Capacity assessment — refusing blood transfusion
PLAB 2 & PRES 3 · communication · hard · 8 minutes
Candidate brief
You are an FY2 doctor/SHO on an acute medical ward. Mr David Price, 58, has severe anaemia following an upper gastrointestinal bleed. His haemoglobin is 58 g/L, and the medical registrar has recommended a red-cell transfusion. Mr Price is refusing the transfusion because he is worried about its risks. Assess his capacity to make this specific decision, address his concerns and agree a safe management plan. You are not required to perform a physical examination.
What examiners look for
Presume that every adult has capacity. Capacity is specific to the particular decision and the time at which it must be made. Do not assume that a patient lacks capacity because they refuse recommended treatment or make a decision clinicians consider unwise. Support decision-making before assessing capacity. Treat reversible problems and provide information using appropriate language, interpreters, communication aids, written material, extra time or a trusted supporter. Assess whether the person can: Understand the relevant information. Retain it long enough to decide. Use or weigh it when reaching the decision. Communicate the choice by any reliable means. Use open questions and teach-back. Do not rely only on asking, “Do you understand?” Explain the proposed treatment, benefits, risks, reasonable alternatives and consequences of refusing. A capacitous adult can refuse treatment, including treatment that may save their life. Family members cannot override that decision. If capacity is lacking, check for an advance refusal and any legally authorised decision supporter. Apply the relevant UK or Irish legal framework. Document the information given, support offered, capacity assessment, patient’s reasoning, decision, senior discussion and ongoing safety plan.
Guideline references
- https://www.gmc-uk.org/professional-standards/ethical-hub/mental-capacity
- https://www.gmc-uk.org/professional-standards/the-professional-standards/decision-making-and-consent
- https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice
- https://healthservice.hse.ie/staff/procedures-guidelines/hse-consent-policy/
- https://www2.healthservice.hse.ie/organisation/national-pppgs/hse-national-consent-policy/
- https://www.decisionsupportservice.ie/resources/codes-practice/code-practice-healthcare-professionals
- https://www.decisionsupportservice.ie/sites/default/files/2023-03/1.%20COP_on_supporting_decision-making_and_assessing_capacity_0.pdf
- https://www.gov.ie/en/department-of-justice-home-affairs-and-migration/publications/assisted-decision-making-capacity-act-2015/
- https://www.gov.uk/government/publications/blood-transfusion-patient-consent/guidelines-from-the-expert-advisory-committee-on-the-safety-of-blood-tissues-and-organs-sabto-on-patient-consent-for-blood-transfusion
- https://www.nice.org.uk/guidance/ng24
- https://www.nhs.uk/tests-and-treatments/blood-transfusion/
- https://www.giveblood.ie/media/publications/other_documents/guidelines_for_the_administration_of_blood_and_blood_components.pdf
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