Capacity in Practice – Best Interests Meetings & Documentation

SJT Textbook: Capacity in Practice – Best Interests Meetings & Documentation

Best Interests Decisions MSRA

This guide covers the practical application of Best Interests Decisions MSRA scenarios. In the Professional Dilemmas paper, you are often tested not just on “what” to decide, but “how” to decide it using the precise framework of the Mental Capacity Act (MCA).

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🎯 THE CORE PRINCIPLE

Under the Mental Capacity Act (MCA) 2005, adults are presumed to have capacity unless proven otherwise. When a person lacks capacity for a specific decision at a specific time, that decision must be made in their best interests using the MCA s.4 checklist.

Best-interests decision-making is not about what clinicians or relatives would want for themselves. It is about what this person would likely have wanted, informed by their past and present wishes, feelings, beliefs and values, and by the views of those involved in their care. The decision-maker must consider whether the person might regain capacity, balance benefits and burdens of options, and select the least-restrictive option that still works.

Many routine decisions can be made quickly by the treating clinician with proportionate consultation and a short best-interests note. For serious, complex, high-risk or contested decisions, a structured Best Interests (BI) meeting is usually appropriate, with clear documentation of attendees, options, risks, benefits, and the MCA s.4 factors. IMCAs, LPAs and ADRTs may all be relevant, and good records are essential for legal and professional scrutiny.

In Best Interests Decisions MSRA questions, you must follow the statutory checklist found in Section 4 of the MCA. You cannot just rely on what you think is “medically best.”

⚡ HIGH-YIELD ACTIONS (What Scores Points)

1. Confirm and record that the person lacks capacity for this specific decision now, using the two-stage test and explaining why the decision cannot safely be delayed.
2. Apply the MCA s.4 checklist: consider past and present wishes and feelings, beliefs and values, and the views of those caring for or interested in the person’s welfare.
3. Check for formal instruments: look for and verify any ADRT (valid and applicable), and confirm registration and scope of any Health and Welfare LPA.
4. Instruct an IMCA for serious medical treatment where the person is unbefriended (no appropriate family or friends to consult).
5. Involve the MDT and those close to the person; hold a BI meeting when decisions are serious, complex, risky, or contested.
6. Explicitly consider less-restrictive alternatives and why more restrictive options may still be necessary, including DoLS where relevant (LPS not yet implemented).
7. Make a clear decision with named responsibility, timescales and review points; escalate unresolved disputes to senior staff and, if necessary, the Court of Protection.
8. Document the decision-making process contemporaneously, linking the rationale explicitly to MCA s.4 and listing the people consulted.
9. Communicate the decision sensitively to staff and family, and record what has been explained and to whom.
10. Review best-interests decisions if circumstances change or the person’s capacity improves.

To score highly in Best Interests Decisions MSRA ranking questions, you must show you understand the hierarchy of decision-makers—from the patient’s past wishes up to the Court of Protection.

These traps either bypass the MCA framework altogether, give inappropriate power to relatives, ignore binding refusals, or delay necessary decisions. High-scoring answers show lawful, person-centred, timely best-interests reasoning with proportionality and proper advocacy.

💬 MODEL PHRASES (Use These in SJT Logic)

* “We have considered their past wishes and values, and consulted [IMCA/LPA/family/MDT] to understand what they would have wanted.”
* “We checked for an ADRT and Health and Welfare LPA; where present, we confirmed validity, applicability and scope.”
* “We have compared options, including less-restrictive alternatives, and this plan is the least restrictive that still meets their needs.”
* “I will document who attended, the MCA s.4 factors considered, the decision and rationale, and when we will review it.”
* “If disagreement continues, we should seek senior and legal advice and consider referring to the Court of Protection.”

Beliefs and wishes • Engage consultees and IMCA • Seek and verify ADRT/LPA • Test MCA s.4 factors • Pick least-restrictive option • Log rationale and attendees • Assign owner for actions • Next review date set

1–2 sentences: Use BEST-PLAN to structure any best-interests decision: start from the person’s beliefs and wishes, bring the right people into the discussion, check ADRT/LPA, work systematically through MCA s.4, choose the least-restrictive workable option, and finish with a clear written plan, owner and review point.

📋 QUICK FAQ

When must I involve an IMCA?
For serious medical treatment decisions where the person lacks capacity and has no family or friends who are able and willing to be consulted. The decision-maker must take the IMCA’s information into account but still makes the final decision.

Does a Health and Welfare LPA overrule clinicians?
An LPA (Health and Welfare) can make decisions within its scope when the person lacks capacity, but those decisions must still be in the person’s best interests under MCA s.4. Clinicians can challenge or seek court guidance if they believe an LPA’s decision is not in the person’s best interests.

Is an ADRT always binding?
An ADRT is binding if it is valid (properly made, not withdrawn, no inconsistent later actions) and applicable to the situation (covers the treatment and circumstances now). For life-sustaining treatment, it must be written, signed and witnessed, and expressly state that it applies even if life is at risk.

Do I need a full Best Interests meeting every time?
No. The MCA expects a proportionate approach. Routine, low-risk decisions may only need a brief BI note. BI meetings are used for serious, complex, high-risk or contested decisions where a more formal structure and record are needed.

What should a good BI note or meeting record include?
Date, time, decision in question, capacity summary, people consulted (including IMCA/LPA), the person’s wishes and values, options considered (including less-restrictive alternatives), application of MCA s.4 factors, the final decision and rationale, named decision-maker, and plan for review.

What is the current position on DoLS and LPS?
As of now, DoLS remains in force; Liberty Protection Safeguards (LPS) have not been implemented. You should still consider DoLS where restrictions amount to deprivation of liberty, alongside your best-interests rationale.

📚 GMC ANCHOR POINTS

* Support patients to make their own decisions wherever possible and presume capacity unless there is evidence otherwise.
* When patients lack capacity, follow relevant law (MCA) and make decisions in their best interests, taking account of past wishes, beliefs and values.
* Involve those close to the patient and other members of the healthcare team as appropriate.
* Keep clear, accurate and contemporaneous records of significant decisions, including capacity assessments and best-interests reasoning.
* Seek advice from seniors, safeguarding teams or legal advisers where there is uncertainty or disagreement about serious decisions.

💡 MINI PRACTICE SCENARIO

A 78-year-old man with advanced dementia is admitted with a fractured neck of femur. He is in pain, repeatedly pulling off monitoring, and unable to understand or retain information about surgery despite support. The orthopaedic team recommends surgery to relieve pain and improve mobility. There are no known relatives, no ADRT or LPA found, and local records confirm he lives alone with care-package support.

Best action: Confirm and record that he lacks capacity for the decision about surgery, instruct an IMCA because this is serious medical treatment and he is unbefriended, hold a proportionate best-interests discussion (or brief BI meeting) with the IMCA and MDT, apply MCA s.4 factors, and proceed with surgery if this is clearly in his best interests, documenting the decision and rationale.

Why: Serious treatment plus lack of family triggers IMCA involvement. A proportionate BI process using MCA s.4 protects his rights while enabling prompt, person-centred care with a defensible record.

🎯 KEY TAKEAWAYS

✓ Best-interests decisions are time and decision specific, grounded in MCA s.4, not paternal instinct.
✓ Start with the person’s wishes, feelings, beliefs and values, then consult those close and the MDT.
✓ IMCA is mandatory for serious treatment if the person is unbefriended; ADRTs are binding if valid and applicable; LPAs act within scope but must still meet best interests.
✓ Choose the least-restrictive workable option and consider DoLS where restrictions amount to deprivation of liberty.
✓ Use proportionate processes: short BI notes for simple decisions, structured BI meetings for serious or contested ones.
✓ Keep detailed, contemporaneous records that clearly map to MCA s.4 and identify who made the decision and when it will be reviewed.
✓ Escalate unresolved disputes to seniors and, where necessary, seek legal advice or Court of Protection input.

🔗 RELATED TOPICS

* → Consent and Capacity (MCA Principles and Two-Stage Test)
* → Safeguarding Adults at Risk
* → Confidentiality and Information Governance
* → Exceptions to Confidentiality (Safeguarding and Public Interest)
* → DoLS and Deprivation of Liberty in Practice
* → Duty of Candour and Communication with Families

📖 FULL PRACTICE QUESTIONS

Example SJT — Best of 3 (8 options; choose three)

You are the medical registrar looking after a 79-year-old woman with severe dementia, admitted with sepsis from a perforated diverticulum. She is drowsy, cannot understand or retain information about surgery despite support, and becomes agitated when examined. The surgeons recommend urgent but not absolutely life-or-death surgery with significant risks. No relatives or friends are contactable; local records show she lives alone with carer visits. There is no record of an ADRT or LPA after a targeted search.

Which THREE of the following actions are the most appropriate?

Options:
A. Proceed to theatre immediately and write a brief note afterwards stating “in best interests”.
B. Ask the ward nurse to sign the consent form “on behalf of the patient” so surgery can go ahead.
C. Instruct an IMCA because this is serious medical treatment and she has no appropriate family or friends, and consider their input before finalising a decision.
D. Convene a proportionate best-interests discussion (or brief BI meeting) with the MDT and IMCA, explicitly applying MCA s.4 factors and considering less-restrictive options.
E. Delay all decisions until a distant relative can be found, even if this risks clinical deterioration.
F. Record a clear capacity assessment explaining why she lacks capacity for this decision and why the decision cannot safely wait.
G. Cancel the operation because there is nobody to give consent and you are worried about complaints.
H. Delegate the entire decision to the IMCA and take no further responsibility yourself.

Example SJT — Rank 5 (best → worst)

An 82-year-old woman with advanced dementia lacks capacity regarding long-term feeding. She has recurrent aspiration and poor oral intake. In her records, you find: (a) an ADRT, made in 2019, refusing long-term artificial feeding if she developed severe dementia; (b) a registered Health and Welfare LPA held by her son, who strongly wants a PEG tube; (c) the MDT is split on risks and benefits. You are the consultant chairing a Best Interests meeting.

Rank the following actions in order of appropriateness (best to worst):

Options:
A. Verify the ADRT’s validity and applicability; if it is valid and applicable to the current situation, respect it and do not insert a PEG, documenting MCA s.4 reasoning and informing the LPA and MDT; seek legal advice or court only if ADRT validity or scope is genuinely in doubt.
B. Follow the LPA’s preference automatically and arrange the PEG because “family know best”.
C. Insert the PEG immediately, reasoning that “nutrition is always in someone’s best interests” and there is no need to consider past wishes.
D. Hold a BI meeting but focus only on current clinical benefits, explicitly disregarding the ADRT and past wishes because “she lacked insight at the time”.
E. Delay any decision indefinitely until complaints and disagreements settle without seeking legal or ethics advice.