This guide breaks down Capacity Assessment MSRA scenarios. In the Professional Dilemmas paper, examiners test your ability to apply the Mental Capacity Act (MCA) 2005 not as a vague concept, but as a rigid legal tool.
Capacity under the Mental Capacity Act (MCA) 2005 is the ability to make a specific decision at the time it needs to be made. You must start by presuming capacity, then provide all practicable support so the person can decide. An unwise decision alone does not mean they lack capacity. Only if there is an impairment or disturbance of the mind/brain that prevents them from understanding, retaining, using/weighing, or communicating information for this decision, at this time, can you conclude they lack capacity.
If capacity is lacking, you move to a structured best-interests process under section 4. This means considering the person’s wishes, feelings, values and beliefs, consulting those close to them and relevant professionals, and choosing the least restrictive option that meets their needs. For serious medical treatment or significant accommodation moves where there is no one appropriate to consult, an Independent Mental Capacity Advocate (IMCA) should be involved.
In MSRA SJT questions, the highest scoring answers show you supporting capacity first, applying the MCA two-stage functional test in a decision- and time-specific way, and documenting findings for each limb. When capacity is lacking, they demonstrate a clear best-interests decision with proportionality, consultation, least restriction, and robust notes. Rushed, global labels such as “no capacity” without support or structure score poorly.
1. Start from a presumption of capacity and identify triggers that suggest a capacity assessment is needed (confusion, delirium, aphasia, serious consequences).
2. Provide all practicable support to maximise capacity: time, pain relief, hearing/visual aids, interpreter, quiet environment, communication tools, and teach-back.
3. Apply the two-stage test: identify any impairment/disturbance of the mind/brain, then assess whether the person can understand, retain, use/weigh, and communicate information for this decision now.
4. Make the assessment decision-specific and time-specific, avoiding blanket labels such as “no capacity for everything”.
5. If capacity is lacking, use the MCA best-interests checklist: consider wishes, feelings, values, beliefs, and likely past and present views.
6. Consult those close to the person and involved professionals; consider any advance decisions or lasting powers of attorney.
7. Choose the least restrictive option that is still effective in meeting the person’s needs and managing risk.
8. Instruct an IMCA when criteria are met (serious medical treatment or accommodation change, no appropriate family/friends to consult).
9. Document support given, findings for each of the four abilities, people consulted, best-interests reasoning, chosen option, and plan for review.
10. Reassess capacity when the impairment or situation changes, particularly in fluctuating conditions such as delirium or dementia.
Trap answers usually jump straight to paternalistic best-interests decisions, ignore support and the four abilities, use global labels, or bypass IMCA and consultation. Safe answers show support, structured assessment, and proportionate, documented best-interests decisions.
* “For this decision today, I need to check whether you can understand, retain, use and weigh the information, and communicate a choice.”
* “Despite support, you are not able to understand or weigh this information now, so we will make a best-interests decision with the least restrictive option and review when you improve.”
* “Because there is no family or friend to consult and this is serious treatment, I will arrange an Independent Mental Capacity Advocate to be involved.”
* “I will document the support we gave, the four-ability assessment, who we spoke to, and why this option is in your best interests.”
C = Consider triggers and presume capacity
A = Aid understanding (time, aids, interpreter, teach-back)
P = Problem with mind/brain identified (stage 1)
A = Assess four abilities (understand, retain, use/weigh, communicate) for this decision
C = Consult those close to the person and relevant professionals
I = Interests (best) using the s.4 checklist
T = Take the least restrictive option that still works
Y = Your notes: write it all down clearly and plan review
Does a risky or “unwise” decision prove lack of capacity?
No. The MCA is clear that a person is not to be treated as unable to decide merely because they make an unwise decision. You must still apply the four-ability test for the specific decision and time.
What exactly is the two-stage test?
Stage 1: Is there an impairment or disturbance in the functioning of the mind or brain?
Stage 2: If so, does that impairment mean the person is unable to understand, retain, use/weigh, or communicate information relevant to this decision at this time?
What must I do before concluding someone lacks capacity?
Provide all practicable support: optimise pain and physiology, use hearing/visual aids, provide an interpreter or communication aids, choose a quiet time and place, and use teach-back to check understanding.
How is a lawful best-interests decision made?
Use the MCA s.4 checklist: consider the person’s wishes, feelings, values, beliefs and likely views, consult those close to them and relevant professionals, think through options, and choose the least restrictive alternative that meets their needs. Record your reasoning.
When do I instruct an IMCA?
When the person lacks capacity, there is no appropriate family/friend to consult, and the decision concerns serious medical treatment or a long-term accommodation move. An IMCA provides independent representation and helps ensure decisions are scrutinised.
Do I need to reassess capacity?
Yes. Capacity can fluctuate with conditions such as delirium, infections, or medication changes. If the impairment changes or the decision needs to be revisited, reassess capacity for that specific decision again.
• Understand and follow capacity law, seeking advice where needed (GMC Good medical practice 2024).
• Support patients to understand options and make decisions wherever possible (GMC Decision making and consent).
• Respect patients’ rights to make lawful decisions, including those you regard as unwise, where capacity is present.
• When capacity is lacking, act in the person’s best interests and avoid disproportionate restriction of their rights and freedoms.
• Communicate clearly with families, carers, and advocates while maintaining confidentiality and respecting the person’s dignity.
• Keep full, accurate, and contemporaneous records of capacity assessments, best-interests decisions, and reviews.
An older adult with pneumonia is drowsy and disorientated. Oxygen saturations are low, and IV antibiotics are recommended urgently. When you try to discuss treatment, they repeatedly say “leave me alone” and cannot explain what is wrong or what might happen if treatment is refused. No family are present, and the decision is time-critical.
Best action: Provide immediate support (optimum positioning, hearing aids, simple explanations), then apply the two-stage test. If they cannot understand or use/weigh the information for this decision now, treat under best interests with the least restrictive option, document the assessment and reasoning, and plan to review capacity when they improve.
Why: This approach respects the MCA principles: support first, then a decision- and time-specific capacity test; where capacity is lacking in an emergency, you act in best interests, proportionately, with clear documentation.
✓ Presume capacity but be alert to triggers for assessment.
✓ Support understanding before testing the four abilities for this decision now.
✓ Use the MCA two-stage test and keep it decision- and time-specific.
✓ When capacity is lacking, follow the best-interests checklist and pick the least restrictive option.
✓ Involve family, friends, and IMCA appropriately in serious decisions.
✓ Document support, assessment, consultees, reasoning, decisions, and review points.
✓ In the SJT, answers that show “support → structured assessment → lawful best interests → documentation” reliably outscore paternalistic shortcuts.
* → Consent in Adults
* → Consent in Children & Young People (Gillick and Fraser)
* → End-of-Life Decision-Making (ADRT, DNACPR)
* → Safeguarding & Vulnerable Groups
* → De-escalation Techniques
* → Supervision of Junior Staff
A 78-year-old man with sepsis, hypotension, and confusion is brought to the emergency department. He is pulling out cannulas and saying “no needles”. When you try to explain the need for IV fluids and antibiotics, he cannot describe his illness, the proposed treatment, or the consequences of refusing. There is no family present, and contact details are not yet available. Treatment is time-critical.
Options:
A. Accept his refusal at face value because “patients have the right to refuse treatment”.
B. Provide oxygen, analgesia, and a quiet environment; re-explain in small chunks; then assess capacity using the two-stage test for this decision now.
C. Conclude that he lacks capacity because his decision is unwise and proceed with treatment without any documentation.
D. If, after support, he cannot understand or use/weigh information about treatment, treat under best interests with IV fluids and antibiotics, choosing the least restrictive option and documenting fully.
E. Delay all treatment until you can speak to a family member the next day.
F. Arrange to involve an IMCA if he continues to lack capacity and further serious decisions are needed and no appropriate family/friends can be identified.
G. Mark in the notes that he has “no capacity for any decisions from now on”.
H. Ask a passer-by in the waiting room to confirm that treatment should go ahead.
Correct three: B, D, F
• B: Maximises capacity by providing support and applies the two-stage test correctly.
• D: Uses a lawful best-interests approach with least restriction and clear documentation for a time-critical decision when capacity is lacking.
• F: Recognises the need for an IMCA where there is no appropriate consultee for ongoing serious decisions.
Why others are weaker/wrong:
• A: Ignores clear evidence of confusion and fails to assess capacity or support understanding.
• C: Misinterprets unwise choice as incapacity and omits documentation and structure.
• E: Dangerous delay in a time-critical condition.
• G: Uses an unlawful global label rather than decision- and time-specific assessment.
• H: Involves an inappropriate third party with no relationship or authority.
Example SJT — Rank 5 (best → worst)
A 70-year-old woman with known dementia is admitted with a hip fracture after a fall. She is in pain but settled with analgesia. She is usually forgetful but can hold simple conversations. The orthopaedic team recommends urgent surgery. She is unsure, repeating questions about what is happening. No family are present initially, but contact numbers are available.
Options:
A. Provide clear, repeated explanations with visual aids, allow time, then assess capacity for the decision about surgery using the four abilities; if lacking, consult family and make a best-interests decision, documenting reasoning and least restrictive options.
B. Decide she lacks capacity because of her dementia diagnosis and consent to surgery without any discussion or assessment.
C. Delay any discussion or capacity assessment and simply list her for surgery as a routine case.
D. Wait 24 hours for family to arrive without assessing capacity or providing analgesia or further support.
E. Ask the anaesthetist to fill in a consent form without talking to the patient or checking the notes.
Ideal order: A (1) > B (2) > C (3) > D (4) > E (5)
• A: Best: supports understanding, assesses capacity for this decision, and, if lacking, uses structured best-interests decision-making with consultation and documentation.
• B: Recognises the need for best interests but incorrectly skips support and a functional assessment; still safer than options that neglect care entirely.
• C: Provides treatment but ignores both capacity law and assessment; paternalistic and poorly documented.
• D: Delays necessary decision-making and pain relief, risking harm and discomfort.
• E: Disengages from responsibility for consent and capacity assessment, breaching guidance and good practice.
