What is the best course of action for an elderly patient requiring urgent life-saving surgery when a relative refuses, citing it will bother the patient?

Assess Mental Capacity Immediately and Proceed with Surgery if Patient Lacks Capacity

The correct answer is (b) - perform a mental capacity assessment on the patient, and if she lacks capacity (which is likely given she was "brought in from a location"), proceed immediately with the life-saving surgery based on best interests determination, as relatives have no legal authority to refuse treatment for incapacitated adults. 1, 2

Why Mental Capacity Assessment is the Critical First Step

The treating physician must determine whether the elderly patient has decision-making capacity before considering any input from relatives. 1 Capacity assessment evaluates whether the patient can:

• Understand the benefits, risks, and alternatives to the proposed surgery 3
• Appreciate the consequences of refusing treatment 3
• Demonstrate reasoning in their thought process 3
• Communicate their wishes 1, 3

If the patient lacks capacity (cannot understand, retain, use information, or communicate a decision), the relative's refusal is legally irrelevant and should be disregarded. 1, 2

Legal Framework: Relatives Cannot Refuse Life-Saving Treatment

Under the Mental Capacity Act 2005, relatives do not have legal authority to consent to or refuse treatment for incapacitated adults unless they hold a valid health and welfare Lasting Power of Attorney. 1, 2 The evidence explicitly states:

• "In the case of a competent adult patient, there is no requirement to inform relatives or other people, unless the patient asks or agrees for this to be done." 1
• Relatives serve only as consultants in best interests decisions, providing information about the patient's values and wishes 1, 4
• The decision-maker is the responsible clinician (consultant surgeon/anesthetist), not the family 1, 4

Best Interests Determination Allows Immediate Surgery

When a patient lacks capacity and requires urgent life-saving treatment, physicians are legally authorized to proceed based on best interests without obtaining consent from relatives or courts. 1, 2 Best interests encompass "welfare in the widest sense, not just medical but social and psychological," requiring consideration of: 1

• The patient's medical condition and prognosis
• Previously expressed values, wishes, and beliefs 1, 4
• What the patient's attitude toward treatment would likely be 1
• General well-being and spiritual/religious welfare 2

The relative's statement that surgery "will bother her" does not constitute a valid best interests argument against life-saving intervention. 1, 2

Why Other Options Are Wrong

Option (a) - Doing Surgery Without Assessment

While this may be the ultimate action, skipping capacity assessment violates professional duties under the Mental Capacity Act 2005. 1 You must document the patient's incapacity and the best interests determination. 1

Option (c) - Power of Attorney Application

This is completely inappropriate in an emergency. 2 Lasting Power of Attorney must be established when the patient has capacity, requires legal documentation, and takes weeks to complete. 1 Waiting for this process would cause fatal delays. 2

Option (d) - Court Submission

Court orders are only necessary for elective procedures in patients lacking capacity who have no legal guardian. 2 In emergency situations where treatment cannot be delayed without causing additional harm or death, the emergency principle protects practitioners from proceeding without court involvement. 2 Submitting to court would result in preventable death. 2

Practical Implementation Algorithm

1. Immediately assess the patient's mental capacity using structured evaluation 1, 3
2. Document findings clearly - if patient lacks capacity, record the grounds for this determination 1
3. Consult with the relative to gather information about patient's values and wishes, but make clear they cannot refuse treatment 1, 4
4. Make best interests determination as the responsible consultant, considering all factors including the relative's input about patient preferences 1, 4
5. Proceed with surgery if it serves the patient's best interests, documenting the decision-making process 1, 2
6. Provide clear communication to the relative explaining that you are acting in the patient's best interests and are legally obligated to provide life-saving treatment 1, 5

Critical Pitfalls to Avoid

• Never delay life-saving treatment to obtain consent from relatives in true emergencies - this violates the duty to act in the patient's best interests and can result in preventable death 2
• Do not assume relatives have legal authority unless they hold valid Lasting Power of Attorney for health and welfare decisions 1, 2
• Do not seek court orders for emergency interventions - this causes fatal delays and is only required for elective procedures 2
• Do not proceed without documenting capacity assessment and best interests determination - this violates professional obligations under the Mental Capacity Act 2005 1

Special Considerations for Elderly Patients

All staff involved in care of older people undergoing surgery should be aware of their duties under the Mental Capacity Act 2005 and professional guidance about best interests determinations. 1 Consultants should make decisions after taking into account the expectations and known wishes of the patient and their relatives/carers, but the final decision rests with the treating physician. 1, 4