CRP08 — Capacity, consent, goals and treatment ceilings

ClinicalEdu V1.14 | Adult NHS educational reading | Editorial review

Learning context and original foundational reading

Clinical urgency and lawful decision making coexist

A patient can be critically ill and still retain capacity for a particular decision. Capacity is decision-specific and time-specific; it should not be inferred solely from age, disability, diagnosis or disagreement with the clinician. The GMC guidance expects meaningful involvement, appropriate support, explanation of material options and good records. When consciousness or cognition is impaired, consider practical communication support and the relevant law before concluding that a patient lacks capacity.

Understand what is being decided

Separate consent to a proposed investigation or treatment from the broader question of where treatment should occur. If a person cannot participate, decisions must follow the law applicable in the relevant UK nation and the patient’s interests, wishes, values and lawful representatives where applicable. The GMC consent guidance was updated in August 2026, so teaching must link to its current version rather than relying on older extracts.

Goals, escalation and resuscitation

A treatment escalation plan considers what interventions are clinically indicated, likely to help and consistent with patient priorities. A decision not to attempt CPR does not mean “do not treat”, and a ceiling for intensive care does not settle every future issue about antibiotics, transfusion, oxygen or hospital transfer. Make those distinctions explicit to patients, families and staff, and confirm that the documented plan is accessible at transitions of care.

Communication with relatives

Family members can provide vital knowledge of baseline values and preferences, but their role as legal decision-makers varies. Avoid presenting consultation as a substitute for the patient’s own consent when capacity is present. Where conflict exists, remain clear about clinical indications and the decision process, listen to concerns, document the reasons and use senior, ethics or legal support as necessary.

Uncertainty and documentation

End-of-life status is not interchangeable with an acute episode that deserves clinical evaluation. Conversely, burdensome interventions are not automatically obligatory merely because they are technically available. Document the particular treatment question, relevant wishes and any authorised decision-maker, options discussed, reasoning, agreed limits, review trigger and responsible clinician.

Worked clinical scenario

An adult with fluctuating delirium refuses transfer, while the family asks for “everything” and the chart contains a DNACPR entry. Explain how to separate capacity, transfer decision, clinical indications and CPR status.

Decision-making capacity, consent and treatment goals

Clinical urgency and lawful decision-making must proceed together. Capacity is decision-specific and time-specific: difficulty communicating, age, disability or a diagnosis of dementia do not by themselves establish lack of capacity. Offer practical support to enable the patient to understand, retain, use or weigh relevant information and communicate a decision. Consider reversible contributors to impaired decision-making, such as delirium, hypoxia or medication effects. Apply the relevant jurisdictional legal framework; the Mental Capacity Act 2005 is central in England and Wales, but local procedures and specialist advice may be necessary.

Explain the material options, benefits, burdens and uncertainties in language suitable for the particular patient. A decision about attempting cardiopulmonary resuscitation is not the same decision as whether to admit, prescribe antibiotics, treat reversible illness or provide other active care. Treatment-escalation planning should reflect goals, clinical judgement and lawful involvement of the patient or appropriate decision-makers. DNACPR documentation must never be treated as a general instruction to withhold care.

If a patient lacks capacity for the specific decision, document the assessment, urgency, people consulted, options considered and rationale under the applicable legal framework. There may be emergency exceptions to ordinary consent processes, but they should not replace meaningful involvement when circumstances permit. If a relative disputes a plan, clarify their role and any legal authority, listen to what they know of the patient's wishes, and seek senior or legal advice where appropriate. Discuss prognosis without implying certainty where none exists. GMC guidance on decision making and consent was updated in August 2026; source-check before publication.

Extended worked cases and reasoning prompts

Case discussion 1

An 86-year-old patient with fluctuating delirium refuses ambulance transfer but is otherwise able to describe some risks. Outline what must be assessed about this particular decision and what support could make participation possible. Contrast a capacitous refusal with a decision made because the clinician considers a person “too frail”.

Case discussion 2

A second patient has a documented DNACPR form. Relatives interpret it as forbidding investigation or antibiotics. Prepare a sensitive explanation of the distinction between CPR, other treatment and the patient's goals.

Structured practice and reflection

1. Write a two-sentence problem representation separating observed facts from assumptions.

2. Name two important alternatives and one potentially harmful missed condition.

3. What is the safest immediate action before a definitive diagnosis is available?

4. Which finding or change would cause you to revise your plan?

5. What would you document or communicate to make responsibility and follow-up explicit?

Further reading — primary organisations

GMC Decision making and consent: https://www.gmc-uk.org/professional-standards/the-professional-standards/decision-making-and-consent

NICE decision making and mental capacity NG108: https://www.nice.org.uk/guidance/ng108

Editorial verification: only selected central documents have been checked live this session; the complete module reference list requires individual date/version checking and clinical reviewer sign-off before public release.

Educational boundary: an online completion record is not evidence of independently assessed clinical competence or accredited BLS/ALS provider certification.

Clinical decision and professional scope

Ethical reasoning during deterioration is the central theme of this chapter. The case begins with: patient with fluctuating delirium, previously stated preferences and a proposed urgent transfer. The educational aim is to practise structured reasoning, seek timely senior help and revisit early judgements as the patient changes. It is not a substitute for individual assessment, escalation policy, approved practical training or independent clinical supervision.

Reasoning in the first clinical encounter

Capacity is assessed for the particular decision at the relevant time and should not be inferred solely from age, diagnosis or delirium label.

Ask what must be recognised now, what is uncertain, which risks cannot wait and what professional or practical resources are available. This is especially important in the following scenario: Patient with fluctuating delirium, previously stated preferences and a proposed urgent transfer.

Evidence, bias and contradictory information

A proposed ceiling of treatment requires discussion of realistic benefits, burdens, preferences and legal authority; it should not be inferred from frailty alone.

Distinguish reliable measurements, recalled history, inferred mechanisms and assumptions. Identify a genuine contradictory fact and explain how it changes the plan. This is especially important in the following scenario: Patient with fluctuating delirium, previously stated preferences and a proposed urgent transfer.

A worked bedside narrative

In a time-critical emergency, seek the appropriate legal and clinical basis for action, then document the rationale and efforts made to involve the patient or relevant people.

Treat the first impression as provisional. Explain the immediate actions, an alternative explanation and the findings that would determine escalation. This is especially important in the following scenario: Patient with fluctuating delirium, previously stated preferences and a proposed urgent transfer.

Follow-up and safety net

Capacity is assessed for the particular decision at the relevant time and should not be inferred solely from age, diagnosis or delirium label.

Specify who repeats observations, the interval dictated by local protocols and what will trigger additional clinical review. This is especially important in the following scenario: Patient with fluctuating delirium, previously stated preferences and a proposed urgent transfer.

Communication and record quality

A proposed ceiling of treatment requires discussion of realistic benefits, burdens, preferences and legal authority; it should not be inferred from frailty alone.

Show that the documentation allows a colleague to see the decision, uncertainty, response and accountable next action. This is especially important in the following scenario: Patient with fluctuating delirium, previously stated preferences and a proposed urgent transfer.

Teaching exercise

In a time-critical emergency, seek the appropriate legal and clinical basis for action, then document the rationale and efforts made to involve the patient or relevant people.

Pause at each stage to write a short problem representation and a concrete decision before looking at the proposed reasoning. This is especially important in the following scenario: Patient with fluctuating delirium, previously stated preferences and a proposed urgent transfer.

Extended case discussion

Initial contact: Patient with fluctuating delirium, previously stated preferences and a proposed urgent transfer. The clinician has incomplete handover details. Record the physiological observations, compare the current presentation with baseline and decide whether urgent response is warranted. This stage is about recognising the need for action, not guessing the final diagnosis.

At the first review: Ask whether the patient can supply a reliable history; consult relevant carers and records; reconcile medication changes; and interpret findings in the context of frailty and multimorbidity. The team must not allow uncertainty about cause to hide objective deterioration.

New information: A colleague reports that the change began earlier than originally thought. The clinician must revise the time course and identify whether this shifts the prioritised differential, appropriate investigation, monitoring frequency or destination of care.

Decision point: Distinguish capacity, consultation, benefits/burdens and escalation planning. Explain a decision that is justified now, a competing option and the circumstances in which it would be appropriate. Clearly distinguish what you know, what you suspect and what needs confirmation.

After the intervention: Arrange reassessment and document the response. A settled score, a single laboratory result or a temporary symptom improvement should not erase the need to review the full trajectory.

Practice lens 1: time and trajectory

Capacity is assessed for the particular decision at the relevant time and should not be inferred solely from age, diagnosis or delirium label. Consider how this principle is affected by imperfect staffing, overnight cover or limited site resources; distinguish a desirable ideal response from what can actually be delivered safely.

Write a structured clinical note using the headings: observed findings; baseline; current concern; differential and important alternatives; agreed actions; accountable reviewer; and explicit reassessment or transfer triggers. Highlight any unresolved question instead of silently closing it.

Practice lens 2: uncertainty and corroboration

A proposed ceiling of treatment requires discussion of realistic benefits, burdens, preferences and legal authority; it should not be inferred from frailty alone. Consider how this principle is affected by imperfect staffing, overnight cover or limited site resources; distinguish a desirable ideal response from what can actually be delivered safely.

Write a structured clinical note using the headings: observed findings; baseline; current concern; differential and important alternatives; agreed actions; accountable reviewer; and explicit reassessment or transfer triggers. Highlight any unresolved question instead of silently closing it.

Practice lens 3: next decision and ownership

In a time-critical emergency, seek the appropriate legal and clinical basis for action, then document the rationale and efforts made to involve the patient or relevant people. Consider how this principle is affected by imperfect staffing, overnight cover or limited site resources; distinguish a desirable ideal response from what can actually be delivered safely.

Write a structured clinical note using the headings: observed findings; baseline; current concern; differential and important alternatives; agreed actions; accountable reviewer; and explicit reassessment or transfer triggers. Highlight any unresolved question instead of silently closing it.

Reading and source-check register

Core reference: GMC Decision making and consent. The reference supports its own clinical or professional recommendations; the case examples, reflective prompts and teaching structure are original educational synthesis, not direct source quotations. Check the operative full guidance and local policy before applying recommendations.

Reflective practice

What did I first assume? Which finding would most quickly falsify that assumption? Was I influenced by site capability or workload? What did I communicate, to whom, and when should that decision be reviewed? Do not include patient-identifiable information in submitted reflections.

Boundary with BLS and ALS

Early recognition, timely escalation, clinical reasoning and team communication support later BLS/ALS theoretical learning. This chapter does not teach or certify CPR, defibrillation, airway procedures or accredited resuscitation competence. Use current Resuscitation Council UK guidance and approved supervised practical training for those skills.