Capacity and refusal of ICU treatment — FFICM MCQ

Correct answer: A — Respect the capacitated refusal and optimise non-invasive/supportive care

The correct answer is A, respect the capacitated refusal and optimise non-invasive/supportive care. The stem confirms he satisfies all four elements of the Mental Capacity Act 2005 functional test: he can understand, retain, use or weigh the information, and communicate his decision. Under the Act, an adult with capacity has the right to refuse any treatment, including life-sustaining intubation, even where the decision appears unwise to clinicians or relatives, provided the refusal is informed and voluntary. Hypoxia and severe illness do not automatically negate capacity; capacity must be formally and functionally assessed rather than assumed, and here it has already been established. The appropriate course is therefore to honour his wishes while maximising comfort and non-invasive support such as high-flow oxygen, CPAP where tolerated, and best supportive/palliative measures. Why the other options are wrong: C. Intubate because his wife requests it: relatives have no legal authority to override a capacitated adult's own treatment decision; her views are not determinative under the Mental Capacity Act. B. Detain him under the Mental Health Act for pneumonia: the Mental Health Act applies to treatment of mental disorder, not physical illness such as pneumonia, so it cannot be used to force intubation here. E. Ignore refusal because hypoxia invalidates capacity automatically: capacity is never presumed absent on the basis of a physiological parameter alone; it requires a specific functional assessment, which he has passed. D. Wait until he loses capacity then intubate: deliberately delaying to exploit an anticipated future loss of capacity in order to override a current valid refusal is unlawful and unethical, and undermines patient autonomy. Key point: A capacitated adult can lawfully refuse life-sustaining treatment, including intubation, and this must be respected regardless of family objection or clinical disagreement.

Reference: GMC, Treatment and care towards the end of life: guidance for doctors, principles and guidance sections; Mental Capacity Act 2005, sections 1-3 (gmc-uk.org/professional-standards/the-professional-standards/treatment-and-care-towards-the-end-of-life)