This position paper has been written by the Irish Association of Speech and Language Therapists (IASLT) to educate Speech and Language Therapists, other stakeholders and the public regarding IASLT’s position with respect to the role of the Speech and Language Therapist (SLT) in assessing capacity and facilitating understanding to support decision making in adults (people over 18 years) with communication disorders.
SLT’s are uniquely qualified to assess & support people with communication difficulties to understand & then communicate that understanding for the purposes of establishing their capacity
The IASLT hold the position that
The IASLT is the recognised professional body for Speech and Language Therapists in the Republic of Ireland. One of the key functions of the IASLT is to represent the views of its members and to inform position statements in relation to the provision of speech and language therapy services for the best interests of service users. Working groups are routinely convened to develop position papers in response to events relevant to SLTs, both within and outside the SLT profession. This working group was established in January 2017.
Speech and Language Therapist (SLT): For the purposes of this document a Speech and Language Therapist is a person who holds a professional qualification in SLT and who is registered with CORU and eligible for membership of the Irish Association of Speech and Language Therapists (IASLT).
The Assisted Decision-Making (Capacity) Act (ADMA, 2015) was enacted to ensure the autonomy of adults in making personal decisions. A cornerstone of the Act is that adults are presumed to have the ability, or capacity to make decisions about their personal lives. In the Act, capacity for decision-making is defined as the ability to understand, at the time the decision is being made, the nature and consequences of the decision in the context of the available choices at that time (ADMA, 2015, s 3 (1)). This means that a person has a right to make decisions (including unwise ones) on their own behalf and is assumed to have decision making capacity to do this unless proven otherwise.
The Act takes a functional approach to decision making capacity. This approach recognises that decisions are complex and cognitive deficits are only relevant if they actually impact on decision making. The legislation supports the premise that all people be assisted and supported to take part in decision making processes that affect them. The Act also outlines the supports which will be made available to people when the Office of Decision Support Service is established within the Mental Health Commission.
Decision making capacity is the ability of the person at the time the decision is to be made to:
When an adult’s capacity to make a decision is called into question, a capacity assessment may be necessary. Capacity is considered on a continuum: a person may have the capacity to make some decisions and not others. Also, a person may have capacity for decision-making at one point in time, and not another. Communication skills are key for quality of life and key for decision making.
It is the position of IASLT that SLT’s are uniquely qualified to assess and support
a person with communication difficulties to understand and then communicate
that understanding for the purposes of establishing their capacity for decision
making. This is an essential component of the work of SLTs in order to ensure
that individuals continue to exercise choice and control in their daily lives
(RCSLT, 2014 cited in IASLT, 2016). It is the IASLT’s position that SLTs have a role
in capacity assessment of adults with known or suspected communication
SLTs have the necessary skills to;
SLT’s have a unique role in identifying the specific nature of communication difficulties in adults. SLT’s also have a unique role supporting and training other professionals in working with speech, language and communication needs. A experts in communication, it is the role of the SLT to assist their healthcare colleagues, and individuals with communication impairment in capacity assessments. IASLT consider that all professionals involved in the capacity assessment including advocates, should receive mandatory training from a speech and language therapist developed by speech and language therapists to ensure that they are able to understand and use the most appropriate mode and level of communication with the individual.
A capacity assessment involves determination of whether the adult being assessed is able to understand the information relevant to the decision, to retain that information long enough to make a voluntary choice, to use or weigh that information as part of the process of making the decision, and to communicate that decision (ADMA, 2015).
Because communication is central to determination of capacity, individuals who have communication disorders are at a disadvantage during a capacity assessment.
According to the Act (ADMA, 2015), an adult has the right to “an explanation of [the decision] given to him or her in a way that is appropriate to his or her circumstances (whether using clear language, visual aids or any other means)”
(ADMA, 2015 s. 3 (3)). The person being assessed also has the right to communicate their decision by talking, writing, using sign language, assistive technology, or any other means.
Individuals with communication impairment may have difficulties in expressing thoughts, asking questions, and demonstrating that they understand the information presented to them. These difficulties can be subtle, complex and sometimes undetermined – requiring specialist SLT assessment, and specialist skills to be in a position to support individuals.
While it is the responsibility of the assessor to provide appropriate communication assistance arrangements IASLT affirms that given their expertise and therefore their ability to contribute most to valid person-led choice the fundamental role of the speech and language therapist needs to be clearly included.
People with communication difficulties need additional support during capacity
assessments but may not always receive this (Jayes, Palmer & Enderby, 2016).
Research shows that staff recognize that they need training and resources to
provide this additional support. As experts in communication, it is the role of
the SLT to assist their healthcare colleagues, and individuals with communication
impairment in capacity assessments. This is supported by HIQA. Expertise and
training in communication is recommended as a fundamental requirement for
those working with individuals with a communication impairment (HIQA 2012,
2016) – this expertise and training becomes even more important where
individuals are making decisions about their lives and care.
Annually in Ireland
The risks of not involving SLTs include
For individuals with a significant communication disability, the formal capacity assessment should require that the assessment is carried out by a suitably qualified person. The IASLT consider that this should be someone who has knowledge of how to communicate most effectively with the person and is independent of any caring or advocacy roles.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Bryan, K & Maxim, J. (2006) Communication disability in the dementias. London: Whurr
Engelter, S, Gostynski, M, Papa, S, Frei, M, Born C, Ajdacic-Gross, V, Gutzwiller, F, Lyrer P (2006). Epidemiology of Aphasia Attributable to First Ischemic Stroke - Incidence, Severity, Fluency, Etiology, and Thrombolysis, Stroke 37:1379-1384
Government of Ireland (2015). The Assisted Decision Making (Capacity) Act. Dublin: The Stationary Office. Available at: http://www.irishstatutebook.ie/eli/2015/act/64/enacted/en/html
Walsh, I, Regan, J, Sowman, R, Parsons, B. and McKay, P. (2007) A needs analysis for the provision of a speech and language therapy service to adults with MHDs, Irish Journal of Psychological Medicine, 24 (3), pp. 89-93. Health & Information Quality Authority (2016).
National Standards for Residential Care Settings for Older People in Ireland
Health & Information Quality Authority (2012). National Standards for Safer Better Healthcare
Health Research Board (2016), Annual Report of the National Disability Database Committee 2015. HRB.
Irish Association of Speech and Language Therapists (2016) Speech and Language Therapy Provision for People with Dementia. IASLT Position Statement, IASLT.
Jayes, M., Palmer, R. & Enderby, P. (2016) An exploration of mental capacity assessment within acute hospital and intermediate care settings in England: a focus group study. Disability and Rehabilitation. Available from: http://dx.doi.org/10.1080/09638288.2016.1224275.
National Aphasia Association. 2017. Aphasia FAQs. [ONLINE] Available at: https://www.aphasia.org/aphasia-faqs/. [Accessed 18 April 2017].
Selassie, A., Zaloshnja, E., Langlois, J., Miller, T., Jones, P. & Steiner, C. (2008). Incidence of long-term disability following traumatic brain injury hospitalization, United States, 2003. Journal of Head Trauma Rehabilitation, 23 (2) p 123-131.
Tighe, Marie. "Assisted Decision Making (Capacity) Act 2015 - SALT Impact Assessment". 2017. Presentation 11.1.2017
Thurman, D., Alverson, C., Dunn, K., Guerrero, J. & Sniezek, J (1999). Traumatic brain injury in the United States: A public health perspective. Journal of Head Trauma Rehabilitation, 14 (6) p 602-615.
Zaloshnja, E., Miller, T., Langlois, J & Selassie, A. (2008). Prevalence of long-term disability from traumatic brain injury in the civilian population of the United States, 2005. Journal of Head Trauma Rehabilitation, 23 (6) p 394-400.