A 71-year-old woman with metastatic lung cancer and capacity is receiving end-of-life care at home. Her pain is increasingly difficult to control and the palliative care team recommends a continuous subcutaneous infusion of diamorphine and midazolam. She agrees but says 'I don't want to become unconscious - I want to stay alert to talk to my family'. The doses proposed would likely cause significant sedation. How should this be managed?

Explain the likely effects of medication and explore her priorities regarding symptom control versus alertness

Start the infusion as planned - adequate pain control is the priority

Reduce the doses even if pain control is suboptimal to maintain alertness

Defer starting the infusion until she becomes less concerned about sedation

Start lower doses and increase without further discussion once she becomes too drowsy to participate

A 37-year-old man with newly diagnosed HIV infection (CD4 250, undetectable viral load on treatment) works as a dentist. He has capacity and refuses to inform his employer or occupational health, citing concerns about discrimination. He follows standard infection control procedures. What is your professional obligation regarding disclosure?

You should maintain confidentiality as he poses minimal risk with standard precautions

You must immediately inform the General Dental Council

You must inform UK Health Security Agency who will inform his employer

You must inform his employer as patients have a right to know

You should seek advice from the GMC ethics department before taking any action

A 56-year-old man with motor neurone disease attended his GP 6 months ago when mobile and made a written advance decision refusing 'ventilation of any kind' if he developed respiratory failure. He is now admitted with type 2 respiratory failure. He has lost speech but can communicate by eye movements. When asked about non-invasive ventilation (NIV), he consistently indicates he wants it. What is the legal status of his advance decision?

It is not applicable as his current wishes differ from the advance decision

It is valid and binding - NIV should not be started

It is not applicable as it was made more than 3 months ago

It is not valid as it was not registered with a solicitor

Court of Protection authorization is required to override the advance decision

A 49-year-old woman with widely metastatic cervical cancer is dying in hospital. She has capacity and pain is well controlled. She specifically requests that her elderly mother, who lives abroad and has dementia, not be informed of her deterioration or death. Her brother strongly objects, saying their mother has a 'right to say goodbye'. What should you do?

Respect the patient's confidentiality and wishes

Inform the mother as she has a right to know about her daughter's condition

Support the brother to inform the mother as this is a family matter

Arrange a best interests meeting to decide what to tell the mother

Compromise by informing the mother only after the patient dies

An 82-year-old woman with severe dementia (MMSE 6/30) and recurrent urosepsis is admitted from a nursing home. She has no advance decision or LPA. Her son (only relative) says 'Mum always said if she got dementia she wouldn't want to be kept alive with antibiotics'. There is no documented evidence of this. She appears comfortable but has sepsis requiring IV antibiotics. What weight should be given to the son's account?

It forms part of the best interests assessment but is not binding

No weight as there is no written advance decision to refuse treatment

It should be determinative as he is the next of kin

It constitutes a valid oral advance decision and antibiotics should be withheld

It should be ignored as the son may have ulterior motives

A 16-year-old boy with a relapsed brain tumor refuses further chemotherapy, stating 'I've had enough - I want to enjoy what time I have left'. He clearly understands his prognosis and the consequences of refusing treatment. His parents, who have parental responsibility, want him to continue treatment and threaten legal action. Assessment confirms he is Gillick competent. What is the legal position?

Parental consent overrides his refusal for life-saving treatment in those under 18

His refusal must be respected as he is Gillick competent

Treatment must continue until he turns 18 and can legally refuse

The decision requires Court of Protection authorization

A best interests decision should be made by the clinical team

A 62-year-old man with capacity and newly diagnosed motor neurone disease asks detailed questions about assisted dying and requests information about traveling to Switzerland for assisted suicide. He is not currently depressed on psychiatric assessment. What is the most appropriate response?

Provide factual information about the law while exploring his concerns and ensuring ongoing support

Refuse to discuss this as it is illegal and you could be accused of assisting suicide

Report him to the police as he is planning to break the law

Refer to psychiatry as this request indicates underlying depression

Advise him that you cannot discuss this but he should consult a lawyer

A 75-year-old man with advanced Parkinson's disease and fluctuating cognition is admitted with aspiration pneumonia. During lucid periods (MMSE 26/30) he requests 'no antibiotics or hospital treatment' and asks to return home for end-of-life care. During confused periods (MMSE 15/30) he asks for 'everything to be done' and wants active treatment. He has no advance decision. How should his capacity be assessed?

Capacity should be assessed separately for each specific decision at the time it needs to be made

He lacks capacity as he has a diagnosis of dementia associated with Parkinson's disease

He has capacity based on his MMSE scores during lucid periods

His family should decide as he gives inconsistent views

He lacks capacity due to the fluctuating nature of his cognition

According to the Mental Capacity Act 2005, which of the following statements about the hierarchy of decision-makers for a patient lacking capacity is correct?

Valid advance decision to refuse treatment takes precedence over Lasting Power of Attorney for Health and Welfare

Court-appointed deputy takes precedence over a registered Lasting Power of Attorney

Lasting Power of Attorney for Health and Welfare takes precedence over advance decisions

Next of kin have legal authority to make treatment decisions if no LPA exists

Independent Mental Capacity Advocate can make binding treatment decisions

A 54-year-old man with metastatic colorectal cancer and hepatic encephalopathy is admitted confused (MMSE 14/30). His wife produces a Lasting Power of Attorney for Health and Welfare document appointing her as his attorney, which was registered 2 years ago. She refuses palliative chemotherapy on his behalf, but his oncologist believes treatment would improve his quality of life and potentially extend survival. What factor should primarily guide the decision?

The patient's best interests, considering all relevant factors

The wife's decision as LPA attorney must be followed

The oncologist's clinical judgment about treatment benefits

The patient's previously expressed wishes about cancer treatment

A Court of Protection decision given the disagreement

Consent and capacity - Free UK Medical PG Review

Quick Overview

Mental capacity assessment is a legal and ethical cornerstone of UK medical practice, governed by the Mental Capacity Act 2005 (MCA). Capacity is decision-specific and time-specific-assume capacity unless proven otherwise. NICE NG108 emphasizes that all practicable steps must be taken to support decision-making before concluding someone lacks capacity.

Core Facts & Concepts

Mental Capacity Act 2005 - Five Statutory Principles:

Presumption of capacity until established otherwise
Support all practicable steps to aid decision-making
Unwise decisions do not prove incapacity
Best interests guide actions for those lacking capacity
Least restrictive option must be chosen

Two-Stage Capacity Test:

Stage	Assessment Criteria
1. Diagnostic threshold	Is there impairment/disturbance of mind/brain function? (temporary/permanent)
2. Functional test	Can the person: Understand, Retain, Use/weigh, Communicate the decision?

📌 Remember: URUC - Understand, Retain, Use/weigh, Communicate

Figure 1: Clinical photograph showing doctor discussing treatment options with elderly patient using visual aids

Consent Requirements by Scenario:

Valid consent needs: Capacity + Voluntary + Informed
Emergency treatment: Proceed in best interests if capacity cannot be assessed (life/limb-threatening)
Advance decisions: Legally binding if valid and applicable; must be written and witnessed for life-sustaining treatment refusal
Lasting Power of Attorney (LPA): Health & Welfare LPA can consent/refuse treatment (only active when patient lacks capacity)
Court of Protection: Resolves disputes; appoints deputies for ongoing decisions

Age-Specific Thresholds:

≥16 years: Presumed capacity (can consent; refusal may be overridden if life-threatening)
<16 years: Gillick competence if sufficient maturity (Fraser guidelines for contraception)
Parental responsibility: Overrides child refusal if in best interests until age 18

Problem-Solving Approach

Capacity Assessment Protocol (NICE NG108):

Optimize conditions: Quiet environment, appropriate timing, communication aids, involve family/advocates
Apply diagnostic threshold: Document impairment (delirium, dementia, learning disability, mental illness, intoxication)
Conduct functional test (URUC):
- Understand: Explain in simple terms; ask patient to repeat back
- Retain: Even brief retention sufficient (minutes acceptable)
- Use/weigh: Can they appreciate consequences? Compare options?
- Communicate: Any method counts (speech, writing, blinking, Makaton)
Document thoroughly: Record what information given, how assessed, reasons for conclusion, who consulted

Figure 2: Flowchart showing capacity assessment steps with decision points

Best Interests Checklist (if capacity lacking):

Consult: Family, carers, LPA, IMCA (Independent Mental Capacity Advocate if no one available)
Consider: Past/present wishes, beliefs, values, other relevant factors
Encourage participation: Support patient involvement maximally
Life-sustaining treatment: Do not assume withholding is in best interests

⚠️ Warning: Deprivation of Liberty Safeguards (DoLS) required if restricting freedom in hospital/care home-apply via supervisory body

Analysis Framework

Capacity vs Consent Scenarios:

Scenario	Capacity Status	Action Required
Fluctuating capacity (delirium)	Assess when optimal; defer if possible	Treat urgently in best interests; reassess when improved
Refuses life-saving treatment	Has capacity	Respect refusal; explore reasons; document clearly
Refuses life-saving treatment	Lacks capacity	Treat in best interests; consider advance decisions/LPA
Advance decision exists	Currently lacks capacity	Follow if valid and applicable to current situation
Disagreement with family	Lacks capacity	Family views inform but don't determine best interests

Red Flags Suggesting Incapacity:

🚩 Cannot retain information even momentarily
🚩 Repeats same questions without incorporating answers
🚩 Cannot describe consequences of choices
🚩 Decision based on delusional beliefs directly

⭐ Clinical Pearl: Capacity can fluctuate-reassess if clinical state changes. A patient may have capacity for simple decisions (what to eat) but not complex ones (surgery consent).

Visual Aid

Capacity Assessment Documentation Template:

Element	Record
Decision	Specific treatment/intervention
Impairment	Diagnosis affecting capacity
URUC assessment	Evidence for each component
Conclusion	Capacity present/absent with rationale
Best interests	If lacking capacity: who consulted, factors considered

Key Points Summary

✓ Presume capacity for every decision unless impairment proven; capacity is decision-specific and time-specific

✓ Two-stage test: (1) Diagnostic threshold-impairment present? (2) Functional test-URUC (Understand, Retain, Use/weigh, Communicate)

✓ Valid consent requires: Capacity + Voluntary + Informed; unwise decisions ≠ incapacity

✓ Best interests: Consult widely (family, LPA, IMCA); consider patient's wishes, beliefs, values; choose least restrictive option

✓ Advance decisions: Legally binding if valid/applicable; must be written and witnessed for life-sustaining treatment refusal

✓ Age thresholds: ≥16 presumed capacity; <16 Gillick competence possible; parental responsibility until 18

✓ Emergency treatment: Proceed in best interests if capacity assessment impossible and treatment urgent-document retrospectively