Risk, Capacity & Safeguarding — MCQs
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A 48-year-old woman with severe anorexia nervosa (BMI 12.8 kg/m²) has been detained under Section 3 of the Mental Health Act. She has capacity regarding treatment decisions but continues to refuse nasogastric feeding. Bloods show: potassium 2.8 mmol/L, phosphate 0.4 mmol/L. Under what legal provision can feeding be administered despite her capacitous refusal?
A 24-year-old man with first-episode psychosis is assessed following a serious suicide attempt by hanging. He has persistent command hallucinations telling him to kill himself. He expresses intent to act on these commands again. He refuses admission. What is the most appropriate immediate management?
A 77-year-old woman with moderate vascular dementia (MMSE 15/30) requires urgent surgery for a perforated bowel. She is confused and repeatedly states 'I want to go home' when surgery is discussed. She has no Lasting Power of Attorney and no advance decision. What is the correct legal basis for proceeding with surgery?
A 61-year-old man with treatment-resistant depression and capacity repeatedly refuses ECT despite explanation that it may be life-saving given his severe self-neglect and suicidal intent. He is not detained under the Mental Health Act. What is the legal position regarding proceeding with ECT?
A 36-year-old woman is brought to the Emergency Department by police after threatening to jump from a bridge. She has borderline personality disorder with multiple previous self-harm episodes but no previous suicide attempts. She is angry and states she wants to leave. Which feature of her presentation would most significantly elevate her risk of completed suicide?
According to the Mental Capacity Act 2005, which of the following statements about advance decisions to refuse treatment (ADRT) is correct?
A 69-year-old man with mild Alzheimer's dementia (MMSE 22/30) is assessed for capacity to consent to cataract surgery. He understands he has cataracts and that surgery can improve his vision. However, he cannot remember the discussion five minutes later and asks the same questions repeatedly. What is the most appropriate approach to capacity assessment?
A 59-year-old woman with no psychiatric history is diagnosed with terminal pancreatic cancer. She has capacity and refuses all treatment including palliative chemotherapy. She expresses thoughts that she would be 'better off dead' and 'does not want to be a burden'. How should her expressed suicidal thoughts be interpreted?
A 43-year-old man with bipolar disorder is admitted during a severe depressive episode with active suicidal ideation. He agrees to informal admission. On day 3, he requests to leave, stating he feels better. Staff are concerned as his mood remains significantly low and he continues to express hopelessness. What is the most appropriate immediate action?
A 27-year-old woman with recurrent depressive disorder attends her GP two months after a significant overdose. She describes ongoing low mood but denies current suicidal thoughts. When assessing her current suicide risk, which aspect of her mental state examination would be most important to explore?
Risk, Capacity & Safeguarding UK Medical PG Practice Questions and MCQs
Question 101: A 48-year-old woman with severe anorexia nervosa (BMI 12.8 kg/m²) has been detained under Section 3 of the Mental Health Act. She has capacity regarding treatment decisions but continues to refuse nasogastric feeding. Bloods show: potassium 2.8 mmol/L, phosphate 0.4 mmol/L. Under what legal provision can feeding be administered despite her capacitous refusal?
- A. Section 63 of the Mental Health Act as treatment for mental disorder (Correct Answer)
- B. Common law doctrine of necessity due to life-threatening metabolic disturbance
- C. Mental Capacity Act best interests as her anorexia impairs decision-making
- D. Implied consent as she has not physically resisted previous interventions
- E. Section 58 of the Mental Health Act with second opinion approval
Explanation: ***Section 63 of the Mental Health Act as treatment for mental disorder*** - For patients detained under Section 3, **Section 63** allows clinicians to provide treatment for a mental disorder without the patient's consent, regardless of their **mental capacity**. - High Court rulings (e.g., **B v Croydon Health Authority**) have established that **nasogastric feeding** for anorexia nervosa is a treatment for the mental disorder, not merely a physical intervention. *Common law doctrine of necessity due to life-threatening metabolic disturbance* - This doctrine is typically used for emergency treatment in patients who **lack capacity** to consent when no other legal framework applies. - Since the patient is already detained under the **Mental Health Act**, the statutory provisions of that Act take precedence over common law. *Mental Capacity Act best interests as her anorexia impairs decision-making* - The **Mental Capacity Act** only applies if the patient is found to **lack capacity** for a specific decision at a specific time. - The prompt explicitly states the patient **has capacity**, making a "best interests" decision under this Act legally inappropriate. *Implied consent as she has not physically resisted previous interventions* - **Implied consent** cannot be assumed in the face of an express, **capacitous refusal** of a specific treatment. - Legal authority to treat against refusal must be derived from statute (like the MHA) rather than an assumption of passive compliance. *Section 58 of the Mental Health Act with second opinion approval* - **Section 58** applies specifically to medications given for more than three months or **Electroconvulsive Therapy (ECT)**, requiring a SOAD (Second Opinion Appointed Doctor). - **Nasogastric feeding** does not fall under Section 58 medications; it is governed by **Section 63**, which does not require a second opinion.
Question 102: A 24-year-old man with first-episode psychosis is assessed following a serious suicide attempt by hanging. He has persistent command hallucinations telling him to kill himself. He expresses intent to act on these commands again. He refuses admission. What is the most appropriate immediate management?
- A. Arrange urgent community mental health team follow-up with daily visits
- B. Prescribe antipsychotic medication and arrange GP review in 48 hours
- C. Detain under Section 2 of the Mental Health Act for assessment and treatment (Correct Answer)
- D. Assess capacity to refuse admission and document the risk-benefit discussion
- E. Contact crisis resolution team for home treatment as alternative to admission
Explanation: ***Detain under Section 2 of the Mental Health Act for assessment and treatment*** - This patient presents a **high-risk psychiatric emergency** due to persistent **command hallucinations** to kill himself, a recent serious suicide attempt by hanging, and expressed intent to act on these commands again. - **Section 2 of the Mental Health Act** allows for the detention of a patient for up to **28 days** for assessment and treatment when they have a mental disorder and there is a significant risk to their health or safety, or to the safety of others, especially when they refuse voluntary admission. *Arrange urgent community mental health team follow-up with daily visits* - Community follow-up, even daily, is **insufficient** for a patient with such a high and immediate risk of serious self-harm, especially after a recent near-fatal attempt and active suicidal intent. - The **lack of a secure environment** and constant supervision means this approach cannot adequately protect the patient from acting on command hallucinations. *Prescribe antipsychotic medication and arrange GP review in 48 hours* - Prescribing antipsychotics alone without immediate secure containment is **dangerous** given the patient's acute suicidal intent and active command hallucinations; these medications take time to become effective. - A **GP review in 48 hours** is far too delayed for a patient in a psychiatric emergency with an immediate and life-threatening risk of suicide. *Assess capacity to refuse admission and document the risk-benefit discussion* - While assessing **capacity** is a crucial step, this patient's severe psychosis and command hallucinations likely impair his capacity to make safe decisions about his care. - Even if capacity were assessed, the **overriding duty to protect life** due to the high and immediate risk of suicide necessitates action under the Mental Health Act, as documentation alone does not mitigate the risk. *Contact crisis resolution team for home treatment as alternative to admission* - **Home treatment** by a crisis resolution team is generally considered for patients who are able to maintain safety in their own environment with support, or where the risk is lower and manageable outside an inpatient setting. - This patient's **recent serious suicide attempt**, persistent command hallucinations, and refusal of voluntary admission indicate that the level of risk is far too high for home treatment, requiring the secure environment of an inpatient unit.
Question 103: A 77-year-old woman with moderate vascular dementia (MMSE 15/30) requires urgent surgery for a perforated bowel. She is confused and repeatedly states 'I want to go home' when surgery is discussed. She has no Lasting Power of Attorney and no advance decision. What is the correct legal basis for proceeding with surgery?
- A. Implied consent based on her previous healthcare engagement
- B. Section 5 of the Mental Capacity Act 2005 acts in connection with care or treatment
- C. Common law doctrine of necessity for emergency treatment
- D. Best interests decision under Mental Capacity Act 2005 with appropriate consultation (Correct Answer)
- E. Next of kin consent as she lacks capacity to consent herself
Explanation: ***Best interests decision under Mental Capacity Act 2005 with appropriate consultation***- Under the **Mental Capacity Act (MCA) 2005**, if a patient lacks the capacity to consent, doctors must act in the patient's **best interests** after considering their past/present wishes and consulting available family or friends.- A **perforated bowel** is life-threatening, making surgery a clear medical priority, but the legal framework still requires the clinician to document the **best interests** process as the legal basis for treatment.*Implied consent based on her previous healthcare engagement*- **Implied consent** is only valid for minor procedures (like taking a pulse) when a patient has **full capacity** and cooperates with the action.- It cannot be used for major surgery, especially when the patient lacks the **cognitive capacity** to understand the implications of the procedure.*Section 5 of the Mental Capacity Act 2005 acts in connection with care or treatment*- While **Section 5** provides legal protection from liability for clinicians, it is the overarching **best interests** process (Section 4) that dictates the decision-making framework.- Section 5 specifically protects those carrying out the acts, but the actual decision to proceed must be rooted in a formal **best interests assessment**.*Common law doctrine of necessity for emergency treatment*- The **Common Law Doctrine of Necessity** has been largely superseded by the **Mental Capacity Act 2005** in jurisdictions like England and Wales.- While it might apply in extreme immediate trauma where no assessment is possible, the MCA provides a more robust and preferred **statutory framework** for patients with dementia.*Next of kin consent as she lacks capacity to consent herself*- In UK law, a **next of kin** has no legal authority to provide consent for an adult patient unless they hold a formal **Lasting Power of Attorney (LPA)**.- Family members should be **consulted** to help determine the patient's preferences, but they cannot sign a consent form on her behalf.
Question 104: A 61-year-old man with treatment-resistant depression and capacity repeatedly refuses ECT despite explanation that it may be life-saving given his severe self-neglect and suicidal intent. He is not detained under the Mental Health Act. What is the legal position regarding proceeding with ECT?
- A. ECT can proceed under common law doctrine of necessity as it is life-saving
- B. ECT cannot proceed as a capacitous refusal must be respected (Correct Answer)
- C. ECT can proceed if authorized by a second opinion appointed doctor (SOAD)
- D. ECT can proceed under Mental Capacity Act if deemed in his best interests
- E. ECT can proceed if two consultant psychiatrists agree it is necessary
Explanation: ***ECT cannot proceed as a capacitous refusal must be respected*** - A patient with **mental capacity** has the legal right to refuse medical treatment, even if that refusal may lead to severe harm or death, as long as they understand the implications. - Since the patient is **not detained under the Mental Health Act**, his **autonomy** is paramount, and his **capacitous refusal** is legally binding and must be respected. *ECT can proceed under common law doctrine of necessity as it is life-saving* - The **common law doctrine of necessity** allows for emergency treatment primarily when a patient **lacks capacity** and immediate intervention is necessary to save their life or prevent severe harm. - It cannot be invoked to override the explicit refusal of a **capacitous adult**, regardless of the potential life-saving nature of the treatment. *ECT can proceed if authorized by a second opinion appointed doctor (SOAD)* - A **Second Opinion Appointed Doctor (SOAD)** is a safeguard under the **Mental Health Act (MHA)** for specific treatments, like ECT, given to **detained patients** who may or may not have capacity. - As this patient is **not detained** under the MHA, the SOAD process does not apply to his situation. *ECT can proceed under Mental Capacity Act if deemed in his best interests* - The **Mental Capacity Act (MCA)** provides a legal framework for making decisions on behalf of individuals who **lack mental capacity** in their best interests. - Since the patient is explicitly stated to **have capacity**, the provisions of the MCA regarding
Question 105: A 36-year-old woman is brought to the Emergency Department by police after threatening to jump from a bridge. She has borderline personality disorder with multiple previous self-harm episodes but no previous suicide attempts. She is angry and states she wants to leave. Which feature of her presentation would most significantly elevate her risk of completed suicide?
- A. Her diagnosis of emotionally unstable personality disorder
- B. The public and potentially lethal nature of her intended method (Correct Answer)
- C. Her current angry and irritable emotional state
- D. History of multiple previous self-harm episodes
- E. Being brought by police indicating lack of social support
Explanation: ***The public and potentially lethal nature of her intended method***- Jumping from a height is a **high-lethality method**, which is a significant predictor of a completed suicide compared to non-lethal self-injury.- The **public nature** and the shift from previous self-harm patterns to a violent method indicate a higher level of **suicidal intent** and clinical urgency.*Her diagnosis of emotionally unstable personality disorder*- While **Borderline Personality Disorder** is associated with an increased long-term risk of suicide, it is a chronic factor rather than an acute differentiator of lethality in this specific presentation.- Diagnosis alone does not provide the immediate risk stratification that the **lethality of the method** does during an acute crisis.*Her current angry and irritable emotional state*- **Irritability and anger** are common features of personality disorders and may increase impulsivity, but they are subjective and transient states.- These emotional states are less objective markers for **suicide completion** risk than the selection of a highly dangerous physical method.*History of multiple previous self-harm episodes*- Frequent **non-suicidal self-injury (NSSI)** is often used as a coping mechanism in BPD and, while a risk factor, it typically involves **low-lethality** methods.- A history of self-harm without previous **suicide attempts** makes the sudden transition to a lethal method like jumping more clinically concerning.*Being brought by police indicating lack of social support*- **Police intervention** suggests an acute crisis and a possible lack of immediate safety nets, but it is not a direct measure of the patient's intent to die.- **Social isolation** is a general risk factor, whereas the mechanism of the attempt (jumping) is a specific, high-risk feature for immediate mortality.
Question 106: According to the Mental Capacity Act 2005, which of the following statements about advance decisions to refuse treatment (ADRT) is correct?
- A. An ADRT must be in writing and witnessed to be legally valid
- B. An ADRT can specify desired treatments as well as refused treatments
- C. An ADRT refusing life-sustaining treatment must be written, signed, witnessed, and include a specific statement (Correct Answer)
- D. An ADRT can be overruled by a Lasting Power of Attorney for Health and Welfare
- E. An ADRT applies to all treatments including those for mental disorder under the Mental Health Act
Explanation: ***An ADRT refusing life-sustaining treatment must be written, signed, witnessed, and include a specific statement*** - Under the **Mental Capacity Act 2005**, an ADRT specifically for **life-sustaining treatment** must be in writing, signed by the person (or by another person in their presence and at their direction), and witnessed by an adult. - It must also include a mandatory **specific statement** that the decision is to apply even if life is at risk, ensuring the patient's intent is unequivocally clear regarding the refusal. *An ADRT must be in writing and witnessed to be legally valid* - General ADRTs for **non-life-sustaining treatments** do not legally require a written format or a witness to be valid; they can be made verbally. - The strict formal requirements (writing, signing, witnessing, specific statement) only apply when the ADRT concerns the refusal of **life-sustaining treatment**. *An ADRT can specify desired treatments as well as refused treatments* - An ADRT is strictly a **refusal of treatment**; it cannot be used to demand or mandate specific medical interventions. - Requests for specific treatments or care preferences are typically expressed in an **Advance Statement**, which is not legally binding but should be considered in a **Best Interests** decision. *An ADRT can be overruled by a Lasting Power of Attorney for Health and Welfare* - A valid and applicable **Advance Decision to Refuse Treatment (ADRT)** takes precedence over decisions made by a **Lasting Power of Attorney (LPA)** for Health and Welfare, regarding the specific treatment refused. - An LPA holder can only make decisions for treatments **not covered** by a valid and applicable ADRT, as the ADRT represents the person's own capable decision. *An ADRT applies to all treatments including those for mental disorder under the Mental Health Act* - ADRTs **do not apply** to treatment for a **mental disorder** if the patient is liable to be detained or is detained under the **Mental Health Act (MHA) 1983**. - However, ADRTs *do* apply to treatments for **physical health conditions**, even if the patient is detained under the MHA.
Question 107: A 69-year-old man with mild Alzheimer's dementia (MMSE 22/30) is assessed for capacity to consent to cataract surgery. He understands he has cataracts and that surgery can improve his vision. However, he cannot remember the discussion five minutes later and asks the same questions repeatedly. What is the most appropriate approach to capacity assessment?
- A. He lacks capacity because he cannot retain information for a reasonable period
- B. He has capacity because he can understand the information when it is explained
- C. Capacity should be assessed using written information he can refer to repeatedly (Correct Answer)
- D. He should be assessed after cognitive enhancing medication has been optimized
- E. His next of kin should make the decision as he has a diagnosis of dementia
Explanation: ***Capacity should be assessed using written information he can refer to repeatedly*** - Under the **Mental Capacity Act 2005**, all **practicable steps** must be taken to support decision-making; providing **written aids** or memory prompts is a crucial adjustment for patients with dementia. - Retention of information only needs to be for a **short period** necessary to make the decision; if the patient can weigh options using the written material, they may still possess capacity. *He lacks capacity because he cannot retain information for a reasonable period* - Capacity cannot be deemed absent until all **supportive measures** (like visual aids or repeat explanations) have been exhausted. - Memory loss alone does not automatically equate to a **lack of capacity** if the information can be held long enough to make a choice at that specific moment. *He has capacity because he can understand the information when it is explained* - Understanding is only one of the four functional tests; the patient must also be able to **retain**, **use and weigh**, and **communicate** the decision. - Simply understanding at the moment of explanation is insufficient if the patient cannot hold that information long enough to perform the **use and weigh** stage of the assessment. *He should be assessed after cognitive enhancing medication has been optimized* - Capacity assessments are **time-specific** and should be based on the person's current presentation rather than delayed for long-term medication adjustments that may have minimal impact on decision-making ability. - Delaying surgery for medication optimization is inappropriate if **simple aids** could facilitate a capacity assessment in the present timeframe. *His next of kin should make the decision as he has a diagnosis of dementia* - A diagnosis of **dementia** does not automatically negate a person's right to make their own decisions; capacity is **decision-specific**. - Substituted decision-making or **Best Interests** meetings only occur after a formal assessment confirms the patient lacks capacity and no **Power of Attorney** is in place.
Question 108: A 59-year-old woman with no psychiatric history is diagnosed with terminal pancreatic cancer. She has capacity and refuses all treatment including palliative chemotherapy. She expresses thoughts that she would be 'better off dead' and 'does not want to be a burden'. How should her expressed suicidal thoughts be interpreted?
- A. As normal adjustment to terminal diagnosis that requires no specific intervention
- B. As indicating comorbid depression requiring psychiatric referral and treatment
- C. As requiring exploration for depression while respecting her autonomous treatment decisions (Correct Answer)
- D. As evidence she lacks capacity to refuse treatment due to impaired judgment
- E. As necessitating Mental Health Act assessment to ensure treatment compliance
Explanation: ***As requiring exploration for depression while respecting her autonomous treatment decisions***- Statements regarding **suicidal ideation** in terminal illness require a careful **risk assessment** and screening for **clinical depression**, as these are not universal features of adjustment.- Patients with **capacity** have the right to refuse treatment, and a potential diagnosis of depression does not automatically invalidate their **autonomy** or ability to weigh medical options.*As normal adjustment to terminal diagnosis that requires no specific intervention*- While some level of distress is expected, expressing a desire to be dead or a fear of being a **burden** are significant indicators that necessitate a proactive **psychological evaluation**.- Dismissing these thoughts as "normal" risks overlooking **treatable mental health comorbidities** that could significantly impact the patient's quality of life.*As indicating comorbid depression requiring psychiatric referral and treatment*- While these thoughts are **red flags**, they are not definitive evidence of a **clinical depressive disorder** without further assessment of somatic and cognitive symptoms.- A referral may be appropriate later, but the initial step for the managing clinician is to explore the **patient's perspective** and depth of their distress.*As evidence she lacks capacity to refuse treatment due to impaired judgment*- Under the **Mental Capacity Act**, a person is presumed to have capacity, and a decision that seems **unwise** or reflects suicidal ideation does not prove incapacity.- Capacity is **task-specific**; the patient's ability to understand, retain, and weigh information about her cancer treatment remains intact unless proven otherwise.*As necessitating Mental Health Act assessment to ensure treatment compliance*- The **Mental Health Act** cannot be used to compel a patient with capacity to undergo treatment for a **physical illness** like pancreatic cancer.- Compulsory admission is only applicable for the treatment of a **mental disorder** when there is a risk to safety, which is not the primary issue regarding her cancer treatment refusal.
Question 109: A 43-year-old man with bipolar disorder is admitted during a severe depressive episode with active suicidal ideation. He agrees to informal admission. On day 3, he requests to leave, stating he feels better. Staff are concerned as his mood remains significantly low and he continues to express hopelessness. What is the most appropriate immediate action?
- A. Allow him to leave as he is an informal patient with capacity to make this decision
- B. Negotiate with him to stay voluntarily and arrange urgent psychiatric review
- C. Implement a Section 5(2) holding power pending Mental Health Act assessment (Correct Answer)
- D. Request a mental capacity assessment regarding his decision to leave
- E. Discharge him with crisis team follow-up and GP notification
Explanation: ***Implement a Section 5(2) holding power pending Mental Health Act assessment*** - **Section 5(2)** allows for the detention of an **informal inpatient** for up to **72 hours** by a doctor (or 6 hours by a nurse, Section 5(4)) if they are at risk and intent on leaving the hospital. - Given his **active suicidal ideation**, severe depressive episode, and staff's concern over his hopelessness, this legal power ensures his safety while awaiting a formal **Mental Health Act assessment**. *Allow him to leave as he is an informal patient with capacity to make this decision* - While **informal patients** generally have the right to leave, this right is overridden if there is an **immediate and significant risk of harm** to themselves or others. - Failing to prevent his departure when he is a high **suicide risk** would constitute a significant breach of the **duty of care** owed by the hospital staff. *Negotiate with him to stay voluntarily and arrange urgent psychiatric review* - While **negotiation** is often a preferred initial approach, the scenario indicates staff concern and patient persistence, making reliance on **voluntary cooperation** insufficient for his immediate safety. - Without a **legal holding power**, the patient can still leave at any moment, creating a dangerous window despite an arranged review for a patient with **active suicidal ideation**. *Request a mental capacity assessment regarding his decision to leave* - **Mental capacity** to make a decision is distinct from the justification for detention under the **Mental Health Act (MHA)**; a patient can have capacity but still require MHA detention due to risk. - Delaying immediate action for a formal capacity assessment is inappropriate when **immediate detention** is required to mitigate **active suicidal risk** under the MHA. *Discharge him with crisis team follow-up and GP notification* - Discharging a patient with **active suicidal ideation** and severe depression is clinically unsafe and does not provide the **level of containment and observation** required for his current state. - **Crisis team follow-up** is typically for patients managed in the community or as a step-down, not for an inpatient exhibiting **acute, severe suicidal intent**.
Question 110: A 27-year-old woman with recurrent depressive disorder attends her GP two months after a significant overdose. She describes ongoing low mood but denies current suicidal thoughts. When assessing her current suicide risk, which aspect of her mental state examination would be most important to explore?
- A. Presence of psychomotor retardation or agitation
- B. Degree of eye contact and rapport during consultation
- C. Presence of guilt, hopelessness, or worthlessness cognitions (Correct Answer)
- D. Assessment of her concentration and memory function
- E. Observation of her self-care and personal appearance
Explanation: ***Presence of guilt, hopelessness, or worthlessness cognitions*** - These negative cognitions about the self and the future, particularly **hopelessness**, are the strongest psychological predictors of **suicide risk**, often more than the depth of depression itself. - Identifying these features is vital because a patient may deny active **suicidal ideation** while still harboring the profound belief that life is not worth living or that things will never improve. *Presence of psychomotor retardation or agitation* - While **psychomotor agitation** can be a marker of distress and increased risk, it is less specific as a predictive tool for suicide than cognitive themes. - These are **biological symptoms** of depression that reflect severity but do not directly quantify the patient's intent or current outlook on survival. *Degree of eye contact and rapport during consultation* - Rapport and **eye contact** help assess current mood and the reliability of the history, but they do not provide a direct measure of **suicidal intent**. - A patient can maintain good rapport and eye contact while still remaining at high risk for suicide due to **internalized hopelessness**. *Assessment of her concentration and memory function* - Difficulties with **concentration and memory** (pseudo-dementia) are common features of depression but are not reliable indicators of **acute suicide risk**. - These findings primarily help in assessing the **functional impairment** of the depressive episode rather than the patient's safety. *Observation of her self-care and personal appearance* - **Self-care** reflects the patient's ability to perform daily activities and provides information on the **severity of depression**, but not necessarily the risk of harm. - A person can maintain a relatively neat **personal appearance** despite feeling a deep sense of **worthlessness** and planning to end their life.
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