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Consent — DFSRH MCQ

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HardConsentDFSRH

A 31-year-old attends a specialist sexual health service for day-case intrauterine contraception insertion under intravenous sedation because of severe vaginismus following previous sexual trauma. At a pre-procedure consultation she demonstrated capacity and gave informed consent to insertion of a copper intrauterine device (Cu-IUD). She specifically declined a levonorgestrel intrauterine system (LNG-IUD) because maintaining predictable menstrual bleeding was important to her. After intravenous midazolam has been administered, but before the speculum examination, she repeatedly says, “Do not put in the copper coil; I want the hormonal one.” She is drowsy and cannot retain or weigh an explanation of the differing bleeding profiles for more than a few moments. Pregnancy has been excluded, there is no clinical emergency, and effective bridging contraception can be provided. What is the most appropriate course of action?

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

Reveal the answer and explanation

Correct answer: B — Insert neither device, allow the sedation to wear off, and reassess her capacity and contraceptive choice

Explanation lettering: C = shown as A · A = shown as C

Consent is continuing permission, not an irrevocable authority conferred by a signed form. Her repeated objection means that the previously agreed Cu-IUD should not be inserted. Conversely, the sedative-associated inability to retain and weigh the comparative information means that she currently lacks capacity to make the new, device-specific decision required for LNG-IUD insertion. A request made in that state does not provide valid consent for substituting a materially different method. This is elective care: pregnancy has been excluded, bridging contraception is available, and capacity is likely to return when sedation resolves. Deferral therefore preserves autonomy and avoids an unnecessary best-interests intervention. A is attractive because the original consent was valid and prior capacitous wishes can remain relevant after loss of capacity, but it cannot justify proceeding despite a clear contemporaneous objection in a non-emergency. C mistakes repeated assent for capacitous informed consent. D is incorrect because a partner is not automatically a proxy decision-maker; in any event, the decision can safely await recovery. E incorrectly invokes best interests where the intervention is non-urgent and the patient can shortly make the decision herself. Treatment without current consent may be justified in an immediate emergency, but no such exception applies here.

Reference: Consent (Last reviewed 15 February 2024) — https://www.rcog.org.uk/guidance/consent/ Decision-making and mental capacity: recommendations (3 October 2018) — https://www.nice.org.uk/guidance/ng108/chapter/Recommendations Consent to treatment: assessing capacity (Last reviewed 8 December 2022) — https://www.nhs.uk/tests-and-treatments/consent-to-treatment/capacity/