Why Consent Stations Are Different
Consent and capacity stations test a completely different skill set from history taking. You are not gathering information — you are providing it. And you are doing so in a way that respects patient autonomy, confirms understanding, and ensures any decision made is genuinely informed.
These stations commonly appear as:
- Explaining a procedure and obtaining consent
- Assessing whether a patient has capacity to refuse treatment
- Managing a patient who lacks capacity
All three require you to understand both the ethical and legal framework — and apply it in real time.
Valid Consent — The Four Requirements
For consent to be legally and ethically valid, all four criteria must be met:
🧠 Mnemonic
VIVA — the four requirements of valid consent:
- Voluntary — free from coercion or undue influence
- Informed — patient has received sufficient information
- Valid — patient has capacity at the time of consenting
- Able to communicate — patient can express their decision
If any one is missing, consent is not valid — regardless of what the patient signs.
The Montgomery Ruling (2015) — What You Must Know
The 2015 Supreme Court ruling in Montgomery v Lanarkshire Health Board changed UK consent law permanently. It replaced the old Bolam standard (what a reasonable doctor would disclose) with a patient-centred standard.
⚠️ Red Flag
The Montgomery standard requires you to disclose:
Any risk that a reasonable person in the patient's position would consider significant — not just what a doctor considers significant.
This means: if the patient would want to know it, you must tell them — even if the risk is rare.
In practice:
- Disclose all significant and material risks, not just common ones
- Ask the patient what matters to them before listing risks
- Discuss alternatives — including doing nothing
- Document the conversation
Structure for Disclosing Risks
"Before I explain the procedure, it would help me to understand — is there anything in particular you're worried about, or anything that's especially important to you?"
Then present risks in order of clinical relevance:
- 1Common and minor (bruising, soreness, temporary discomfort)
- 2Rare but serious (nerve damage, serious bleeding, permanent complications)
- 3Specific to this patient (higher bleeding risk on anticoagulants, higher infection risk if immunosuppressed)
Assessing Capacity — The Mental Capacity Act 2005
The MCA 2005 provides the legal framework for assessing capacity in England and Wales.
The Two-Stage Test
Stage 1: Is there an impairment or disturbance of the mind or brain?
(dementia, delirium, intoxication, severe depression, learning disability, brain injury)
Stage 2: Does that impairment mean the person cannot make this specific decision?
🧠 Mnemonic
The four-part capacity test — CURE:
- Comprehend — can they understand the information given?
- Use — can they weigh it up and use it to reach a decision?
- Retain — can they hold the information long enough to decide?
- Express — can they communicate their decision by any means?
Inability to meet ANY ONE element means the person lacks capacity for that decision at that time.
The Five MCA Principles — Know These
💡 Tip
These five principles underpin the MCA and are directly assessed by examiners:
- 1A person must be assumed to have capacity unless established otherwise
- 2All practicable steps must be taken to help them before concluding they lack capacity
- 3An unwise decision does not mean lack of capacity
- 4Any decision made on behalf of someone without capacity must be in their best interests
- 5The least restrictive option must be chosen
Assessing Capacity in the OSCE — Step by Step
Step 1: Check for an impairment
"Before we discuss the operation, can I ask — have you had any problems with your memory or concentration recently?"
Step 2: Explain clearly in lay terms
Provide a brief, jargon-free explanation of:
- What the procedure involves
- Why it is being recommended
- The main risks and benefits
- Alternative options, including doing nothing
Step 3: Test comprehension
"In your own words, could you tell me back what you understand about the procedure?"
Step 4: Test ability to weigh information
"Given what I've told you about the risks and benefits, how are you thinking about this?"
"What are the main things you are weighing up?"
Step 5: Test communication of a decision
"So what are you leaning towards?"
💎 Clinical Pearl
If a patient gives an unusual or apparently unwise answer, do NOT immediately conclude they lack capacity. Explore their reasoning first:
"Can you help me understand how you reached that decision?"
An unwise decision made with clear reasoning is still a valid decision.
When a Patient Lacks Capacity
⚠️ Red Flag
Capacity is:
- Decision-specific — a patient may have capacity for some decisions but not others
- Time-specific — capacity can fluctuate (delirium improves, intoxication wears off)
- Not a permanent label — reassess regularly
If a patient lacks capacity, in order:
- 1Check for a valid Advance Decision (living will) — if applicable, it is legally binding even if the patient is now unconscious
- 2Check for a Lasting Power of Attorney (LPA) for health and welfare — the attorney may be authorised to consent
- 3If none, treat in the patient's best interests — consider their known wishes, values, cultural beliefs, and involve family
- 4For serious or contested decisions — involve senior clinicians, ethics committee, or the Court of Protection
Specific Scenarios
Jehovah's Witness Refusing Blood Transfusion
If the patient has capacity — their refusal is legally binding, even if it leads to death.
"I want to make sure I fully understand your wishes. Can you tell me more about your decision, so I can make sure we explore every alternative?"
💎 Clinical Pearl
Ask about advance decisions early. If a valid, applicable advance decision exists, it is legally binding even when the patient is unconscious. If no advance decision exists, document the refusal carefully, ensure the patient understands the consequences, and discuss with the team.
Teenager Refusing Treatment — Gillick Competence
- Children under 16 can consent to treatment if they are Gillick competent — they understand the nature, purpose, and implications of the treatment
- In UK law, a child under 16 generally cannot refuse treatment that an adult with parental responsibility consents to
- A person aged 16–17 is presumed to have capacity under the MCA
Patient with Dementia
- Capacity must be formally assessed — do not assume lack of capacity from a diagnosis alone
- Use simple language, give information in small chunks, allow processing time
- Involve a familiar person if it helps (but they cannot consent on behalf of an adult)
What Examiners Mark in Consent Stations
| Criterion | Marks |
|---|---|
| Checking patient's existing understanding | 2 |
| Clear jargon-free explanation of procedure | 3 |
| Disclosing common risks | 2 |
| Disclosing serious/rare risks (Montgomery standard) | 2 |
| Discussing alternatives including no treatment | 2 |
| Checking comprehension in patient's own words | 2 |
| Offering opportunity for questions | 1 |
| Mentioning documentation/consent form | 1 |
| Communication and rapport | 5 |
| Total | 20 |