A 75-year-old male patient is brought into his GP practice by his wife. He had received an invitation by the practice to come in for his annual flu vaccination. He has a history of Parkinson's dementia, type 2 diabetes mellitus and obesity. He requires carers four times a day, and on his last visit to the GP he scored 5 out of 30 on an MMSE (mini-mental state examination). He has a Do Not Attempt Resuscitation (DNAR) form but does not have an advanced directive.

His wife asks the GP whether he can have his flu vaccination, which of the following is the best next step?

Options:
explanation: The first part of this choice is correct: the patient's capacity should be assessed in keeping with Principle 1 of the Mental Capacity Act (2005). However, there is nothing in the stem to suggest that giving the patient the flu jab would be against their best interests
name: Assess whether the patient has capacity for this decision. If the patient does not have capacity, then do not give the flu vaccination because it is not in the patient's best interests
label: c
answer: no
explanation: This is incorrect. The patient's capacity needs to be assessed before making a decision here. The presence of a DNAR form only means that, in the event of a cardiac arrest, the patient should not have cardiopulmonary resuscitation. It does not mean the patient cannot have other treatments. This is a common misconception amongst patients
name: Do not assess whether the patient has capacity for this decision because they have a DNAR. Do not give the vaccination because the patient has a DNAR
label: e
answer: no
explanation: This is best answer. The Mental Capacity Act (2005) states that all patients should be assumed to have capacity unless proven otherwise (Principle 1). Therefore, it is important to assess this patient's capacity, even though you know their condition and previous MMSE scores make it unlikely that they do have capacity. If an individual does not have capacity for a particular decision then the doctor must make a decision that both, acts in the patient's best interests (Principle 4), and is the least restrictive option (Principle 5). In this case, the information in the stem suggests that having the vaccination would be in the patient's best interests: he is at risk, and there is no evidence that it would have been against his wishes when he did have capacity
name: Assess whether the patient has capacity for this decision. If the patient does not have capacity, then give the flu vaccination because it is in the patient's best interests
label: a
answer: yes
explanation: The first part of this choice is correct: the patient's capacity should be assessed in keeping with Principle 1 of the Mental Capacity Act (2005). However, if the patient does not have capacity, the GP should think about what is in the patient's best interests (Principle 4). In this case, that is done by giving the vaccination
name: Assess whether the patient has capacity for this decision. If the patient does not have capacity, then the GP cannot give the flu vaccination
label: b
answer: no
explanation: The first part of this choice is correct: the patient's capacity should be assessed in keeping with Principle 1 of the Mental Capacity Act (2005). However, if there is no advanced directive then the doctor will have to act in the patient's best interests (Principle 4). An advanced directive is a helpful tool for a patient to create (when they have capacity). Not having one though, should not preclude treatment if they are deemed not to have capacity
name: Assess whether the patient has capacity for this decision. If the patient does not have capacity, then do not give the flu vaccination because the patient does not have an advanced directive
label: d
answer: no

Correct answer: a


Learning point: Assessing a patient's capacity is essential before making healthcare decisions, particularly for those with cognitive impairments like dementia.