Capacity Assessment

•    Decision-specific: must relate to the particular decision at hand 

                                                                (e.g., consenting to surgery ≠ consenting to a flu vaccine)

•    Time-specific: capacity can fluctuate (e.g., delirium, metabolic disturbance)

•    Criteria (Mental Capacity Act 2005, UK):

1.    Understand relevant information

2.    Retain that information long enough to make a decision

3.    Weigh information to arrive at a choice

4.    Communicate decision (verbal, sign language, gestures)

•    Presumption of capacity unless proven otherwise

•    Supported decision-making encouraged whenever possible

Best Interests

•    Applies when a patient lacks capacity

•    Must consider:

o    Patient’s past and present wishes

o    Beliefs and values (e.g., religious or cultural)

o    Views of family and close friends (not decision-makers, but inform judgement)

o    Potential for regaining capacity

•    Multidisciplinary input (e.g., MDT meetings) often important

•    Avoid assumptions based solely on age, appearance, or condition

Advance Directives (Advance Decisions to Refuse Treatment, ADRT)

•    Legally binding if:

o    Valid: patient had capacity when made, not withdrawn, not overridden by a later decision

o    Applicable: specific to current circumstances

•    Can refuse life-sustaining treatment if explicitly stated and signed/witnessed

•    Cannot demand specific treatments (only refuse)

DNACPR (Do Not Attempt Cardiopulmonary Resuscitation)

•    Covers CPR only

o    Does not preclude other active treatments (e.g., antibiotics, fluids, oxygen)

•    Ideally discussed with the patient and/or family

•    Must document discussion clearly

•    Can be a clinical decision but should involve patient wherever feasible

•    In emergencies, if no form is present → presume CPR is appropriate

Restraint and Deprivation of Liberty

Restraint

•    Only justified if:

o    Necessary to prevent harm

o    Proportionate to risk and severity

•    Examples: bed rails, sedation, physical holds

Deprivation of Liberty

•    Applies when patient:

o    Lacks capacity

o    Is under continuous supervision and control

o    Is not free to leave

•    Requires legal safeguards under Deprivation of Liberty Safeguards (DoLS)

o    Independent assessments

o    Authorisation from local authority or court

Extra Revision Pearls

•    Doctrine of double effect: giving medications (e.g., opioids) to relieve suffering even if it may shorten life is ethically permissible if intention is symptom relief, not death

•    Gillick competence: minors (<16) can consent if judged competent to understand fully

•    Parental refusal: parents cannot demand treatment against child's best interests

•    Duty of candour: obligation to be open when things go wrong → apologise, explain, remedy where possible