Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward of a provincial hospital. The ward follows the Mental Health Act (Republic Act [RA] 11036). Two weeks later she has regained decision-making capacity. She asks that her sister and a close friend be allowed to see her records, join discussions of proposed treatment, and help her think through her options, while she still makes the decisions herself. Which arrangement under RA 11036 is she asking for?

Supported decision making lets a service user who has capacity designate up to three supporters, who may access medical information, consult on proposed treatment, and attend appointments, while the service user keeps the decision. A legal representative can act as substitute decision maker when capacity is impaired, and an advance directive records treatment preferences for a future crisis.

Core concept

The situation describes a service user who has regained decision-making capacity and now wants two trusted people to help her access information, discuss options, and think through treatment choices—while she alone makes the final decision. Under RA 11036, this is the defining feature of supported decision making.

Key point! Capacity is the dividing line. When the person has capacity, supporters assist but do not decide. When capacity is impaired, a legal representative may act as a substitute decision maker.

Why the other options do not fit

Option	What it actually means	Why it is wrong here
Advance directive	A written record of treatment preferences made in advance, to guide care during a future crisis when the person cannot express their wishes	The woman is not documenting future preferences; she is asking for current, ongoing support from two named people
Legal representation	A person authorized to act on behalf of the service user, typically as a substitute decision maker when capacity is impaired	She has regained capacity and explicitly states she will still make the decisions herself
Substitute decision making	Another person makes decisions for the service user because the service user cannot make them independently	This directly contradicts the scenario: the woman retains decision-making authority
Supported decision making	The service user with capacity designates up to 3 supporters who may access medical information, consult on proposed treatment, and attend appointments—while the service user keeps the decision	This matches every element of the scenario

Clinical reasoning in psychiatric nursing practice

The distinction between supported and substitute decision making is not merely legal terminology; it reflects a fundamental ethical stance about autonomy in mental health care. The systematic review by Francis and colleagues highlights that most people with mental ill health want to be involved in decisions about their care, and supporting them to make their own treatment decisions is an ethical imperative under the Convention on the Rights of Persons with Disabilities ^[1]. Yet the same review notes widespread reports of people with mental ill health being excluded from decision-making in practice ^[1]. This gap between principle and practice is exactly what RA 11036's supported decision-making provision is designed to close.

The integrative review by Gurtner and colleagues reinforces that shared or supported decision-making has the potential to strengthen patient autonomy and encourages patients to become involved in decisions regarding their treatment ^[2]. In a psychiatric ward setting, a nurse who understands this distinction can advocate for the service user's right to choose supporters, facilitate access to information, and ensure the care team does not inadvertently slide into substitute decision making when the person still has capacity.

Watch out! A common exam trap is to confuse supported decision making with substitute decision making. The trigger word is capacity. If the stem says the person "has regained capacity" or "can make decisions," the answer is supported decision making. If the stem says "capacity is impaired" or "unable to decide," the answer shifts to substitute decision making or legal representation.

Key point! Under RA 11036, a service user with capacity may designate up to 3 supporters. These supporters can access medical information, consult on proposed treatment, and attend appointments—but the service user retains the final decision. This is not a transfer of authority; it is a scaffolding of autonomy.