aids
• arranging a professional interpreter
• checking glasses, hearing aids and other equipment
• choosing a quieter environment
• allowing time for the person to process and respond
• asking when they are usually most alert
• addressing pain, anxiety, breathlessness or other barriers
• involving a trusted person when the patient wants this
• offering independent advocacy where appropriate

Not every option will suit every patient. The support should respond to the person in front of you, not become another checklist completed without thinking.

England and Wales

The Mental Capacity Act 2005 says a person must not be treated as unable to make a decision unless all practicable steps to help them have been taken without success.

National Institute for Health and Care Excellence guidance also emphasises accessible information, effective communication, involvement in decisions and recording the support provided.

This matters when capacity is assessed. A person should not fail an assessment because staff used complex language, rushed the conversation or ignored a known communication need.

Scotland

The Adults with Incapacity (Scotland) Act 2000 uses its own legal framework, but participation remains central.

The adult’s past and present wishes should be considered, appropriate assistance should be offered so they can communicate their views, and people exercising relevant functions should encourage the adult to use and develop the skills they still have.

The Mental Welfare Commission for Scotland’s supported decision-making material also stresses the importance of autonomy, communication, advocacy and helping people express their will and preferences.

Northern Ireland

The Mental Capacity Act (Northern Ireland) 2016 is described by the Department of Health as fundamentally a supported decision-making statute.

However, the Act is being implemented in phases and has not been fully commenced. Students should therefore follow current Health and Social Care trust procedures and the legal framework that applies to the particular decision.

Support Is Not Persuasion

There is a difference between helping someone understand and repeatedly pushing them until they agree.

Good support explains the options, checks understanding, responds to questions and gives the person room to decide.

Pressure, threats, withholding relevant information or presenting only one acceptable answer can undermine consent. A patient is allowed to refuse, change their mind or make a decision that other people consider unwise if they have capacity to make it.

The goal is not agreement. The goal is a decision that genuinely belongs to the patient.

A Placement Example

A patient with expressive aphasia after a stroke is asked whether they agree to a proposed care plan. They struggle to produce words and become frustrated.

It would be wrong to assume that difficulty speaking means they cannot understand or decide.

The team could reduce background noise, use short sentences, present information in stages, ask questions that can be answered using gesture or a communication board, and involve speech and language therapy. The patient may need more time than the ward routine normally allows.

If they can understand, retain, use or weigh the information and communicate their decision by any means, their speech difficulty does not remove their capacity.

When a Trusted Person Is Involved

A relative, friend, advocate or carer may help staff understand how the person communicates and what usually works well.

But support should not turn into someone else answering every question for the patient.

Where possible, speak directly to the person, check whether they want the other individual involved and remain alert to undue influence. A familiar voice can be reassuring, but the decision still belongs to the patient while they have capacity.

Why Timing Matters

Decision-making ability may change during the day or as an illness improves.

A person with delirium may be clearer after treatment and rest. Someone with Parkinson’s disease may communicate better when their medicines are working effectively. A patient who is exhausted after a long procedure may be better able to decide the following morning, if the decision can safely wait.

Urgent decisions cannot always be delayed. When time allows, choosing the person’s best decision window can make the difference between making a decision themselves and having one made on their behalf.

What Should Be Documented?

Documentation should show more than the final answer.

Depending on your role and local process, the record may include:

• the specific decision being discussed
• how information was explained
• communication aids, interpreting or advocacy used
• who the patient wanted involved
• barriers that were identified and addressed
• the person’s responses in their own words where possible
• whether another time or environment improved the conversation
• who was informed and what happened next

As a student, document within your level of responsibility and ask the registered nurse to review anything you are unsure about.

The Student Nurse’s Role

You may be the person who notices that the patient understands much more when questions are slowed down, or that their hearing aid battery is flat, or that relatives are speaking over them.

You can:

• ask the patient what helps them communicate
• make sure basic communication equipment is available
• reduce avoidable distractions
• give the person time to answer
• report changes in cognition or communication
• involve your practice supervisor or the registered professional
• raise concerns if a decision feels rushed or the patient is not being heard

You are not expected to resolve a complex legal assessment alone. Your observations can still make the process safer and more person-centred.

The Bleepbook Takeaway

“They cannot decide” should never be the first conclusion when “we have not found the right way to support them” may still be true.

Supported decision-making takes patience, flexibility and proper communication. It protects autonomy and makes capacity assessments fairer.

References

Department of Health Northern Ireland. Mental Capacity Act background.

Legislation.gov.uk. Mental Capacity Act 2005.

Mental Welfare Commission for Scotland (2024). Supported decision-making: good practice.

National Institute for Health and Care Excellence. Decision-making and mental capacity (NG108).

Scottish Government. Adults with Incapacity (Scotland) Act 2000: principles.