Consent & Capacity (MCA)

SJT Textbook: Consent & Capacity (MCA)

Consent and Capacity MSRA

This guide covers the essential legal frameworks for Consent and Capacity MSRA scenarios. In the Professional Dilemmas paper, you must demonstrate that you can switch fluently between the Montgomery ruling (for those with capacity) and the Mental Capacity Act (for those without).

🎥 Video Lesson (YouTube)

🎧 Podcast Lesson (Spotify / Apple / Amazon)

🎯 THE CORE PRINCIPLE

Consent is only valid if it is voluntary, informed, and given by a person who has capacity for that specific decision at that specific time. Capacity is decision-specific and time-specific; you must support the person to decide before concluding that they lack capacity. For adults with capacity, the Montgomery standard applies: you must explain material risks and reasonable alternatives, including the option of no treatment, in a way that makes sense to that individual.

If capacity is in doubt, you must apply the Mental Capacity Act 2005 two-stage test: is there an impairment or disturbance of the mind or brain, and because of that, can the person not understand, retain, use/weigh the relevant information, or communicate a decision? If they lack capacity, decisions must follow the MCA best-interests checklist, involve those close to them and any LPA, consider any valid ADRT, involve an IMCA if unbefriended for serious decisions, and choose the least restrictive option.

In the SJT, high-scoring options show capacity-first thinking, give a Montgomery-standard consent conversation when capacity is present, and when capacity is lacking they use the MCA framework with good documentation, not relatives signing “consent” forms or convenience-based decisions.

In Consent and Capacity MSRA questions, the first step is always the “Two-Stage Test.” You cannot assume incapacity just because a decision is unwise.

⚡ HIGH-YIELD ACTIONS (What Scores Points)

1. Presume capacity and actively support decision-making before concluding incapacity (quiet space, time, interpreter, decision aids).
2. Apply the MCA two-stage test whenever capacity is uncertain and record the assessment.
3. For capacitated adults, give a Montgomery-standard discussion: benefits, harms, material risks, and reasonable alternatives, including no treatment, tailored to what matters to that patient.
4. Use teach-back or similar to check understanding and correct misunderstandings.
5. When capacity is lacking, check for and respect any valid and applicable ADRT, and identify any Health and Welfare LPA.
6. Make best-interests decisions using the statutory checklist, involving those close to the person and any IMCA if required.
7. Choose the least restrictive option that still achieves the clinical aim, and review restrictions regularly.
8. Use professional interpreters for consent/capacity discussions where language is a barrier and avoid relying on family interpreters except in true emergencies.
9. Keep a clear contemporaneous record of capacity assessment, consent or best-interests decision, who was involved, and the reasoning.

To score highly in Consent and Capacity MSRA ranking questions, you must prioritise patient autonomy above all else, unless capacity is proven to be absent.

Low-scoring options either bypass the MCA by handing power to relatives, ignore Montgomery by giving generic information, equate “unwise” with “no capacity”, or dangerously delay emergency care for the sake of paperwork. Good options keep autonomy, legality and safety in balance.

💬 MODEL PHRASES (Use These in SJT Logic)

* “An unwise choice on its own does not mean you lack capacity; let me check that you can understand, use and weigh this information.”
* “Because I am not confident you can use and weigh this information right now, I will apply the Mental Capacity Act and make a best-interests decision, involving people who know you where possible.”
* “I will check for any lasting power of attorney or advance decision and choose the least restrictive option that keeps you safe.”
* “We will use a professional interpreter so everything is clear and you can ask questions in your own language.”

Capacity first • Options and alternatives • Needs and values • Specific material risks • Enable understanding • Note the decision • Talk-back to check understanding.

📋 QUICK FAQ

Does an unwise decision mean the patient lacks capacity?
No. Under the MCA, an unwise decision does not equal incapacity. You must still apply the two-stage test: look for impairment or disturbance of mind or brain, and check whether they can understand, retain, use/weigh or communicate the decision.

What does Montgomery actually require?
You must ensure a capacitated patient is aware of material risks and reasonable alternatives. Material risks are those a reasonable person in the patient’s position would likely attach significance to, or that this particular patient is likely to find significant, based on their values and circumstances.

What should I do if the patient lacks capacity and there is no family or LPA?
The treating clinician makes the decision using the MCA best-interests checklist and should instruct an IMCA for serious treatment decisions or accommodation moves where the person is unbefriended.

Can relatives consent on behalf of an adult without capacity?
Not usually. Relatives and friends should be consulted and contribute to best-interests decisions, but they do not have legal authority to consent unless they hold a valid Health and Welfare LPA or are acting under a court order.

What about emergencies?
If treatment is immediately necessary to save life or prevent serious deterioration and the patient cannot consent, you should treat in their best interests, respect any known valid ADRT, and document your reasoning. You should not delay life-saving treatment to obtain signatures.

📚 GMC ANCHOR POINTS

• Shared decision making and tailored discussions of benefits, risks and alternatives (GMC Decision making and consent).
• Recording key elements of consent and capacity assessments in the notes (GMC Decision making and consent; Good medical practice 2024).
• Respecting decisions made by adults with capacity, even when you disagree (GMC ethical guidance).
• Applying the Mental Capacity Act and acting in a person’s best interests when they lack capacity (GMC guidance on consent and capacity; MCA Code of Practice).
• Special considerations for children and young people, including Gillick competence and the role of those with parental responsibility (GMC 0–18 years guidance).

💡 MINI PRACTICE SCENARIO

A 70-year-old man with advanced COPD is admitted with pneumonia. After fluids and antibiotics he is alert and scores normally on a brief cognition screen. You propose non-invasive ventilation, but he says he never wants to go on any machines and would rather “take his chances”. He understands he may die without it.

Best action: Accept that he has capacity for this decision, ensure he understands the material risks and alternatives (including likely outcomes with and without treatment), explore what matters to him, confirm and document his decision and safety-net.

Why: He appears to understand, retain and weigh the information, so under Montgomery you must respect his capacitated refusal after an adequate discussion, even if you disagree.

🎯 KEY TAKEAWAYS

✓ Capacity is decision- and time-specific; support it before concluding incapacity.
✓ Montgomery requires tailored discussion of material risks and reasonable alternatives for capacitated adults.
✓ An unwise decision alone does not mean the person lacks capacity.
✓ When capacity is lacking, use the MCA best-interests checklist, involve the right people, and choose the least restrictive option.
✓ Relatives are not default decision-makers; LPA, ADRT, IMCA and the court have specific legal roles.
✓ Emergencies allow best-interests treatment without delay, but you must still respect any valid ADRT and document your reasoning.

Here is your summary checklist for answering Consent and Capacity MSRA questions correctly:

🔗 RELATED TOPICS

* → Sharing Information with Consent
* → Exceptions to Confidentiality (Safeguarding and Public Interest)
* → Patient Confidentiality Principles
* → Safeguarding Adults and Deprivation of Liberty (DoLS)
* → Children and Young People: Gillick Competence and Fraser Guidelines

📖 FULL PRACTICE QUESTIONS

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

Scenario

You are the medical registrar reviewing a 58-year-old woman with symptomatic gallstones. She has full capacity and no cognitive concerns. You recommend laparoscopic cholecystectomy. She is anxious and says she is thinking about “just leaving it and seeing how things go”. You have time to talk with her before the theatre list is finalised. You want to ensure your approach meets legal and ethical standards for consent.

Options:
A. Briefly tell her that gallbladder surgery is routine, ask her to sign the consent form, and move on to the next patient.
B. Give her the hospital leaflet on gallbladder surgery and ask her to read it; if she does not object, list her for surgery.
C. Explore what matters most to her (for example pain, work, caring roles), explain the benefits and material risks of surgery for someone in her situation, discuss reasonable alternatives including non-operative management, check understanding and document the discussion.
D. Ask her husband to persuade her to accept surgery while you prepare the consent paperwork.
E. Emphasise that not having surgery would be “silly”, minimise discussion of complications to avoid frightening her, and list her anyway.
F. Offer to postpone any decision until she can be seen by a different consultant who may present things differently.
G. Explain that you must tell her all material risks and reasonable alternatives, invite questions, suggest time to think if needed, and record her decision even if she declines surgery.
H. Tell her that if she signs now you can guarantee there will be no serious complications.

Example SJT — Rank 5 (best → worst)

Scenario

A 79-year-old man in a care home is admitted with signs of peritonitis and septic shock. He is drowsy, disorientated and clearly unable to understand the proposed surgery. You suspect delirium. There is no record of any Health and Welfare LPA. Nurses recall that he “might have signed something years ago about not wanting certain treatments”, but no document is available on the electronic record or in the notes. No family or friends are currently contactable. The surgical team feel he needs an urgent laparotomy to have a chance of survival.

Options:
A. Apply the MCA two-stage test, document that he lacks capacity due to delirium, proceed with urgent life-saving surgery in his best interests while continuing to check for any ADRT or LPA, and record your rationale.
B. Delay surgery until the following day to allow time to try to contact relatives and find any ADRT, even though this may worsen his prognosis.
C. Cancel surgery because an ADRT might exist somewhere, and offer only palliative care without further attempts to clarify.
D. Ask the senior nurse who knows him best to sign the consent form on his behalf to “cover” the team.
E. Proceed with surgery but do not document capacity or best interests, adding a generic signed consent form afterwards.

Options:
A. Proceed now in best interests with documentation and continued checks.
B. Delay surgery to search for family and paperwork.
C. Cancel surgery because of a possible but unconfirmed ADRT.
D. Seek staff signature as proxy “consent”.
E. Proceed without any MCA documentation or proper record.