Ethics & Law — MCQs
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A 17-year-old girl with anorexia nervosa (BMI 14.5 kg/m²) is admitted for nutritional support. She has capacity and consistently refuses nasogastric feeding, stating she wants to die. Her parents consent to treatment on her behalf. Mental health assessment confirms she has capacity despite her mental illness. What is the legal basis for proceeding with nasogastric feeding?
A 46-year-old man with end-stage renal failure has been on haemodialysis for 5 years. He has capacity and decides to stop dialysis, fully understanding this will lead to his death within 2-3 weeks. His wife is extremely distressed and asks you to section him under the Mental Health Act to prevent him from 'committing suicide'. What is the most appropriate management?
A 68-year-old woman with advanced ovarian cancer has capacity and refuses further chemotherapy. Her daughter, who has Lasting Power of Attorney for Property and Financial Affairs, insists that her mother continue treatment and threatens to sue if treatment is stopped. The patient remains adamant she wants to stop. What is the most appropriate course of action?
A 43-year-old man is admitted to intensive care following a traumatic brain injury with intracranial haemorrhage. He undergoes emergency neurosurgery but fails to improve. After 5 days, he remains ventilator-dependent with absent brainstem reflexes. Two sets of brainstem death tests are performed by appropriately qualified doctors and confirm brainstem death. His wife asks when he will wake up. What is the correct explanation of his legal status?
A 78-year-old man with severe dementia (MMSE 8/30) and a history of recurrent aspiration is admitted with pneumonia. He lacks capacity regarding treatment decisions. His daughter, who visits daily, states he would not want a nasogastric tube or PEG feeding if he could no longer swallow safely. His son, who lives abroad and rarely visits, insists on artificial nutrition and hydration, stating 'we cannot let him starve'. Neither has Lasting Power of Attorney. What framework should guide the decision-making process?
A 52-year-old woman with advanced motor neurone disease has a valid advance decision refusing intubation and mechanical ventilation. She is admitted with aspiration pneumonia and develops type 2 respiratory failure. As her respiratory function deteriorates, she loses capacity due to hypercapnic encephalopathy (GCS 10). Her advance decision is verified as valid and applicable. Her husband pleads with the team to intubate her, saying 'she would want to live to see our daughter's wedding next month'. What should be done?
A 15-year-old girl attends the emergency department requesting emergency hormonal contraception after unprotected sexual intercourse 36 hours ago. She appears to understand the treatment and its implications. She specifically requests that her parents are not informed as they would be very angry. Her boyfriend is 17 years old. What is the most appropriate course of action?
A 70-year-old man with metastatic prostate cancer is receiving end-of-life care at home. He has been prescribed subcutaneous morphine 5-10mg every 2 hours as needed for pain and subcutaneous midazolam 2.5-5mg every 4 hours as needed for agitation. Over the past 24 hours his pain and agitation have increased significantly, and he has required the maximum doses of both medications. He is now very drowsy but still responsive. His family are concerned that the medications are hastening his death and request that they be reduced. What is the correct ethical and legal principle that applies?
A 25-year-old woman with severe learning disability (IQ 42) and autism is admitted with suspected appendicitis requiring urgent appendicectomy. She becomes extremely distressed during examination and refuses to allow anyone to touch her abdomen. Her mother, who is her registered Lasting Power of Attorney for Health and Welfare, consents to the surgery. The patient continues to resist and will require physical restraint to proceed. What is the legally correct approach?
A 59-year-old man with end-stage heart failure is receiving palliative care on the ward. He has capacity and has clearly expressed that he does not want cardiopulmonary resuscitation (CPR). A DNACPR order has been completed and signed by the consultant. His wife visits and becomes very distressed when she discovers the DNACPR order. She was not informed about it and states she would never have agreed to it. She demands the order be cancelled. What is the most appropriate action?
Ethics & Law UK Medical PG Practice Questions and MCQs
Question 11: A 17-year-old girl with anorexia nervosa (BMI 14.5 kg/m²) is admitted for nutritional support. She has capacity and consistently refuses nasogastric feeding, stating she wants to die. Her parents consent to treatment on her behalf. Mental health assessment confirms she has capacity despite her mental illness. What is the legal basis for proceeding with nasogastric feeding?
- A. Parental consent is valid as she is under 18 years of age
- B. Treatment can proceed under the Mental Health Act (Correct Answer)
- C. Treatment can proceed under common law doctrine of necessity
- D. Her refusal must be respected; nasogastric feeding cannot be given
- E. Treatment can proceed under the Mental Capacity Act in her best interests
Explanation: ***Treatment can proceed under the Mental Health Act*** - **Anorexia nervosa** is legally classified as a mental disorder; therefore, **nasogastric feeding** can be authorized under the **Mental Health Act** as it is considered medical treatment for the disorder itself.\n - This remains an applicable legal framework even when a patient is deemed to have **capacity** but is refusing life-saving treatment for their mental health condition.\n\n*Parental consent is valid as she is under 18 years of age*\n - While individuals with **parental responsibility** can technically consent for those under 18, it is ethically and legally preferable to use the **Mental Health Act** in cases of profound refusal by a **Gillick competent** minor.\n - Using parental consent to override a competent 17-year-old's refusal of invasive treatment is legally controversial and less robust than statutory frameworks.\n\n*Treatment can proceed under common law doctrine of necessity*\n - The **doctrine of necessity** is generally reserved for emergency situations where a patient **lacks capacity** and immediate action is required to save life or prevent serious harm.\n - Since this patient has been assessed as having **capacity**, the doctrine of necessity is not the appropriate primary legal basis for long-term nutritional support.\n\n*Her refusal must be respected; nasogastric feeding cannot be given*\n - In the UK, while a competent minor can **consent** to treatment, their **refusal** of life-saving treatment can be overridden by a court or under the **Mental Health Act**.\n - Because the refusal leads to a high risk of death from a treatable mental disorder, medical professionals have a duty of care to intervene using the appropriate legal mechanisms.\n\n*Treatment can proceed under the Mental Capacity Act in her best interests*\n - The **Mental Capacity Act (MCA)** only applies to individuals who **lack the capacity** to make a specific decision at a specific time.\n - Since the scenario explicitly states the patient has **capacity** despite her illness, the MCA cannot be used as the legal basis for treatment.
Question 12: A 46-year-old man with end-stage renal failure has been on haemodialysis for 5 years. He has capacity and decides to stop dialysis, fully understanding this will lead to his death within 2-3 weeks. His wife is extremely distressed and asks you to section him under the Mental Health Act to prevent him from 'committing suicide'. What is the most appropriate management?
- A. Detain under Section 2 of the Mental Health Act for assessment
- B. Arrange urgent psychiatric assessment to determine if sectioning is appropriate
- C. Respect his decision and arrange supportive end-of-life care (Correct Answer)
- D. Continue dialysis in his best interests until psychiatric review is complete
- E. Apply to the Court of Protection for authorization to continue treatment
Explanation: ***Respect his decision and arrange supportive end-of-life care*** - A person with **mental capacity** has an absolute legal right to refuse medical treatment, even if that refusal results in death or appears unwise to others. - Refusing treatment for a physical illness is not legally considered **suicide**, and clinicians must provide **palliative care** to ensure comfort during the natural dying process. *Detain under Section 2 of the Mental Health Act for assessment* - The **Mental Health Act (MHA)** is intended for the treatment of mental disorders and cannot be used to force treatment for physical conditions in a **capacitous patient**. - There is no evidence of a **mental disorder** or lack of capacity provided in the scenario to justify detention. *Arrange urgent psychiatric assessment to determine if sectioning is appropriate* - While a psychiatric review may help support the patient's emotional wellbeing, it cannot be used as a tool to **override autonomy** when capacity is already established. - Sectioning is inappropriate for a patient making a **competent refusal** of life-sustaining physical treatment. *Continue dialysis in his best interests until psychiatric review is complete* - **Best interests** decisions are only applicable under the **Mental Capacity Act** when a patient lacks the capacity to decide for themselves. - Continuing treatment against the express wishes of a capacitous patient constitutes **battery** (unlawful physical contact) in a legal context. *Apply to the Court of Protection for authorization to continue treatment* - The **Court of Protection** primarily deals with decisions for individuals who **lack capacity**; it would not authorize treatment against a capacitous adult's refusal. - Legal intervention is unnecessary here as the legal principle of **patient autonomy** is clear regarding the right to refuse dialysis.
Question 13: A 68-year-old woman with advanced ovarian cancer has capacity and refuses further chemotherapy. Her daughter, who has Lasting Power of Attorney for Property and Financial Affairs, insists that her mother continue treatment and threatens to sue if treatment is stopped. The patient remains adamant she wants to stop. What is the most appropriate course of action?
- A. Follow the daughter's wishes as she holds Lasting Power of Attorney
- B. Respect the patient's decision and discontinue chemotherapy (Correct Answer)
- C. Apply to the Court of Protection for a decision
- D. Continue chemotherapy until family consensus is reached
- E. Refer to the hospital ethics committee for guidance
Explanation: ***Respect the patient's decision and discontinue chemotherapy***- A patient with **mental capacity** has the absolute legal and ethical right to refuse any medical treatment, even if that refusal may result in death.- The principle of **autonomy** dictates that a capacitous patient's decision overrides the views of family members, including those with certain types of power of attorney.*Follow the daughter's wishes as she holds Lasting Power of Attorney*- The daughter holds a **Lasting Power of Attorney (LPA) for Property and Financial Affairs**, which grants no authority over **health and welfare** decisions.- An LPA for Health and Welfare would only become active if the patient **loses capacity**, which is explicitly stated not to be the case here.*Apply to the Court of Protection for a decision*- The **Court of Protection** is typically involved when a patient **lacks capacity** and there is a dispute regarding their best interests or treatment.- Since the patient has **undisputed capacity** and has made a clear decision, her wishes are legally binding and do not require judicial intervention.*Continue chemotherapy until family consensus is reached*- Forcing medical treatment on a patient who has **capacity** and refuses it constitutes **medical battery** and is a violation of their rights.- Healthcare professionals must respect the **autonomy** of a competent patient; family consensus is not required when the patient's wishes are clear.*Refer to the hospital ethics committee for guidance*- While an **ethics committee** can be helpful in morally ambiguous situations, the legal and ethical framework concerning a capacitous patient's right to refuse treatment is clear.- The patient's **right to autonomy** is paramount and does not necessitate committee approval to be upheld.
Question 14: A 43-year-old man is admitted to intensive care following a traumatic brain injury with intracranial haemorrhage. He undergoes emergency neurosurgery but fails to improve. After 5 days, he remains ventilator-dependent with absent brainstem reflexes. Two sets of brainstem death tests are performed by appropriately qualified doctors and confirm brainstem death. His wife asks when he will wake up. What is the correct explanation of his legal status?
- A. He is legally dead and mechanical ventilation is maintaining organ perfusion only (Correct Answer)
- B. He is legally alive until mechanical ventilation is discontinued
- C. He is in a persistent vegetative state and requires ongoing care
- D. His prognosis is uncertain and further time is needed before determining his status
- E. He is legally alive but withdrawal of treatment is appropriate as it is futile
Explanation: ***He is legally dead and mechanical ventilation is maintaining organ perfusion only*** - In the UK, **brainstem death** is the legal definition of death; once two sets of tests confirm this, the individual is **legally dead** even if the heart is still beating. - The **ventilator** is not providing life-sustaining treatment but is merely **maintaining perfusion** to organs, often to allow for potential organ donation or family support. *He is legally alive until mechanical ventilation is discontinued* - Legal death is determined by the **irreversible cessation** of **brainstem function**, not by the removal of medical technology or the cessation of the heartbeat. - The time of death is recorded when the **second set of brainstem tests** is completed, regardless of when the ventilator is switched off. *He is in a persistent vegetative state and requires ongoing care* - In a **persistent vegetative state (PVS)**, the **brainstem remains functional**, allowing for spontaneous breathing and sleep-wake cycles, unlike brainstem death. - Patients with brainstem death have **absent brainstem reflexes** (e.g., no cough, gag, or pupillary response), indicating total and permanent loss of brain function. *His prognosis is uncertain and further time is needed before determining his status* - The prognosis is no longer uncertain once **brainstem death** is confirmed, as it represents **irreversible brain damage** and clinical death. - **Brainstem death testing** is only performed after a period of observation ensures that reversible factors (like sedation or hypothermia) have been excluded. *He is legally alive but withdrawal of treatment is appropriate as it is futile* - This statement incorrectly identifies the legal status; withdrawal of treatment applies to **critically ill** patients who are still alive, not those who have already met **death criteria**. - Once **brainstem death** is confirmed, the patient is **legally deceased**, making the concept of "futile treatment" irrelevant as life has already ended.
Question 15: A 78-year-old man with severe dementia (MMSE 8/30) and a history of recurrent aspiration is admitted with pneumonia. He lacks capacity regarding treatment decisions. His daughter, who visits daily, states he would not want a nasogastric tube or PEG feeding if he could no longer swallow safely. His son, who lives abroad and rarely visits, insists on artificial nutrition and hydration, stating 'we cannot let him starve'. Neither has Lasting Power of Attorney. What framework should guide the decision-making process?
- A. The daughter's view should take precedence as she is more involved in his day-to-day care
- B. A best interests decision should be made considering all relevant factors including both family views (Correct Answer)
- C. The son's view should be followed as he is legally entitled to refuse withdrawal of life-sustaining treatment
- D. Artificial nutrition must be provided as withdrawing it would constitute euthanasia
- E. The Court of Protection must make the decision as the family disagree
Explanation: ***A best interests decision should be made considering all relevant factors including both family views*** - Under the **Mental Capacity Act (MCA) 2005**, when a patient lacks capacity and has no **Lasting Power of Attorney (LPA)**, the clinical team must act in the patient's **best interests**. - This involves weighing the patient's **previously expressed wishes**, current values, and the views of all family members, regardless of their level of daily involvement. *The daughter's view should take precedence as she is more involved in his day-to-day care* - While the daughter may have better insight into the patient's **values and wishes**, she does not have the **legal authority** to override other family members or the medical team without an LPA. - The decision-making process requires a **holistic evaluation** of all viewpoints rather than a simple hierarchy based on proximity of care. *The son's view should be followed as he is legally entitled to refuse withdrawal of life-sustaining treatment* - Next of kin do not have a **legal right** to demand or refuse specific treatments unless they have been formally appointed as an **LPA for Health and Welfare**. - **Artificial nutrition and hydration (ANH)** is considered a medical treatment and can be legally withheld if it is deemed to be of no clinical benefit or not in the patient's **best interests**. *Artificial nutrition must be provided as withdrawing it would constitute euthanasia* - Withdrawing or withholding **clinically non-beneficial** treatment (like PEG feeding in end-stage dementia with aspiration) is the omission of treatment, not an active act of killing. - The medical consensus is that **euthanasia** involves an active intent to end life, whereas stopping ANH in this context is allowing the **underlying disease process** to take its course. *The Court of Protection must make the decision as the family disagree* - Disagreement between family members should initially be managed through **mediation**, expert second opinions, and case conferences; the **Court of Protection** is a last resort. - Legal intervention is generally reserved for **intractable disputes** or specific complex cases, such as those involving patients in a **permanent vegetative state (PVS)**.
Question 16: A 52-year-old woman with advanced motor neurone disease has a valid advance decision refusing intubation and mechanical ventilation. She is admitted with aspiration pneumonia and develops type 2 respiratory failure. As her respiratory function deteriorates, she loses capacity due to hypercapnic encephalopathy (GCS 10). Her advance decision is verified as valid and applicable. Her husband pleads with the team to intubate her, saying 'she would want to live to see our daughter's wedding next month'. What should be done?
- A. Intubate as the husband's request suggests she may have changed her mind
- B. Respect the advance decision and provide non-invasive treatment and palliative care (Correct Answer)
- C. Seek an urgent Court of Protection ruling given the conflicting information
- D. Intubate temporarily until capacity can be reassessed
- E. Proceed with non-invasive ventilation as it is not explicitly mentioned in the advance decision
Explanation: ***Respect the advance decision and provide non-invasive treatment and palliative care*** - A valid and applicable **Advance Decision to Refuse Treatment (ADRT)** has the same legal weight as a contemporaneous decision; it must be followed even if it leads to death. - Under the **Mental Capacity Act 2005**, family perspectives cannot override a legally binding ADRT once it is verified as valid and applicable to the patient's current situation. *Intubate as the husband's request suggests she may have changed her mind* - A spouse or **Next of Kin** does not have the legal authority to override a patient's own valid advance refusal of treatment. - There is no documented evidence that the patient **withdrew the decision** while she still had the capacity to do so. *Seek an urgent Court of Protection ruling given the conflicting information* - A **Court of Protection** ruling is unnecessary when an ADRT is already confirmed as both valid and applicable to the clinical context. - The husband’s statement about a future event does not constitute sufficient **new circumstances** to invalidate the existing legal document. *Intubate temporarily until capacity can be reassessed* - Performing a procedure explicitly refused in an ADRT, such as **intubation**, constitutes **battery** and is a breach of the law. - Capacity is unlikely to be regained due to the progressive nature of **Motor Neurone Disease** and the current state of **hypercapnic encephalopathy**. *Proceed with non-invasive ventilation as it is not explicitly mentioned in the advance decision* - While **non-invasive ventilation (NIV)** might be permissible if not specifically excluded, the primary legal requirement is to uphold the refusal of **intubation** and respect the overall intent of the ADRT. - The focus should remain on **palliative care** and comfort measures that align with the patient’s established wishes for end-of-life care in advanced MND.
Question 17: A 15-year-old girl attends the emergency department requesting emergency hormonal contraception after unprotected sexual intercourse 36 hours ago. She appears to understand the treatment and its implications. She specifically requests that her parents are not informed as they would be very angry. Her boyfriend is 17 years old. What is the most appropriate course of action?
- A. Provide emergency contraception and maintain confidentiality as she demonstrates Gillick competence (Correct Answer)
- B. Refuse to provide treatment until parental consent is obtained
- C. Provide emergency contraception but inform the parents as she is under 16
- D. Report to police immediately as this constitutes statutory rape
- E. Provide treatment but inform social services of child protection concerns
Explanation: ***Provide emergency contraception and maintain confidentiality as she demonstrates Gillick competence***- Under **Gillick competence** (and Fraser guidelines), a minor under 16 can consent to **medical treatment**, including contraception, if they demonstrate sufficient maturity and understanding of the advice and its implications.- Maintaining **confidentiality** is crucial when a Gillick-competent minor explicitly requests it, especially when involving parents would deter them from seeking necessary care, provided it is in their **best interest**.*Refuse to provide treatment until parental consent is obtained*- Refusing treatment based solely on age, despite demonstrated **Gillick competence**, undermines the minor's **autonomy** and legal right to confidential medical care.- Delaying or denying **emergency contraception** significantly increases the risk of an unwanted pregnancy, which could have serious **physical and psychological consequences** for the minor.*Provide emergency contraception but inform the parents as she is under 16*- Informing parents against the minor's explicit wishes, when she is **Gillick competent** and there are no overriding **safeguarding concerns**, constitutes a breach of **confidentiality**.- The **Fraser guidelines** specifically permit providing contraceptive advice and treatment to minors without parental knowledge if the clinician deems it necessary for the minor's well-being and they cannot be persuaded to involve their parents.*Report to police immediately as this constitutes statutory rape*- While the **age of consent** in the UK is 16, consensual sexual activity between individuals close in age (such as 15 and 17) does not automatically warrant an immediate police report for **statutory rape**.- There is no mention of **coercion**, **exploitation**, or a significant **power imbalance** which would necessitate an urgent police referral in this scenario.*Provide treatment but inform social services of child protection concerns*- A referral to social services for child protection concerns is typically indicated when there is evidence of **abuse**, **neglect**, or **significant harm** to the child, not merely consensual sexual activity between peers.- Automatically reporting such situations without specific indicators of harm can erode trust between young people and healthcare providers, potentially deterring them from seeking vital **sexual health services**.
Question 18: A 70-year-old man with metastatic prostate cancer is receiving end-of-life care at home. He has been prescribed subcutaneous morphine 5-10mg every 2 hours as needed for pain and subcutaneous midazolam 2.5-5mg every 4 hours as needed for agitation. Over the past 24 hours his pain and agitation have increased significantly, and he has required the maximum doses of both medications. He is now very drowsy but still responsive. His family are concerned that the medications are hastening his death and request that they be reduced. What is the correct ethical and legal principle that applies?
- A. The doctrine of double effect justifies giving medications that relieve suffering even if they may shorten life (Correct Answer)
- B. The medications should be reduced as the family have Lasting Power of Attorney for health decisions
- C. Continue current medications as this represents assisted dying which is legal in palliative care
- D. The doses should be reduced to avoid any possibility of hastening death
- E. Increase the doses further as patients at end of life cannot become addicted to opioids
Explanation: ***The doctrine of double effect justifies giving medications that relieve suffering even if they may shorten life*** - The **Doctrine of Double Effect** states that an action with both a good and a bad effect is permissible if the **primary intention** is to achieve the good effect (pain relief), and the bad effect (potential life shortening) is an unintended but foreseen consequence. - In palliative care, the ethical and legal principle allows clinicians to provide **titrated analgesia and sedation** for severe symptom control, provided the goal is to alleviate **suffering** and improve comfort, not to intentionally hasten death. *The medications should be reduced as the family have Lasting Power of Attorney for health decisions* - A **Lasting Power of Attorney (LPA)** holder must act in the patient’s **best interests**; demanding a reduction in necessary medication that results in untreated pain and agitation would generally not align with these interests. - Medical professionals are not legally obligated to follow requests from family members or an LPA that would result in **substandard care**, cause unnecessary patient suffering, or go against established clinical guidelines. *Continue current medications as this represents assisted dying which is legal in palliative care* - **Assisted dying** and euthanasia remain **illegal** in the UK and most other jurisdictions; palliative care aims to manage symptoms and improve quality of life, distinctly separate from intentionally ending life. - The provision of symptom-relieving medications, even at high doses, with the primary intent to alleviate **suffering** is ethically and legally distinct from **assisted dying** or euthanasia. *The doses should be reduced to avoid any possibility of hastening death* - Reducing effective doses when a patient is experiencing **significant uncontrolled pain** and agitation would be unethical, leading to prolonged suffering and a poor quality of death. - Clinical guidelines prioritize **beneficence** (doing good) and **non-maleficence** (avoiding harm, including suffering) through appropriate symptom control, even if there's a theoretical, often negligible, risk of slightly shortening lifespan. *Increase the doses further as patients at end of life cannot become addicted to opioids* - While **opioid addiction** is not a relevant clinical concern in the terminal phase, doses should still be carefully **titrated** based on symptom severity and the patient's response, rather than indiscriminately increased. - Increasing doses without careful assessment or monitoring could lead to unnecessary **toxicity**, profound sedation that impairs communication, or other adverse effects that diminish the patient's remaining quality of life.
Question 19: A 25-year-old woman with severe learning disability (IQ 42) and autism is admitted with suspected appendicitis requiring urgent appendicectomy. She becomes extremely distressed during examination and refuses to allow anyone to touch her abdomen. Her mother, who is her registered Lasting Power of Attorney for Health and Welfare, consents to the surgery. The patient continues to resist and will require physical restraint to proceed. What is the legally correct approach?
- A. Proceed with surgery immediately as the mother has LPA authority and has consented
- B. Assess the patient's capacity regarding this specific decision and act in her best interests if she lacks capacity (Correct Answer)
- C. Detain under Section 2 of the Mental Health Act to allow treatment
- D. Obtain a court order as treatment against her wishes would otherwise constitute assault
- E. Delay surgery and manage conservatively unless her condition becomes immediately life-threatening
Explanation: ***Assess the patient's capacity regarding this specific decision and act in her best interests if she lacks capacity***- Under the **Mental Capacity Act (MCA) 2005**, capacity is **decision-specific** and must be formally assessed even if the patient has a documented learning disability.- If the assessment confirms she lacks capacity, treatment must be carried out in her **best interests**, involving the **LPA holder** as part of the collaborative decision-making process.*Proceed with surgery immediately as the mother has LPA authority and has consented*- An **LPA authority** does not bypass the legal requirement to first perform a **capacity assessment** on the patient for the specific decision at hand.- The **presumption of capacity** remains the starting point; the clinician cannot delegate the formal assessment of capacity to the relative.*Detain under Section 2 of the Mental Health Act to allow treatment*- The **Mental Health Act** is designed for the assessment and treatment of **mental disorders**, not primarily for the management of physical conditions like **appendicitis**.- Using this Act to force physical surgery for a non-psychiatric condition is legally inappropriate when the **MCA** provides the correct framework.*Obtain a court order as treatment against her wishes would otherwise constitute assault*- A **court order** is generally not required for standard surgical procedures if the medical team and **LPA holder** agree it is in the patient's **best interests**.- **Reasonable force** or restraint can be used under the MCA if it is a **proportionate** response to prevent serious harm (e.g., sepsis from a ruptured appendix).*Delay surgery and manage conservatively unless her condition becomes immediately life-threatening*- Delaying treatment for suspected **appendicitis** solely due to distress can result in **perforation and sepsis**, which would violate the principle of acting in the patient's **best interests**.- Clinical necessity and the high risk of deterioration usually justify proceeding with necessary surgery once the **legal framework** of the MCA is satisfied.
Question 20: A 59-year-old man with end-stage heart failure is receiving palliative care on the ward. He has capacity and has clearly expressed that he does not want cardiopulmonary resuscitation (CPR). A DNACPR order has been completed and signed by the consultant. His wife visits and becomes very distressed when she discovers the DNACPR order. She was not informed about it and states she would never have agreed to it. She demands the order be cancelled. What is the most appropriate action?
- A. Cancel the DNACPR order as the wife's consent was not obtained
- B. Maintain the DNACPR order as the patient has capacity and has made this decision (Correct Answer)
- C. Remove the DNACPR order from the notes but keep an informal record of the patient's wishes
- D. Seek a second opinion from another consultant before deciding whether to maintain the order
- E. Arrange a best interests meeting with the family to determine whether the order should stand
Explanation: ***Maintain the DNACPR order as the patient has capacity and has made this decision*** - A patient with **mental capacity** has the legal right to refuse medical treatment, including **CPR**, and their autonomous decision must be respected even if family members disagree. - While clinicians have a duty to involve patients in **DNACPR** decisions (Tracey v Cambridge), once a competent patient refuses treatment, family members have no **legal authority** to override that choice. *Cancel the DNACPR order as the wife's consent was not obtained* - Family members do not have the power of **veto** over a competent patient's medical decisions, and their consent is not legally required for a **DNACPR** order. - Canceling the order would violate the patient's **autonomy** and ignore his clear expressed wish to avoid a procedure he deems inappropriate. *Remove the DNACPR order from the notes but keep an an informal record of the patient's wishes* - Documentation regarding end-of-life care must be clear, formal, and easily accessible in the **medical records** to ensure all staff follow the patient's wishes during an emergency. - Keeping **informal records** is clinically dangerous and professionally inappropriate as it leads to confusion and potential harm if CPR is mistakenly performed. *Seek a second opinion from another consultant before deciding whether to maintain the order* - A second opinion is not necessary when a patient with **capacity** has clearly expressed their refusal of treatment; the consultant's signature on the existing order is already valid. - Delaying the maintenance of the order through unnecessary consultation risks performing **non-consensual** treatment if the patient suffers an arrest in the interim. *Arrange a best interests meeting with the family to determine whether the order should stand* - A **best interests meeting** is a process used under the **Mental Capacity Act** only when a patient lacks the capacity to make their own decisions. - Since this patient has capacity, his clinical team must follow his wishes directly rather than deferring to a **group consensus** or family opinion.
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