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ANH Decision-Making in Dementia — MRCPsych Paper B MCQ

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HardOld Age PsychiatryANH Decision-Making in DementiaMRCPsych Paper B

An 82-year-old man in an English care home has severe dementia and can no longer swallow safely. Despite all practicable support, he lacks capacity to decide whether to receive clinically assisted nutrition and hydration through a PEG tube. A consultant geriatrician is responsible for the proposed treatment. There is no valid and applicable advance decision, health and welfare lasting power of attorney, or court-appointed deputy. His adult son is available for consultation, and there is no unresolved disagreement. Under the Mental Capacity Act 2005, who is the legal decision-maker?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — The consultant geriatrician responsible for the proposed treatment, following the MCA best-interests process

Explanation lettering: E = shown as A · C = shown as B · D = shown as C · B = shown as D · A = shown as E

B is correct. For proposed medical treatment, the clinician responsible for providing it is ordinarily the MCA decision-maker. The consultant must determine and record the man's best interests, considering the clinical benefits and burdens, less restrictive alternatives, and his past and present wishes, feelings, beliefs and values. The son and multidisciplinary team must be consulted, but their agreement does not make the decision collective. The care-home manager and GP are not responsible for this proposed procedure. “Next of kin” confers no automatic decision-making authority. An IMCA is generally required for serious medical treatment only when nobody appropriate other than paid staff is available to consult. Court of Protection referral is not automatic for clinically assisted nutrition and hydration; it is considered when a serious dispute or material uncertainty cannot otherwise be resolved.

Reference: National Institute for Health and Care Excellence. Decision-making and mental capacity (NG108), recommendations 1.1.77–1.1.96. 2018. https://www.nice.org.uk/guidance/NG108/chapter/recommendations