In a 46‑year‑old man with paranoid schizophrenia who has not taken his antipsychotic medication for several days and presents with an urgent hip‑fracture requiring surgery, who has the final authority to determine his capacity to consent to the procedure?

Who Determines Capacity to Consent for Surgery in This Patient?

The treating physician (you, as the medical consultant, or the surgeon) makes the final determination of capacity, not the psychiatrist—though psychiatric consultation provides valuable input to inform this medical decision. 1

Legal Framework for Capacity Determination

Under the Mental Capacity Act 2005 (or equivalent U.S. state laws), it remains the treating doctor's responsibility to determine whether the patient has capacity and to make treatment decisions deemed necessary and in the patient's best interests. 1 The treating physician must be prepared to justify these decisions to the courts if necessary. 1

• Capacity is decision-specific and must be assessed by the person treating the patient (in this case, the surgical team with your medical consultation support). 1
• The psychiatrist serves as a consultant to help evaluate factors affecting capacity (such as active psychotic symptoms, insight impairment, or medication non-adherence), but does not hold final authority over the surgical consent decision. 1

Capacity Assessment Criteria

The patient must demonstrate all four abilities to have capacity: 1

• Understand the information about the procedure, risks, and benefits
• Retain that information long enough to make a decision
• Use and weigh the information to reach a decision
• Communicate the decision

A highly irrational decision based on persistent misinterpretation of information may indicate lack of capacity, though determining incapacity on grounds of irrationality requires legal advice. 1

Clinical Urgency Considerations

This case involves critical time pressure that influences the decision-making process:

• Delaying hip fracture surgery beyond 48 hours significantly increases mortality, pressure sores, pneumonia, and thromboembolic complications. 1, 2
• There is no evidence that delaying surgery to allow pre-operative physiological stabilization improves outcomes. 1, 2
• The window for safe delay must be weighed against the time needed to obtain better forms of consent or restore capacity. 3

Practical Approach in This Case

If the patient lacks capacity after formal assessment, you (the treating physician) can proceed with surgery under the doctrine of best interests without requiring family consent, though you should make reasonable efforts to contact family. 1

Steps to take:

1. Formally assess capacity yourself using the four-criteria framework, documenting the assessment thoroughly. 1
2. Utilize psychiatric consultation to evaluate whether medication non-adherence has caused acute decompensation and whether rapid treatment could restore capacity within the safe delay window. 4, 3
3. Make reasonable attempts to contact family (check emergency contacts, social work records, previous admission notes), but document that family cannot be reached after diligent effort. 1, 5
4. Check for advance directives or Lasting Power of Attorney in the medical record. 1
5. If capacity is lacking and surgery cannot be safely delayed, proceed with surgery as it is both necessary and in the patient's best interests, documenting your justification. 1

Common Pitfalls to Avoid

• Do not delay surgery waiting for psychiatric "clearance"—the psychiatrist provides consultation, not authorization. 1
• Do not assume the patient lacks capacity solely because of his schizophrenia diagnosis—capacity must be proven absent, not assumed. 1
• Do not delay surgery for minor reasons when the patient lacks capacity and surgery is clearly indicated—this increases mortality. 1, 2
• Awaiting family contact is not an acceptable reason to delay urgent surgery when reasonable efforts have failed and the patient lacks capacity. 1, 2

Documentation Requirements

You must document: 1

• The specific capacity assessment performed (all four criteria)
• Why the patient lacks capacity (e.g., psychotic symptoms preventing understanding of risks)
• Attempts made to contact family members
• Why surgery is necessary and in the patient's best interests
• Why delay would cause harm
• Consultation with psychiatry and their input