Psych CASC / OSCE · Consultation-liaison — capacity and consent
Assess capacity for treatment refusal — CASC communication station
MRCPsych/FRANZCP-style CASC: disclose information in plain language, use teach-back, assess four abilities, explore voluntary refusal vs incapacity, outline supports and pathways, involve family with consent, and close with a clear plan.
On this page & tools
Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar called by the medical team. [1]
Candidate instructions. Assess the person’s decision-making capacity regarding IV antibiotics for community-acquired pneumonia. Explain the condition and treatment in accessible language. Use teach-back. Explore reasons for refusal. If capacity appears present, respect a voluntary informed refusal while ensuring they understand consequences. If capacity appears impaired, explain supports, possible need for emergency treatment or a substitute decision pathway under local law (no invented section numbers), and involve supports with consent. Avoid coercion and humiliation. [1][2]
Candidate scenario
Your patient is 58, admitted with fever and hypoxia. Chest imaging and clinical findings support bacterial pneumonia. The medical team recommends IV antibiotics. The patient says: "I do not want needles. Hospitals experiment on people. I will drink water and be fine." Collateral is available from a partner in the waiting room if the patient agrees. English is fluent. No acute agitation. [1]
Marking domains
- Empathy, calm pace, non-stigmatising language
- Clear explanation of diagnosis, benefits, risks, alternatives including no antibiotics
- Teach-back for understanding and retention
- Exploration of appreciation (does the illness apply to them?) and reasoning/weighing
- Clear communication of a choice; check consistency
- Assessment of voluntariness (fear, coercion, mistrust)
- Supports offered; partner involvement only with consent
- Pathway explained without invented statute numbers; least restrictive tone
- Summarises and checks understanding; documents plan verbally [1][2][3]
Reveal assessor key
Open. Introduce role; explain you are here to help them make an informed choice about antibiotics, not to force a decision. Check comfort, pain, hearing, and privacy. [1]
Inform. Simple explanation: infection in the lung; IV antibiotics reduce risk of worsening breathing, sepsis, and death; risks include allergy and cannula problems; alternatives include oral antibiotics if appropriate or no treatment with higher risk of deterioration. Invite questions. [1]
Assess abilities. Teach-back: "Can you tell me in your own words what the doctors think is wrong and what they suggest?" Probe appreciation: "Do you think this infection is in your lungs?" Explore experiment belief without mockery — is it a fixed delusion, mistrust from past care, or cultural fear? Ask them to weigh options and state a choice. [1][2]
If capacity present. Respect refusal if voluntary and informed; negotiate least harmful plan (oral therapy, close monitoring, early warning symptoms); invite partner with consent; safety-net. [1][3]
If capacity absent. Explain concern that illness/beliefs are blocking use of the information; offer supports (more time, written info, treat hypoxia/delirium if present); if deterioration is imminent, explain emergency treatment principles under local law; if not, identify lawful substitute/best-interests process in principle-level language. Avoid inventing section numbers. [2][3]
Close. Summarise conclusion for this decision today; agree review time; thank them; signpost how to reach the team. [1]
References
- [1]Appelbaum PS Clinical practice. Assessment of patients' competence to consent to treatment N Engl J Med, 2007.PMID 17978292
- [2]Sessums LL, Zembrzuska H, Jackson JL Does this patient have medical decision-making capacity? JAMA, 2011.PMID 21791691
- [3]Buchanan A Mental capacity, legal competence and consent to treatment J R Soc Med, 2004.PMID 15340019