How can I ensure informed consent is adequately obtained from patients with cognitive impairments?

To ensure that informed consent is adequately obtained from patients with cognitive impairments, health professionals must first assume capacity and then carefully assess the patient's mental capacity in line with the Mental Capacity Act 2005, documenting this assessment in the care record ¹. This assessment should be collaborative, involving the patient as much as possible and using communication aids or specialist support such as interpreters, speech and language therapists, or advocates to facilitate understanding and decision-making ¹,². Practitioners should recognise that capacity is decision-specific and time-specific, meaning the patient only needs to retain information relevant to the particular decision at hand and for the time necessary to make that decision ². It is important not to conflate lack of insight with lack of capacity, nor to assume incapacity simply because a patient makes a decision perceived as risky or unwise ².

Where cognitive impairments such as executive dysfunction are present, assessments should be supplemented by real-world observations of the patient's decision-making abilities to gain a complete picture ². If the patient refuses to engage in capacity assessment, efforts should be made to understand and address the reasons for refusal, including consulting carers or family and reviewing records ². When a patient lacks capacity, decisions should be made in their best interests, involving family, carers, or legally appointed deputies where appropriate ¹,².

In practice, this means providing information about treatment in accessible formats, checking understanding, and supporting the patient to participate as fully as possible in decisions about their care ¹,². Documentation of consent or reasons for refusal must be thorough, and any advance decisions to refuse treatment should be checked for validity and applicability ¹,². Recent literature highlights the importance of recognising fluctuating capacity and the need for ongoing assessment, especially in older adults with cognitive impairment, to ensure consent remains informed and valid (Mayo and Wallhagen, 2009; Hogan et al., 2018).