This document discusses consent, mental capacity, and best interests decision-making regarding medical treatment for incompetent patients. It provides information on: - The essential elements of consent including competence, voluntariness, and being informed - Factors considered under the Mental Capacity Act when assessing a person's ability to make a decision - Determining best interests by considering the patient's wishes, clinical opinion, input from those close to the patient, and respecting the patient's autonomy - Options like lasting power of attorney and independent advocates when a person lacks capacity

1. Consent & Mental Capacity

2. Consent
• The agreement to a treatment or procedure
• Does not have to be given in writing; it can be given orally or
even implied from the circumstances
e.g. holding an arm out for an injection, nodding the head
• Consent is limited to the procedures which the patient has
been informed of and agreed to. Except in an emergency it
cannot be exceeded to include other procedures
• Consent can be withdrawn prior to the procedure
Essentials elements of Consent :
1. The patient must be competent to give consent.
2. It must be voluntary, and not coerced.
3. The patient must be provided with information about the
procedure

3. Competence
( Mental Capacity )
The Mental Capacity Act 2005 (MCA)
states that a person lacks capacity if
they cannot do one or more of the
following:
1. Understand the information relevant to
the decision
2. Retain that information
3. Use or weigh that information as part of
the process of making the decision
4. Communicate the decision (whether by
talking, using sign language or any
other means).

4. Competence
( Mental Capacity )
 Capacity can evolve and fluctuate over time,
and treatment should be postponed if
capacity can be restored.
 It is task specific – a person may have
capacity to make a particular decision but
lack capacity for other more complex
decisions.
 Before it is concluded that someone lacks
capacity to make a decision all possible
steps should be given to help them to reach
the decision
 Consider treatment options which are least
restrictive of the person’s rights or future
choices and which promote the greatest
freedom

5. What to do when not Competent
?
Assessment of “Best Interest”Best Interest
What would the patient – with his previous wishes , values , thoughts , current
circumstances – do ?
Clinical Team :
The assessment of best interests is carried out by the doctor or other healthcare staff
responsible for carrying out the particular medical treatment or procedure .
Others who are close to the patient :
where practical and appropriate, others who are close to the patient should be
consulted about what might be in the patient’s best interests and, wherever possible,
The patient :
should still be involved in the decision-making process.
Lasting power of attorney (LPA)
is a legal document which allows a person (donor) to appoint someone to take
decisions (attorney) for him in the event of loss of capacity.
Independent mental capacity advocate (IMCAs)
independent advocates who represent the views of vulnerable people lacking capacity to
make important decisions about serious medical treatment when there are no family
members or friends who can be consulted

6. Best
Interest
Clinical Team
Relatives
Others who
are close to
the patient
Patient
Lasting
Power of
Attorney
Independent
Mental
Capacity
Advocate
What to do when not Competent
?
Assessment of “Best Interest”
Court of
Protection

7. Case 1
Caren is 73 years old and is diagnosed Alzheimer patient &
currently showing severe cognitive impairment .
A few years ago she was brought to hospital with Bleeding per
Rectum . However, she was terrified of being outside of
her home environment and finds it hard to trust anyone.
she refused all investigations , and the doctors treating her
at the time did not feel her condition was serious enough to
warrant investigation under restraint.
She has now come to hospital again with recurrent rectal
bleeding.
she needs a colonoscopy , which is unacceptable to her.
Without investigation & prober management deterioration is
inevitable. However, Caren is clearly uncomfortable and
frightened in hospital and she is terrified of needles. It will be
difficult to carry out treatment without her co-operation. she
lives in a home and has a good relationship with hercarers.
Her sister visits her frequently.

8. Questions:
• What factors should be considered in
assessing the ‘best interests’ of an
incompetent adult patient?
• Who makes the decision about
Caren’s best interests?
• What if the clinical team and Caren’s
relatives disagree about what
treatment is in her best interests?

9. Susie is 24 years old and has Down’s syndrome and a mental age of 10. She is very loving
and has a happy-go-lucky personality. She is also extremely pretty. She lives with her
parents and younger sister. For the past 10 years she has gone to a daycare centre four
times a week to socialize with other people and to give her parents some respite from
looking after her.
Recently, she has been bad tempered and tearful. Susie’s mother is worried by this change in
temperament and brings her to see you, her GP. You ask Susie what is making her upset.
Reluctantly she tells you that she is cross because people at the daycare centre will not let
her play with her new friend, a 30-year-old man called Steve. You contact the daycare
centre and find out that Susie and Steve have been separated because they keep being
discovered kissing each other and, on one occasion, Steve had undressed Susie. The
daycare centre explained that it was not a punishment, but that neither Susie nor Steve
had any understanding of what they were doing and were acting on instinct. They did not
understand the implications of a sexual relationship or the risks of pregnancy. They had not
wanted to tell Susie’s mother as they felt they would be in trouble for letting things get out of
hand in the first instance. You suggest that everything should be discussed openly and
honestly. A month later Susie’s mother comes to see you with her husband. Susie’s
temperament has not improved and the atmosphere at home is very tense. Susie often talks
about Steve and how much she misses him. Her mother feels that it is unfair to keep them
separated, but she is worried that they may end up having a sexual relationship and that
Susie may get pregnant. Her mother does not want to deprive Susie of a life that can be
enjoyed to the utmost but she feels that Susie will not understand the changes in her body if
she became pregnant and feels that Susie would find it a terrifying experience. She asks
you whether you can arrange for Susie to be sterilized.
Case 1I

10. Questions
• What legal authority does a healthcare
professional have to treat a person
lacking
capacity?
• It is lawful for Susie to be sterilized?
• Is sterilization in her best interests?
• Is it necessary to seek court approval?

11. Case III
A schizophrenic woman is 33 weeks
pregnant. She has been sectioned
under the Mental Health Act.
The obstetrician considers that there is
a high risk of placenta-abruption
and she would like to carry out a
caesarean section. However, the
woman is violent and aggressive and
is refusing all antenatal interventions.

12. Questions
• Does mental disorder equate to lack of
capacity?
• Can a person with a mental disorder
be treated without consent?

13. References
 100 cases in clinical ethics & law .
Carolyn Johnston & Penelope Bradbury
 MCQs For MRCOG Part II .
Richard de Courcy-Wheeler
 Mental Capacity Act
UK Legislation