Assisted Decision-Making (Capacity) Act Ireland: A Training Guide

The Assisted Decision-Making (Capacity) Act 2015 changed how capacity is understood and supported across Irish health and social care, replacing the old Wards of Court system with a framework built around supported, rather than substitute, decision-making. For frontline healthcare and care staff, that shift has direct, practical training implications. Here is what the Act actually requires, how the Decision Support Service fits in, and what it means for day-to-day practice.

What the Act changed

The Assisted Decision-Making (Capacity) Act 2015 became fully operational on 26 April 2023, replacing the Wards of Court system that had previously governed decision-making for people who lacked capacity. Rather than treating a person as either fully capable or entirely incapable, the Act establishes a functional, issue- and time-specific test of capacity: a person's capacity is assessed in relation to a specific decision, at a specific time, rather than assumed globally from a diagnosis or condition. The guiding principle underpinning the whole Act is a presumption of capacity — every adult is presumed to have capacity to make their own decisions unless the contrary is shown, and any support provided must be the least restrictive option available.

The hierarchy of supported decision-making arrangements

The Act creates a graduated set of formal support arrangements, moving from the least to the most restrictive depending on a person's needs. A Decision-Making Assistant supports someone to gather information, understand options and communicate their own decisions, without making decisions on their behalf. A Co-Decision-Maker jointly makes decisions with the person, for decisions the person has chosen to share. A Decision-Making Representative, appointed by the courts, is empowered to make certain decisions on behalf of a person who has been assessed as lacking capacity for those specific decisions, and represents the most restrictive tier of the three. The Act is explicit that these arrangements exist on a spectrum precisely so that support can be matched to what an individual actually needs, rather than defaulting to full substitute decision-making.

Advance Healthcare Directives

Part 8 of the Act introduced Advance Healthcare Directives (AHDs), which allow a person to set out their wishes about medical treatment in advance, including specific treatment refusals, for a time when they may no longer have capacity to communicate those wishes directly. A person making an AHD can also appoint a Designated Healthcare Representative to ensure the directive is respected. For healthcare staff, this means AHDs need to be actively looked for, understood and honoured as part of care planning, not treated as an afterthought once a patient has already lost capacity.

Who can act as the healthcare professional for an AHD or capacity assessment

A statutory instrument made under the Act, S.I. No. 204/2023, prescribes which classes of healthcare professional are recognised for the specific purposes set out in the regulations, including roles connected to advance healthcare directives and capacity-related assessment. The prescribed classes are registered nurses and registered midwives (as defined under the Nurses and Midwives Act 2011), and occupational therapists, social workers, and speech and language therapists registered under the Health and Social Care Professionals Act 2005. Importantly, none of these professionals can act in this capacity for a person who is their immediate family member, a restriction the regulations define broadly to include spouses, children, parents, siblings, grandparents and aunts or uncles. This is a detail worth building directly into any staff-facing training material, since it affects who within a multidisciplinary team can actually take on this role for a given patient.

The Decision Support Service

The Decision Support Service (DSS) operates as a function of the Mental Health Commission and is the body responsible for the practical operation of the Act. It maintains registers of decision-making assistants, co-decision-makers, decision-making representatives and registered advance healthcare directives, processes applications relating to these arrangements, and publishes Codes of Practice that set out expected standards for professionals and supporters operating under the Act. For healthcare providers, the DSS's Codes of Practice are a key reference point when building internal policies and staff training, since they translate the Act's principles into more concrete, practice-level guidance.

What this means for staff training

Because the Act reframes capacity as decision-specific rather than global, and introduces a defined hierarchy of supports plus a formal directive system, healthcare and care staff need training that covers several distinct things: how to apply the functional test of capacity in real situations, how the presumption of capacity and least-restrictive-option principle should shape everyday interactions, how to recognise and respond appropriately to a Decision-Making Assistant, Co-Decision-Maker or Decision-Making Representative, how to locate and act on an Advance Healthcare Directive, and when and how to refer a case to the Decision Support Service. This sits alongside, rather than replaces, an organisation's existing safeguarding training for vulnerable adults, since capacity assessment and safeguarding concerns frequently intersect in practice. Providers delivering mental health services will also want to look at how ADMCA principles interact with obligations under Ireland's mental health legislation, covered in Learnsignal's guide to Mental Health Act compliance.

Practical steps for embedding this in a healthcare setting

• Make functional capacity assessment training a standard part of induction for any clinical or care role involving decision-specific interactions with patients or service users.
• Build a clear internal process for locating and verifying an Advance Healthcare Directive as part of admission and care-planning procedures.
• Train staff to recognise the different tiers of supported decision-making and understand the practical boundaries of each role.
• Reference the Decision Support Service's published Codes of Practice directly when writing internal capacity and consent policies, rather than relying on general summaries alone.
• Revisit training periodically as DSS guidance and case law develop, since this remains an evolving area of practice compared with more settled areas of healthcare compliance.

Frequently asked questions

What is the core principle behind the Assisted Decision-Making (Capacity) Act?

A presumption of capacity for every adult, combined with a functional test that assesses capacity for a specific decision at a specific time, and a requirement that any support given be the least restrictive option available.

Who regulates and oversees arrangements made under the Act?

The Decision Support Service, which operates as a function of the Mental Health Commission, maintains the relevant registers, processes applications, and publishes Codes of Practice for professionals and supporters operating under the Act.

Can any healthcare professional witness or act in relation to an Advance Healthcare Directive?

No. S.I. No. 204/2023 prescribes specific classes of healthcare professional — registered nurses, registered midwives, occupational therapists, social workers and speech and language therapists — and none of them can act in this capacity for an immediate family member.

The Assisted Decision-Making (Capacity) Act asks healthcare and care providers to treat capacity as something assessed carefully and specifically, not assumed. Building that discipline into everyday training, alongside ongoing CPD for healthcare staff, is what turns the Act's principles into consistent, defensible practice on the ground.

Where capacity decisions meet practice

The Act changed the legal basis for decisions made on someone else’s behalf, and two situations show what that means day to day. Advance healthcare directives are the mechanism for a person recording decisions while they still have capacity, which is the Act working as intended. Covert administration of medicines is the harder case, where capacity, consent and care practice collide and the legal position is least intuitive.