Consent in Adults

SJT Textbook: Consent in Adults

Consent in Adults MSRA

This guide covers the fundamental principles of Consent in Adults MSRA scenarios. In the Professional Dilemmas paper, you must move beyond “getting a signature” to demonstrating a genuine “Shared Decision Making” process as mandated by the Montgomery ruling.

🎥 Video Lesson (YouTube)

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🎯 THE CORE PRINCIPLE

Consent is a voluntary, informed choice made by a person with capacity after a genuine two-way conversation about options, risks, benefits, and uncertainties. It is a process, not a signature. Adults with capacity are entitled to decide what happens to their own bodies, even if their choice is risky or contrary to medical advice.

Post-Montgomery, doctors must ensure patients are aware of material risks (serious or personally significant) and reasonable alternatives that a reasonable person in that patient’s position would regard as important. That includes the option of no treatment. The Mental Capacity Act (MCA) 2005 applies when capacity is in doubt in England and Wales, with a presumption of capacity, support to decide, and a best-interests process if capacity is lacking.

In MSRA SJT questions, high-scoring answers show shared decision-making: tailoring information to the individual, using teach-back or interpreters, assessing capacity when indicated, respecting valid refusals, and documenting the discussion and outcome thoroughly.

In Consent in Adults MSRA questions, the legal standard has shifted from “Bolam” (what doctors think) to “Montgomery” (what patients want).

⚡ HIGH-YIELD ACTIONS (What Scores Points)

1. Clarify the specific decision and timeframe, including reasonable alternatives and doing nothing.
2. Explore what matters to the patient (values, fears, work, caring responsibilities, quality of life).
3. Explain benefits, material risks, and uncertainties of each option in clear, non-technical language.
4. Present reasonable alternatives, including non-operative or conservative management where available.
5. Support understanding with time, written or accessible information, and professional interpreters where needed.
6. Use teach-back to check understanding and correct misconceptions.
7. Consider and formally assess capacity when there are indicators of cognitive impairment or fluctuating mental state.
8. Respect capacitated decisions, including refusals of life-saving treatment, without coercion.
9. In cases of lacking capacity, follow the MCA best-interests process, involving those who know the person well.
10. Document the content of discussions, the decision made, capacity assessment (if relevant), and safety-netting plans.

To score highly in Consent in Adults MSRA ranking questions, you must prioritise “Material Risk.” A risk of 1% might be negligible to a surgeon but critical to a pianist if it involves nerve damage.

Trap options are typically paternalistic, conceal information, bypass capacity law, or treat consent as a tick-box exercise rather than a shared decision. Safe answers maximise autonomy, transparency, and documentation.

💬 MODEL PHRASES (Use These in SJT Logic)

* “What matters most to you about this decision so we can focus on the information that is most relevant?”
* “To check I have explained things clearly, can you tell me in your own words what you are thinking of choosing and why?”
* “Because I am concerned about your thinking and memory today, I would like to do a capacity assessment using the legal test.”
* “You have made a clear, informed decision; I respect that and will document what we have discussed and how we will support you.”
* “If you change your mind or new questions come up, you can contact us and we can revisit this decision.”

M = Meaningful risks (including serious but rare)
A = Alternatives, including no treatment
T = Tailored information to this patient’s situation and values
E = Enough time and support to understand
R = Record the discussion and decision
I = Involve patient values and preferences
A = Ask teach-back to confirm understanding
L = Law: follow Montgomery and the MCA if capacity is in doubt

📋 QUICK FAQ

Do I need to list every possible risk?
No. Focus on material risks: those that are serious or that a reasonable person in this patient’s position would likely consider significant. Still mention serious harms even if rare, especially if they would matter to this patient.

Can a capacitated adult refuse life-saving treatment?
Yes. If they have capacity for that decision and are properly informed, their refusal must be respected, even if it leads to serious harm or death. You should explore reasons, offer support, and document carefully.

When should I assess capacity formally?
Assess when there are red flags such as confusion, delirium, brain injury, learning disability without support, fluctuating mental state, or a decision that seems inconsistent with the person’s known values in a way that suggests impaired thinking.

What if the patient does not want detailed information?
Explore why, explain the implications of not hearing key risks, check they understand that serious harms may still occur, and record their preference. Keep the door open for them to access more information later.

Can family members decide for a capacitated adult?
No. Family can support understanding if the patient wants them involved, but the decision remains the patient’s, provided they have capacity.

How detailed should documentation be?
Record which options were discussed, key material risks and benefits, the patient’s questions and values, capacity assessment if relevant, the decision reached, any leaflets or resources given, and safety-net advice or follow-up plans.

📚 GMC ANCHOR POINTS

• Shared decision-making and tailored information (GMC “Decision making and consent”).
• Respect for patient autonomy and lawful consent (GMC “Good medical practice”, communication and decision-making).
• Awareness of and adherence to capacity law and the Mental Capacity Act where relevant.
• Keeping clear, accurate, and timely records of discussions and decisions.
• Being honest, open, and not misleading when explaining risks and benefits.
• Taking account of patients’ priorities, beliefs, and values in planning care.
• Escalating or seeking advice when unsure how law and guidance apply to a complex consent situation.

💡 MINI PRACTICE SCENARIO

A 58-year-old with severe aortic stenosis is offered valve replacement. You explain options including surgery, TAVI if available, and medical management. She is very anxious about rare peri-operative stroke and is considering refusing surgery despite understanding that without it she is at high risk of death in the next few years. She clearly explains back the options and risks.

Best action: Respect her refusal, confirm and document that she has capacity and has understood material risks and alternatives, offer further opportunities to discuss, and arrange supportive and palliative planning as appropriate.
Why: This approach aligns with Montgomery and GMC consent guidance: she is capacitated, informed, and making a values-based choice that must be respected, with a clear record and ongoing support.

🎯 KEY TAKEAWAYS

✓ Consent is a process of shared decision-making, not a signature.
✓ You must discuss material risks and reasonable alternatives tailored to the individual.
✓ Support understanding with time, questions, teach-back, and interpreters.
✓ Respect capacitated refusals, even when you disagree with the decision.
✓ Use the MCA when capacity is in doubt and document best-interests reasoning.
✓ Good documentation protects patients, clinicians, and organisations.
✓ The safest SJT option usually maximises autonomy, transparency, and clear records.

🔗 RELATED TOPICS

* → Capacity Assessment (MCA in Adults)
* → Consent in Children and Young People (Gillick and Fraser)
* → Communicating with Non-English Speakers (interpreters)
* → Equality, Diversity and Inclusion in Decision-Making
* → Confidentiality and Information Sharing
* → End-of-Life Decisions and DNACPR

📖 FULL PRACTICE QUESTIONS

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

A 45-year-old man with ulcerative colitis is offered elective colectomy with ileostomy. There is also the option of continued medical therapy and, in some centres, pouch surgery in future. He is worried about body image and work but is tired of repeated flares. You have time for a full discussion.

Options:
A. Tell him that surgery is clearly the best option and there is no need to discuss medical therapy in detail.
B. Explain surgery, medical therapy, and doing nothing in equal detail, including material risks and uncertainties, and explore which outcomes matter most to him.
C. Ask his partner to make the decision as they will live with the consequences too.
D. Use simple diagrams and written information, then ask him to explain back his understanding in his own words.
E. Ask him to sign the consent form quickly so theatre scheduling is not delayed.
F. Arrange an independent interpreter because he has a mild speech impediment but speaks fluent English.
G. Document in the notes which options were discussed, which risks were highlighted, his questions, and his provisional decision, and plan a review for further discussion.
H. Tell him he must have surgery because it is the “right” decision and you cannot accept refusal.

Example SJT — Rank 5 (best → worst)

A 72-year-old man with stable angina is offered coronary angiography with possible PCI. Conservative management with optimisation of medication is a reasonable alternative. He lives alone and is anxious about hospital procedures but wants to stay well enough to look after his garden. He has mild hearing loss but no cognitive impairment.

Options:
A. Arrange a quiet room, speak clearly with written information, describe angiography, PCI, and optimised medical management, including material risks and alternatives, and allow time for questions before recording his decision.
B. Focus on angiography and PCI only, explaining that this is the “gold standard” and that other options are not worth considering.
C. Ask his adult son to decide for him because the risks feel high.
D. Hand him a generic leaflet on coronary procedures and book him for angiography without further discussion.
E. Tell him that if he refuses angiography, you will discharge him from the clinic because you cannot help him.