PLAB 2 Consent, Capacity & Mental Capacity Act — Questions and Answers
Question 1: A 78-year-old woman with advanced dementia requires a hip replacement following a fractured neck of femur. She lacks capacity to consent. Under the Mental Capacity Act 2005, what is the most appropriate way to proceed?
- Seek consent from her next of kin
- Proceed under best interests following a best interests assessment, consulting the patient's family, carers, and any advance decisions, and consider appointing an IMCA if there is no one to consult (Correct answer)
- Apply to the Court of Protection before any treatment
- Wait until she regains capacity
Correct answer: Proceed under best interests following a best interests assessment, consulting the patient's family, carers, and any advance decisions, and consider appointing an IMCA if there is no one to consult
When a patient lacks capacity, treatment proceeds under the MCA 2005 best interests principle. For medical decisions: consult family/carers (they advise on patient's wishes/values but do not consent); check for Lasting Power of Attorney (healthcare); check for Advance Decision to Refuse Treatment; appoint an IMCA if no appropriate consultee is available. Surgery can proceed in best interests.
Question 2: A 45-year-old man with paranoid schizophrenia refuses oral antipsychotic medication. His community psychiatric nurse reports he is responding to command hallucinations and there is risk to others. Under which legislation can he be treated without consent?
- Mental Capacity Act 2005
- Mental Health Act 1983 (as amended 2007) — compulsory detention and treatment for mental disorder is governed by the MHA, not the MCA (Correct answer)
- Common law doctrine of necessity
- Consumer Rights Act
Correct answer: Mental Health Act 1983 (as amended 2007) — compulsory detention and treatment for mental disorder is governed by the MHA, not the MCA
The Mental Health Act 1983 (amended 2007) provides the framework for compulsory detention and treatment of mental disorder in England and Wales, independently of capacity. It can apply even if the patient has capacity. The MCA covers those who lack capacity for non-psychiatric decisions. A patient with schizophrenia can be detained under MHA Section 2 (assessment) or Section 3 (treatment).
Question 3: Under the MCA 2005, what are the two diagnostic tests required to establish that a person lacks capacity?
- Age over 65 and confirmed diagnosis of dementia
- A diagnostic threshold (the person has an impairment or disturbance in mind or brain) AND a functional test (as a result, they cannot understand, retain, weigh, or communicate information relevant to the decision) (Correct answer)
- Psychiatric assessment and neuroimaging
- GP assessment and consultant review
Correct answer: A diagnostic threshold (the person has an impairment or disturbance in mind or brain) AND a functional test (as a result, they cannot understand, retain, weigh, or communicate information relevant to the decision)
The MCA two-stage test: (1) Diagnostic — is there an impairment or disturbance in the functioning of the mind or brain? (2) Functional — as a result, can the person understand information, retain it long enough to make a decision, weigh it, and communicate their decision? Both tests must be satisfied, and capacity is decision-specific and time-specific.
Question 4: What is a 'Lasting Power of Attorney' (LPA) for health and welfare, and what can the attorney decide?
- A legal document allowing a solicitor to manage medical decisions
- A legal document (registered with the Office of the Public Guardian) appointing a trusted person to make health and welfare decisions on behalf of someone who has lost capacity, including consent to and refusal of medical treatment (Correct answer)
- A document allowing a family member to access medical records
- A document giving a GP the power to override a patient's treatment preferences
Correct answer: A legal document (registered with the Office of the Public Guardian) appointing a trusted person to make health and welfare decisions on behalf of someone who has lost capacity, including consent to and refusal of medical treatment
A Health and Welfare LPA is a legal document that appoints an attorney to make decisions about personal welfare and medical treatment when the donor loses capacity. The attorney can consent to or refuse treatment on the donor's behalf, but only within the scope granted in the LPA and only when the donor lacks capacity.
Question 5: An 82-year-old woman has a valid Advance Decision to Refuse Treatment (ADRT) refusing artificial ventilation. She is now incapacitated with respiratory failure. The family is insisting on ventilation. What should you do?
- Follow the family's wishes as next of kin
- Respect the valid ADRT — it is legally binding under the MCA 2005, and the patient's prior autonomous refusal overrides the family's request (Correct answer)
- Proceed with ventilation pending court review
- Discuss with ethics committee before deciding
Correct answer: Respect the valid ADRT — it is legally binding under the MCA 2005, and the patient's prior autonomous refusal overrides the family's request
A valid and applicable ADRT is legally binding under the MCA 2005 and has the same force as a contemporaneous refusal by a capacitous patient. For an ADRT refusing life-sustaining treatment to be valid, it must be written, signed, witnessed, and state that it applies 'even if life is at risk'. Family wishes cannot override a valid ADRT.
Question 6: A 20-year-old patient with a learning disability is to have a dental procedure. His carer says he needs to give consent but she will sign the form on his behalf if needed. What is the correct approach?
- Allow the carer to sign the consent form — this is standard practice for those with learning disabilities
- Assess the patient's capacity for this specific decision; if he has capacity (even with support), he must consent himself; if he lacks capacity, proceed under best interests under the MCA — no one else can sign a consent form on his behalf in England and Wales (Correct answer)
- Ask a senior clinician to decide without involving the patient
- Apply a general rule that all patients with learning disabilities lack capacity
Correct answer: Assess the patient's capacity for this specific decision; if he has capacity (even with support), he must consent himself; if he lacks capacity, proceed under best interests under the MCA — no one else can sign a consent form on his behalf in England and Wales
A learning disability does not automatically mean lack of capacity — capacity is decision-specific and must be assessed. If capacity is present (with appropriate support and communication), the patient must consent himself. If capacity is absent, treatment proceeds under MCA best interests. Crucially, no one else can sign a consent form on behalf of an adult who lacks capacity in England and Wales (unlike in Scotland where legal guardians can consent).
PLAB 2 Consent, Capacity & Mental Capacity Act
A 78-year-old woman with advanced dementia requires a hip replacement following a fractured neck of femur.
She lacks capacity to consent.
Under the Mental Capacity Act 2005, what is the most appropriate way to proceed?