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Decision-making for serious medical treatment in an adult lacking capacity — MRCEM SBA MCQ

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HardProfessional practice and researchDecision-making for serious medical treatment in an adult lacking capacityMRCEM SBA

A 46-year-old man is brought to an emergency department in England after a machinery crush injury. An associated traumatic brain injury has left him unable to understand or weigh information about treatment despite appropriate support. Haemorrhage is controlled, and wound care, analgesia and antibiotics are underway. The orthopaedic team considers his leg non-salvageable and proposes an above-knee amputation. He is stable, and the team judges that the decision can safely wait until tomorrow; recovery of decision-making capacity in that period is unlikely. An independent mental capacity advocate (IMCA) is available today. Enquiries have found no appropriate family or friends to consult, and he has no known health and welfare attorney, deputy or advance refusal. There is no dispute among the treating clinicians. What is the most appropriate approach to the amputation decision?

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Correct answer: C — Continue supportive care; instruct an IMCA and consider their report before making the best-interests decision.

The traumatic brain injury has caused a decision-specific inability to understand or weigh the proposed treatment. An above-knee amputation has major, lasting consequences and is serious medical treatment. Because there is nobody appropriate to consult and the decision can safely wait for the available advocate’s input, the NHS body should instruct an IMCA. The treating decision-maker must consider the IMCA’s report when deciding what is in the patient’s best interests; the IMCA does not make that decision. Necessary care to prevent deterioration continues meanwhile. ([nice.org.uk](https://www.nice.org.uk/guidance/NG108/chapter/recommendations)) A overlooks the IMCA duty: agreement among clinicians does not replace independent advocacy. B applies the exception for a decision too urgent to await an IMCA, which the stated safe interval excludes. D gives excessive weight to possible future recovery when capacity is unlikely to return before a decision is needed. E adds a court ruling despite the absence of a dispute or other stated reason requiring one; serious medical treatment does not, by itself, require court approval. ([gov.uk](https://www.gov.uk/government/publications/independent-mental-capacity-advocates/making-decisions-the-independent-mental-capacity-advocate-service-web-version))

Reference: Decision-making and mental capacity: recommendations (3 October 2018) — https://www.nice.org.uk/guidance/NG108/chapter/recommendations Mental Capacity Act Code of Practice, chapters 8 and 10 (First published 2007; GOV.UK publication page last updated 14 October 2020) — https://assets.publishing.service.gov.uk/media/5f6cc6138fa8f541f6763295/Mental-capacity-act-code-of-practice.pdf Making decisions: the Independent Mental Capacity Advocate service (Publication date not stated on the checked web page) — https://www.gov.uk/government/publications/independent-mental-capacity-advocates/making-decisions-the-independent-mental-capacity-advocate-service-web-version