The man who refuses help
Joseph is 78 and lives alone in a third-floor flat with a lift. He has vascular dementia diagnosed eight months ago and type 2 diabetes. He receives two 30-minute domiciliary visits a day for breakfast and medication. In the last six weeks he has fallen twice, once requiring A&E with a wrist fracture. He now walks by holding furniture and refuses to use the walking frame the physiotherapist provided. He sends carers away when they suggest a shower and has worn the same clothes for nine days. His daughter, who lives 40 minutes away, wants four visits a day, a key safe and a medication dispenser. Joseph says: 'I've managed all my life. I want to be left alone.' The GP has asked for a review. He can state his name, date and that he wants no help, but cannot explain what he would do if he fell again. The care agency has a waiting list and cannot increase visits for two weeks.
1. How should the team assess whether Joseph has capacity to refuse the additional support, and what should happen if he is found to lack capacity for this decision?
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Assess capacity for the specific decision. The team should not assume Joseph lacks capacity because he has dementia or because his choices seem unwise. Capacity is decision-specific: can he understand the relevant information about falls risk, medication, hygiene and what would happen after a fall; retain it long enough; weigh it; and communicate a choice? The GP or trained assessor should use a structured conversation, not a one-off question. Explaining with simple language, hearing aids and a familiar person may improve his understanding. His ability to state his name and address is not proof of capacity for this decision.
If he has capacity. His refusal should be respected, even if professionals disagree. The team should offer a risk-reduction plan: a falls alarm, a medication review, a key safe only if he agrees, and regular review. They should document the conversation and the risks he accepts.
If he lacks capacity. The decision must be made in his best interests, considering past and present wishes, his daughter's views and the least restrictive option. A best-interests meeting should consider increased visits, a key safe, an OT assessment, a medication dispenser and a falls service. Restricting his choices further, such as moving him to a care home, requires a lawful and proportionate process. The reasoning must be recorded, because 'safe' is not the same as 'least restrictive'.
2. The agency cannot increase visits for two weeks. What interim, proportionate plan would you propose, and how would you justify it to the daughter?
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Interim plan. With only two visits for two weeks, the agency should prioritise what keeps Joseph safe and maintains his dignity: medication, food and hydration, and a way to summon help. A daily welfare phone call, a falls alarm, a GP medication review and an OT home assessment can be arranged before more visits are available. The daughter could be asked to provide a spare key only if Joseph agrees or a best-interests decision supports it. The care plan should specify what carers do if he refuses: they should not force care, but should record, offer and report.
Justifying to the daughter. Explain that the agency cannot increase visits for two weeks, but that it is not ignoring the risk. Be explicit about what has been prioritised and what has not: for example, 'We can ensure medication and a daily check, but we cannot provide four visits. We will review on [date].' Acknowledge her fear and ask her to help with meals or calls if she can. Do not promise what the agency cannot deliver.
Reasoning. Proportionality means matching the response to the level of risk and the available resources, while being honest about the gap. The daughter's views are important but do not override Joseph's rights if he has capacity. If he lacks capacity, her knowledge of his routines is valuable evidence for best interests. The plan should be reviewed, not treated as permanent.