Psychiatry · Easy
This case is fictional and exists for study. It describes no real patient.
74 years · male
A 74-year-old male with a history of mild vascular dementia is admitted to the medical ward with right leg cellulitis, which has fully resolved following a 5-day course of intravenous antibiotics. The multidisciplinary team recommends a temporary 2-week stay in a residential rehabilitation unit to rebuild his physical confidence and mobility. However, the patient expresses a strong desire to return directly to his home, where he lives alone with visiting carer support twice daily. During a formal discussion, he clearly understands his condition, retains the explanation of the risks and benefits of going home versus going to rehab, weighs these options logically, and consistently communicates his decision to return home.
Vital signs
- HR
- 72 bpm
- BP
- 128/82 mmHg
- RR
- 16/min
- Temp
- 36.8 °C
- SpO₂
- 98%
Examination findings
- Resolved cellulitis on right lower leg with non-tender, intact skin
- Oriented to person and place, mild short-term memory impairment
Investigations
| White Blood Cell Count | 6.2 10^9/L | reference: 4.0-11.0 |
| C-reactive Protein | 4 mg/L | reference: 0-5 |
Question 1 of 3
Which statement best describes the assessment of this patient's decision-making capacity regarding his discharge destination?
Decision-making capacity is time- and decision-specific. Under statutory capacity principles, a person has capacity if they can understand the information relevant to the decision, retain that information, use or weigh it as part of the decision-making process, and communicate their decision. The patient demonstrates all four stages. Option D is incorrect because a diagnostic label like dementia does not automatically mean a lack of capacity. Option C is incorrect because making an unwise decision or disagreeing with clinicians does not equate to lacking capacity. Option A is incorrect because an adult with capacity makes their own decisions independently of family consent.
Teaching point: Capacity is decision-specific and depends on the functional ability to understand, retain, weigh, and communicate information, not on medical diagnoses or clinical agreement.
Question 2 of 3
Which of the following is the single most appropriate action regarding the patient's discharge plan?
Because the patient has decision-making capacity regarding his discharge destination, his autonomous choice must be respected, even if the clinical team considers it carries higher risk than rehabilitation. Therefore, arranging safe home discharge with domiciliary support is correct (Option C). Option D is incorrect because 'best interests' decisions only apply when a person lacks capacity. Option B is incorrect because mental health legislation cannot be used to force physical rehabilitation on a competent patient. Option A is incorrect because Deprivation of Liberty Safeguards apply only to patients who lack capacity to consent to their care arrangements.
Teaching point: An adult patient with capacity has the legal and ethical right to refuse medical recommendations and make decisions that clinicians view as unwise.
Question 3 of 3
If the patient subsequently develops acute delirium secondary to a new infection and loses the ability to understand or retain information, what is the next best management step regarding decisions about his care?
When a patient temporarily or permanently lacks capacity, healthcare professionals must act in the patient's best interests, selecting the least restrictive option for their clinical management (Option C). Option D is incorrect because necessary medical treatment and discharge planning should not be indefinitely delayed if waiting poses risk. Option A is incorrect because general practitioners do not hold sole legal decision-making authority; the responsible clinician/team makes best interests determinations after consulting relevant parties. Option B is incorrect because past preferences inform best interests decisions, but an acutely unwell, confused patient cannot be unsafely discharged without proper best interest evaluation and acute medical management.
Teaching point: When a patient lacks decision-making capacity, clinicians must act in their best interests while applying the least restrictive principles.
Key learning points
- Decision-making capacity is time-specific and decision-specific, and cannot be determined solely by a patient's medical diagnosis.
- The four functional criteria for capacity are understanding, retaining, weighing information, and communicating the decision.
- A patient with capacity has the legal right to make an unwise decision, and best interests decisions apply only when capacity is absent.
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