Who makes the final decision to consent to surgery for a 46-year-old patient with paranoid schizophrenia and a hip fracture, who lacks capacity to consent due to impaired insight and has no family members or healthcare proxy?

Decision-Making for a Patient with Schizophrenia Lacking Capacity for Surgical Consent

In the case of a 46-year-old patient with paranoid schizophrenia who lacks capacity to consent to urgent hip fracture surgery and has no family members, an Independent Mental Capacity Advocate should be consulted to help make the final decision based on the patient's best interests. 1

Assessment of Capacity

When a patient with schizophrenia presents with a hip fracture requiring urgent surgery:

1. A formal capacity assessment should be conducted by a healthcare professional with expertise in evaluating decision-making capacity 2
2. The assessment should evaluate four key abilities:
   • Understanding of the surgical procedure and its risks/benefits
   • Appreciation of how the surgery applies to their situation
   • Reasoning about treatment options
   • Ability to communicate a choice 2, 3
3. Capacity is decision-specific - the patient may have capacity for some decisions but not others 1

In this case, the surgeon has determined the patient lacks capacity due to:

• Paranoid schizophrenia affecting insight
• Not taking medications for several days
• Inability to understand the implications of the hip fracture surgery

Decision-Making Process for Incapacitated Patients

When a patient lacks capacity and has no family members:

1. Document the grounds for lack of capacity - The treating team must clearly record why they believe the patient lacks capacity 1

2. Determine best interests - Consider the patient's welfare in the widest sense:

   • Medical aspects (need for urgent hip fracture repair)
   • Social and psychological factors
   • Nature of the treatment and prospects of success
   • Likely outcome of treatment
   • What the patient's attitude toward treatment would likely be 1

3. Consult an Independent Mental Capacity Advocate (IMCA) - When a patient lacking capacity is to undergo serious medical treatment and no family members are available, consultation with an IMCA should be sought under Sections 35-37 of the Mental Capacity Act 1

4. Emergency treatment provision - If identifying a surrogate decision-maker would delay treatment and increase risk of death or serious harm, physicians can provide emergency care without formal consent 3

Role of the Independent Mental Capacity Advocate

The IMCA will:

• Gather information about the patient's condition and circumstances
• Evaluate if the proposed surgery is in the patient's best interests
• Represent the patient's rights and previous expressed wishes
• Help make the final decision regarding consent for surgery 1, 2

Documentation Requirements

The healthcare team must document:

1. The grounds for determining lack of capacity
2. The treatment to be undertaken
3. How the treatment is in the patient's best interests
4. The consultation with the IMCA
5. The final decision-making process 1

Important Considerations

• Least restrictive option - Any intervention should cause the least restriction of the patient's rights and freedom of action 1

• Avoid assumptions - A diagnosis of schizophrenia alone does not automatically mean lack of capacity 2

• Urgency of the situation - Hip fractures require prompt surgical intervention to reduce morbidity and mortality, which must be factored into the decision-making process 1

• Separate consent processes - Be aware that consent for surgery and consent for anesthesia are separate domains and may require separate capacity evaluations 4

By following this structured approach and consulting an Independent Mental Capacity Advocate, the healthcare team can ensure that the final decision regarding hip fracture surgery is made in the best interests of this vulnerable patient with paranoid schizophrenia.