An 82-year-old woman with advanced heart failure is dying in hospital. She has been unconscious for 48 hours. Her Lasting Power of Attorney for Health and Welfare (LPA-HW) (her daughter) requests that clinically assisted nutrition and hydration (CANH) via nasogastric tube be started, stating 'my mother would want everything possible done'. The medical team believes CANH would not prolong meaningful survival and may cause distress. What is the most appropriate course of action?
Q142
A 17-year-old boy with Type 1 diabetes has repeatedly missed clinic appointments and has poor glycaemic control (HbA1c 98 mmol/mol). He understands the long-term risks but states he 'doesn't care' and finds diabetes management 'boring'. His parents are very concerned. On capacity assessment, he can understand, retain, and weigh information about his diabetes and communicate his decision. From a consent and capacity perspective, what is his legal status regarding refusing diabetes treatment?
Q143
A 68-year-old man with metastatic renal cell carcinoma has a valid Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision documented in his notes following discussion with him 2 weeks ago. He is admitted with sepsis secondary to pneumonia and becomes hypotensive. The on-call medical registrar is uncertain whether the DNACPR means other resuscitation measures should be withheld. What is the correct interpretation of the DNACPR decision in this context?
Q144
A 35-year-old woman with emotionally unstable personality disorder is admitted following an overdose. She has capacity and is medically fit for discharge but expresses thoughts of further self-harm. The psychiatric team assesses her as not meeting criteria for detention under the Mental Health Act. She refuses admission to the mental health unit voluntarily and wants to leave. As she walks toward the exit, nursing staff physically prevent her from leaving and call security. What is the legal status of this action?
Q145
A 41-year-old woman with terminal pancreatic cancer with liver metastases is receiving end-of-life care on the ward. She has been receiving morphine for pain control but over the past 24 hours has become increasingly distressed with severe pain despite dose escalation. She is now requiring subcutaneous morphine every hour and has developed delirium. The palliative care team recommends commencing a midazolam infusion for symptom control in addition to morphine. Her brother claims this is 'euthanasia' and threatens legal action. What is the most appropriate response?
Q146
A 53-year-old man with end-stage alcoholic liver disease is admitted with hepatic encephalopathy (grade 3). He has been abstinent from alcohol for only 3 months. The hepatology team considers him potentially suitable for liver transplantation assessment, but concerns exist about his capacity to engage with the assessment process given his encephalopathy. His partner states he was adamant about wanting assessment before this admission. What is the most appropriate next step?
Q147
Which of the following statements about advance decisions to refuse treatment (ADRT) under the Mental Capacity Act 2005 is correct?
Q148
An 87-year-old woman with severe dementia (MMSE 4/30) is admitted from a nursing home with bowel obstruction secondary to advanced ovarian cancer. She is in pain but comfortable with analgesia. The surgical team assesses her as high-risk for surgery (30% mortality). She has no advance care plan or lasting power of attorney. Her daughter wants 'everything done' while her son thinks surgery would be too burdensome. What framework should guide the treatment decision?
Q149
A 14-year-old girl with sickle cell disease presents with acute chest syndrome requiring exchange transfusion. She is Gillick competent and consents to treatment. However, her parents refuse on religious grounds (Jehovah's Witnesses). The consultant believes the transfusion is life-saving and urgent. What is the most appropriate immediate course of action?
Q150
A 66-year-old man with motor neurone disease has made a written advance decision to refuse 'ventilation, including non-invasive ventilation' witnessed by two people. He is now admitted with aspiration pneumonia and respiratory distress. He is drowsy (GCS 13) and hypercapnic. His wife states he made the advance decision 8 months ago when depressed after diagnosis, and she believes he has changed his mind as he seemed more positive recently. What is the most appropriate management?
Ethics & Law UK Medical PG Practice Questions and MCQs
Question 141: An 82-year-old woman with advanced heart failure is dying in hospital. She has been unconscious for 48 hours. Her Lasting Power of Attorney for Health and Welfare (LPA-HW) (her daughter) requests that clinically assisted nutrition and hydration (CANH) via nasogastric tube be started, stating 'my mother would want everything possible done'. The medical team believes CANH would not prolong meaningful survival and may cause distress. What is the most appropriate course of action?
A. Commence CANH as the attorney has legal authority to make this decision
B. Refuse to commence CANH as it is not clinically indicated
C. Apply to Court of Protection as there is disagreement about CANH
D. Seek a second opinion from another consultant
E. Arrange a best interests meeting to discuss the decision with the attorney (Correct Answer)
Explanation: ***Arrange a best interests meeting to discuss the decision with the attorney***
- When there is a disagreement between a medical team and a **Lasting Power of Attorney (LPA)**, the first step is to engage in a formal **best interests assessment** and communication to resolve the conflict.
- The medical team must consider the attorney's perspective on the patient's **prior wishes and values** while balancing clinical outcomes and the potential for **treatment futility**.
*Commence CANH as the attorney has legal authority to make this decision*
- An LPA cannot demand treatment that is deemed **clinically inappropriate** or non-beneficial by the medical team.
- While they have the authority to consent or refuse, their decisions must be made in the patient's **best interests**, not based on personal preferences or demands for futile care.
*Refuse to commence CANH as it is not clinically indicated*
- Unilateral refusal without proper consultation with the **legal proxy** (LPA) can lead to serious ethical and legal conflicts.
- Doctors should aim for a **consensus-building approach** rather than an abrupt refusal when the patient's representative holds a different view.
*Apply to Court of Protection as there is disagreement about CANH*
- Referral to the **Court of Protection** is usually a last resort when local resolution, such as a best interests meeting or mediation, fails.
- While mandatory for certain cases involving **prolonged disorders of consciousness**, it is premature in an imminent **end-of-life** scenario before attempting to reach an agreement.
*Seek a second opinion from another consultant*
- While a **second opinion** can be helpful in complex cases, it does not address the core requirement to involve the **LPA** in the best interests decision-making process.
- The immediate priority is communication and reconciliation of views through a structured **meeting**, rather than simply validating the medical team's existing stance.
Question 142: A 17-year-old boy with Type 1 diabetes has repeatedly missed clinic appointments and has poor glycaemic control (HbA1c 98 mmol/mol). He understands the long-term risks but states he 'doesn't care' and finds diabetes management 'boring'. His parents are very concerned. On capacity assessment, he can understand, retain, and weigh information about his diabetes and communicate his decision. From a consent and capacity perspective, what is his legal status regarding refusing diabetes treatment?
A. His parents can override his refusal until he turns 18
B. The court can override his refusal as it is life-threatening (Correct Answer)
C. He can refuse treatment as he is Gillick competent
D. He has capacity under the Mental Capacity Act 2005 so his decision must be respected
E. His refusal can be overridden by doctors acting in his best interests
Explanation: ***The court can override his refusal as it is life-threatening***
- In the UK, while a **16-17 year old** is presumed to have capacity, their **refusal of life-saving treatment** can still be overridden by the **High Court** to protect their welfare.
- This distinction exists because the legal system prioritizes the **best interests** and survival of a minor over their absolute autonomy until they reach age 18.
*His parents can override his refusal until he turns 18*
- While **parental responsibility** allows for consent, overriding a **capacitous 17-year-old's** refusal is legally complex and ethically fraught for parents alone.
- In practice, if a minor with capacity refuses essential treatment, a **court order** is usually sought rather than relying solely on parental override.
*He can refuse treatment as he is Gillick competent*
- **Gillick competence** specifically applies to children **under the age of 16** to determine if they can consent to treatment without parental knowledge.
- Even if deemed competent, a minor's **refusal** of treatment that prevents death or severe permanent harm is not legally absolute.
*He has capacity under the Mental Capacity Act 2005 so his decision must be respected*
- The **Mental Capacity Act (MCA) 2005** applies to those aged 16 and over, but it does not grant them the same absolute right to **refuse life-saving treatment** as an adult (18+).
- For minors, the **Children Act 1989** and common law allow the courts to intervene if the minor's decision will lead to significant harm or death.
*His refusal can be overridden by doctors acting in his best interests*
- Doctors cannot unilaterally override a **capacitous minor's** refusal; they must seek legal authorization through the **judicial system** (e.g., the High Court).
- While the medical team must act in the patient's **best interests**, they must follow due legal process when autonomy and life-preservation conflict in a minor.
Question 143: A 68-year-old man with metastatic renal cell carcinoma has a valid Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision documented in his notes following discussion with him 2 weeks ago. He is admitted with sepsis secondary to pneumonia and becomes hypotensive. The on-call medical registrar is uncertain whether the DNACPR means other resuscitation measures should be withheld. What is the correct interpretation of the DNACPR decision in this context?
A. All resuscitation measures including IV fluids and antibiotics should be withheld
B. The DNACPR only applies to chest compressions and ventilation in the event of cardiac arrest (Correct Answer)
C. The DNACPR should be reviewed by the consultant before any active treatment
D. The DNACPR indicates the patient should receive palliative care only
E. The DNACPR means ICU admission should not be considered
Explanation: ***The DNACPR only applies to chest compressions and ventilation in the event of cardiac arrest*** - A **DNACPR decision** is specific to the event of a **cardiac or respiratory arrest**; it does not preclude other active treatments like antibiotics or fluid resuscitation.- Clinical interventions for reversible conditions, such as **sepsis and pneumonia**, should continue unless a separate **ceiling of treatment** has been documented.*All resuscitation measures including IV fluids and antibiotics should be withheld*- **DNACPR** is not synonymous with "Do Not Treat"; withholding fluids and antibiotics in this context constitutes a medical error.- Decisions regarding **active medical management** are independent of the decision to forgo cardiopulmonary resuscitation.*The DNACPR should be reviewed by the consultant before any active treatment*- While documentation should be clear, a valid **DNACPR** does not freeze clinical management or require a consultant's review before starting **life-saving treatments** for sepsis.- **Acute treatment decisions** (e.g., managing hypotension) must be made based on clinical urgency regardless of the presence of a DNACPR.*The DNACPR indicates the patient should receive palliative care only*- **Palliative care** is a separate management goal and is not automatically triggered by a **DNACPR instruction**.- Patients can be "full active treatment" for an acute illness while simultaneously having a **DNACPR** in place for end-of-life planning.*The DNACPR means ICU admission should not be considered*- **ICU admission** and mechanical ventilation/organ support are separate from **cardiopulmonary resuscitation (CPR)** following an arrest.- Decisions regarding **Escalation of Care** to the ICU should be made based on the patient's prognosis and the reversibility of the acute condition, not the DNACPR status alone.
Question 144: A 35-year-old woman with emotionally unstable personality disorder is admitted following an overdose. She has capacity and is medically fit for discharge but expresses thoughts of further self-harm. The psychiatric team assesses her as not meeting criteria for detention under the Mental Health Act. She refuses admission to the mental health unit voluntarily and wants to leave. As she walks toward the exit, nursing staff physically prevent her from leaving and call security. What is the legal status of this action?
A. Lawful under common law duty of care
B. Unlawful deprivation of liberty as she has capacity and is not detained (Correct Answer)
C. Lawful under Mental Capacity Act Deprivation of Liberty Safeguards
D. Lawful as a proportionate response to risk of serious harm
E. Requires retrospective Section 5(2) application within 6 hours
Explanation: ***Unlawful deprivation of liberty as she has capacity and is not detained***
- Since the patient has **capacity** and the psychiatric team has determined she does not meet the criteria for the **Mental Health Act (MHA)**, there is no legal basis to physically prevent her from leaving.
- Restricting the movements of a capacitous individual who is not under formal detention constitutes **unlawful imprisonment** or an illegal deprivation of liberty.
*Lawful under common law duty of care*
- **Common law** allows for intervention to prevent immediate harm to others or to the person themselves if they **lack capacity**, which is not the case here.
- A duty of care does not override the fundamental right of a **capacitous patient** to make unwise decisions, including the decision to leave the hospital.
*Lawful under Mental Capacity Act Deprivation of Liberty Safeguards*
- **Deprivation of Liberty Safeguards (DoLS)** only apply to patients who **lack mental capacity** to consent to the arrangements for their care or treatment.
- Because this patient has been explicitly identified as having **capacity**, the Mental Capacity Act cannot be used to justify her detention.
*Lawful as a proportionate response to risk of serious harm*
- While the risk of self-harm is present, **proportionality** does not grant legal authority to detain a person who possesses decision-making **capacity**.
- Legal detention for mental health reasons must strictly follow statutory frameworks like the **Mental Health Act**; clinical risk alone is insufficient for physical restraint.
*Requires retrospective Section 5(2) application within 6 hours*
- **Section 5(2)** is a holding power for patients already admitted as **inpatients** for mental health treatment and cannot be applied **retrospectively** to justify an illegal act.
- As the patient is medically fit for discharge and the psychiatric team already declined MHA detention, this section is **inapplicable** and cannot fix an unlawful restraint.
Question 145: A 41-year-old woman with terminal pancreatic cancer with liver metastases is receiving end-of-life care on the ward. She has been receiving morphine for pain control but over the past 24 hours has become increasingly distressed with severe pain despite dose escalation. She is now requiring subcutaneous morphine every hour and has developed delirium. The palliative care team recommends commencing a midazolam infusion for symptom control in addition to morphine. Her brother claims this is 'euthanasia' and threatens legal action. What is the most appropriate response?
A. Discontinue plans for midazolam to avoid legal complications
B. Explain that symptom control with appropriate drugs is not euthanasia and is standard palliative care (Correct Answer)
C. Contact hospital legal team before commencing midazolam
D. Arrange transfer to hospice where midazolam can be given
E. Wait for the patient to lose consciousness before starting midazolam
Explanation: ***Explain that symptom control with appropriate drugs is not euthanasia and is standard palliative care***
- This response is based on the **doctrine of double effect**, where an action intended for a good effect (symptom relief) is ethically permissible even if it carries a risk of a secondary, unintended bad effect (hastening death).
- Providing **midazolam** for terminal restlessness and **morphine** for refractory pain is standard practice in **end-of-life care** to ensure a comfortable death and does not constitute euthanasia since the primary intent is not to kill.
*Discontinue plans for midazolam to avoid legal complications*
- Withholding necessary medication would result in **unnecessary suffering** and fails the clinician's duty of beneficence toward the patient.
- Clinical decisions should be based on the **patient's clinical needs** and symptom management best practices rather than fear of unsubstantiated legal threats.
*Contact hospital legal team before commencing midazolam*
- Involving the legal team for standard **palliative care protocols** causes unnecessary delays in treating a patient in acute distress and pain.
- The primary responsibility is to alleviate the patient's **severe pain and delirium** immediately, which is legally protected under established medical ethical guidelines.
*Arrange transfer to hospice where midazolam can be given*
- Transferring a **terminally ill** patient in moderate to severe distress is clinically inappropriate and would cause further agitation and physical discomfort.
- End-of-life symptom control, including **syringe drivers** and sedative infusions, can and should be managed in a ward setting when a patient is too unstable for transfer.
*Wait for the patient to lose consciousness before starting midazolam*
- Waiting for loss of consciousness ignores the patient's current **agitation and distress**, allowing symptoms to remain untreated while the patient is still aware of pain.
- The goal of midazolam in this context is to manage **terminal delirium**, and it should be titrated to effect based on current symptoms, not delayed based on consciousness levels.
Question 146: A 53-year-old man with end-stage alcoholic liver disease is admitted with hepatic encephalopathy (grade 3). He has been abstinent from alcohol for only 3 months. The hepatology team considers him potentially suitable for liver transplantation assessment, but concerns exist about his capacity to engage with the assessment process given his encephalopathy. His partner states he was adamant about wanting assessment before this admission. What is the most appropriate next step?
A. Proceed with transplant assessment as expressed by his partner
B. Wait until encephalopathy resolves before any assessment-related decisions (Correct Answer)
C. Perform formal capacity assessment regarding transplant assessment now
D. Refer to psychiatry to assess his capacity
E. Exclude him from transplant assessment due to insufficient abstinence period
Explanation: ***Wait until encephalopathy resolves before any assessment-related decisions***
- Capacity is **decision-specific** and **time-specific**; the **Mental Capacity Act** mandates that all practicable steps be taken to support decision-making, including waiting for **reversible conditions** to resolve.
- **Grade 3 hepatic encephalopathy** causes significant cognitive impairment, making it impossible to provide **informed consent** for a complex transplant process until the medical state is stabilized.
*Proceed with transplant assessment as expressed by his partner*
- While the partner's report of the patient's **prior wishes** is relevant, it does not bypass the need for a contemporaneous and **valid consent** once the patient recovers.
- Significant medical decisions should not rely solely on **second-hand reports** if the underlying cause of incapacity is expected to be **temporary**.
*Perform formal capacity assessment regarding transplant assessment now*
- Assessing capacity during a peak of **metabolic encephalopathy** is inappropriate as the patient is clearly incapacitated by a **treatable impairment** of the mind or brain.
- A capacity assessment should be deferred until the person is at their **optimal cognitive baseline** to ensure a fair and accurate evaluation.
*Refer to psychiatry to assess his capacity*
- Capacity assessments are the responsibility of the **treating clinician** or medical team; a specialist psychiatric referral is not required for obvious **organic causes** of confusion.
- Psychiatry would likely give the same advice: that a valid assessment cannot be completed until the **acute confusion** is medically managed.
*Exclude him from transplant assessment due to insufficient abstinence period*
- While the **6-month abstinence rule** is common, it is a clinical eligibility criterion and does not address the immediate ethical and legal issue of **mental capacity**.
- Excluding the patient prematurely based on abstinence alone, without finishing the **clinical and psychosocial workup**, is inappropriate at this stage.
Question 147: Which of the following statements about advance decisions to refuse treatment (ADRT) under the Mental Capacity Act 2005 is correct?
A. An ADRT must be reviewed annually to remain valid
B. An ADRT refusing life-sustaining treatment must be in writing, signed and witnessed (Correct Answer)
C. An ADRT can specify which treatments the person wishes to receive
D. A lasting power of attorney for health and welfare automatically overrides any previous ADRT
E. Healthcare professionals who follow a valid ADRT can be prosecuted if the patient dies
Explanation: ***An ADRT refusing life-sustaining treatment must be in writing, signed and witnessed***
- Under the **Mental Capacity Act 2005**, any advance decision to refuse **life-sustaining treatment** has strict formal requirements to ensure its validity.
- It must be **documented in writing**, signed by the person making it, and include a **witness signature** to be legally binding.
*An ADRT must be reviewed annually to remain valid*
- There is **no statutory requirement** for an ADRT to be reviewed annually under the Mental Capacity Act.
- While regular reviews are recommended to ensure the decision still reflects the patient's **current wishes**, the document remains valid until **withdrawn or invalidated**.
*An ADRT can specify which treatments the person wishes to receive*
- An ADRT is strictly used to **refuse specific medical treatments** when a person lacks capacity; it cannot be used to demand specific care.
- Requests for specific treatments are known as **advance statements**, which reflect preferences but are **not legally binding** on clinicians.
*A lasting power of attorney for health and welfare automatically overrides any previous ADRT*
- A **Lasting Power of Attorney (LPA)** only overrides a previous ADRT if the LPA was **created after** the ADRT and grants specific authority over that treatment.
- Decisions are based on the **most recent** valid expression of the patient's wishes at the time they had capacity.
*Healthcare professionals who follow a valid ADRT can be prosecuted if the patient dies*
- Healthcare professionals are **legally protected** from liability for withholding treatment if they believe a **valid and applicable** ADRT exists.
- Conversely, ignoring a valid ADRT could result in a charge of **battery** or human rights violations for providing treatment against a patient's wishes.
Question 148: An 87-year-old woman with severe dementia (MMSE 4/30) is admitted from a nursing home with bowel obstruction secondary to advanced ovarian cancer. She is in pain but comfortable with analgesia. The surgical team assesses her as high-risk for surgery (30% mortality). She has no advance care plan or lasting power of attorney. Her daughter wants 'everything done' while her son thinks surgery would be too burdensome. What framework should guide the treatment decision?
A. The daughter's wishes as she is the eldest child
B. A best interests decision considering all relevant factors (Correct Answer)
C. The surgical team's clinical judgement about appropriateness
D. A family meeting to reach consensus
E. Independent Mental Capacity Advocate (IMCA) decision
Explanation: ***A best interests decision considering all relevant factors***- Under the **Mental Capacity Act 2005**, when a patient lacks capacity and has no **Lasting Power of Attorney** or advance directive, decisions must be made in their **best interests**.- This framework requires a holistic assessment involving the patient's **past wishes**, values, clinical prognosis, and the views of **family members** to determine the most appropriate course of action.*The daughter's wishes as she is the eldest child*- In English law, family members (including the eldest child) do not have the **legal authority** to mandate specific treatments unless they hold a **Lasting Power of Attorney** for Health and Welfare.- While her views are a vital component of the **best interests** consultation, they are not the sole determining factor in the decision-making process.*The surgical team's clinical judgement about appropriateness*- Clinical judgement is necessary to determine the **medical feasibility** and risks, but it cannot be the sole framework for a patient lacking capacity.- A **best interests** decision must go beyond clinical facts to include the patient's **socio-cultural values** and prior lifestyle preferences.*A family meeting to reach consensus*- While a family meeting is a helpful tool to facilitate discussion and gather information, **consensus** is not a legal requirement for a decision to be made.- If the family cannot agree, the **medical professional** (the decision-maker) must still proceed based on what is in the patient's **best interests**.*Independent Mental Capacity Advocate (IMCA) decision*- An **IMCA** is generally only appointed for serious medical decisions when a patient lacks capacity and has **no family or friends** to represent them.- Furthermore, an IMCA does not make the final decision; their role is to **support and represent** the patient during the best interests assessment process.
Question 149: A 14-year-old girl with sickle cell disease presents with acute chest syndrome requiring exchange transfusion. She is Gillick competent and consents to treatment. However, her parents refuse on religious grounds (Jehovah's Witnesses). The consultant believes the transfusion is life-saving and urgent. What is the most appropriate immediate course of action?
A. Proceed with transfusion based on the girl's consent alone
B. Respect parental refusal as they have legal responsibility
C. Proceed with transfusion in the child's best interests without delay (Correct Answer)
D. Seek urgent High Court authorisation before proceeding
E. Arrange second opinion from another consultant
Explanation: ***Proceed with transfusion in the child's best interests without delay***- In a life-threatening emergency, a doctor's primary duty is to act in the **best interests** of the patient, and life-saving treatment should not be delayed by parental refusal.- Since the patient is **Gillick competent** and consenting, this further supports the clinical decision, although the **duty of care** to preserve life is the overriding legal justification in urgent scenarios.*Proceed with transfusion based on the girl's consent alone*- While **Gillick competence** allows a child under 16 to consent, the legal framework in the UK often requires more than just the minor's consent when parents are in active disagreement for major procedures.- The immediate clinical justification in this emergency is the **best interests** principle rather than solely the patient's status as a competent minor.*Respect parental refusal as they have legal responsibility*- **Parental responsibility** does not grant parents the right to refuse **life-saving treatment** that is clearly in the child's best interests.- The courts and medical ethics prioritize the **right to life** and welfare of the child over the religious or personal beliefs of the parents.*Seek urgent High Court authorisation before proceeding*- While a **court order** is the standard procedure for resolving disputes regarding a minor's care, it is not appropriate if the delay would result in **death or serious harm**.- In this **acute chest syndrome** case, the treatment is described as **urgent**, making any legal delay clinically negligent.*Arrange second opinion from another consultant*- Seeking a **second opinion** is a useful step in non-emergency disputes to confirm clinical necessity but is inappropriate in an **acute emergency**.- The primary focus must remain on the **immediate stabilization** and life-saving intervention for the patient.
Question 150: A 66-year-old man with motor neurone disease has made a written advance decision to refuse 'ventilation, including non-invasive ventilation' witnessed by two people. He is now admitted with aspiration pneumonia and respiratory distress. He is drowsy (GCS 13) and hypercapnic. His wife states he made the advance decision 8 months ago when depressed after diagnosis, and she believes he has changed his mind as he seemed more positive recently. What is the most appropriate management?
A. Provide non-invasive ventilation as his wife suggests he changed his mind
B. Attempt to assess his current wishes despite reduced consciousness (Correct Answer)
C. Follow the advance decision and withhold non-invasive ventilation
D. Apply for Court of Protection urgent decision
E. Start non-invasive ventilation pending psychiatric review of the advance decision
Explanation: ***Attempt to assess his current wishes despite reduced consciousness***
- With a **GCS of 13**, the patient may still have the capacity to communicate or display **current preferences**, which must be explored before relying on a previous document.
- An **Advance Decision to Refuse Treatment (ADRT)** can be overridden if there are reasonable grounds to believe that the patient has **changed their mind** since it was drafted.
*Provide non-invasive ventilation as his wife suggests he changed his mind*
- While the wife's testimony creates **reasonable doubt**, her statement alone does not automatically invalidate a formal, **written ADRT**.
- The primary duty is to the patient's **autonomy**, necessitating a direct assessment of the patient rather than relying solely on third-party reports.
*Follow the advance decision and withhold non-invasive ventilation*
- Following an ADRT when there is **genuine doubt** regarding its current validity or applicability can lead to irreversible harm if the patient has indeed changed their mind.
- Under the **Mental Capacity Act**, if there is doubt about whether an ADRT is valid and applicable, clinicians should provide treatment in the patient's **best interests** while resolving that doubt.
*Apply for Court of Protection urgent decision*
- The **Court of Protection** is a last resort and is not the immediate first step when the patient is still potentially able to communicate or when clinical urgency exists.
- Clinical teams should first attempt to resolve **uncertainty** at the bedside through assessment and consultation with family before seeking legal intervention.
*Start non-invasive ventilation pending psychiatric review of the advance decision*
- A **psychiatric review** regarding past depression is not the standard procedure for validating an ADRT, as **mental health issues** at the time of signing do not automatically invalidate capacity.
- The priority is the **contemporaneous assessment** of the patient's wishes and current medical state rather than a retrospective analysis of his prior mental state.
