Framework	When it applies	What it allows	Limits / cannot do
⚖️ Common law	Immediate emergencies when diagnosis/risks are unclear and there’s no time to determine capacity.	Act to preserve life/prevent serious deterioration; use necessary & proportionate restraint until formal assessment is possible.	Not for ongoing care once capacity can be assessed or where a statutory framework (MCA/MHA) clearly applies.
🧠 Mental Capacity Act (MCA)	Patient lacks capacity for a specific decision (time- and decision-specific).	Treat and, if needed, restrain when in the person’s best interests; use the least restrictive option; consider past/present wishes, values, and consultees/LPA/IMCA.	Cannot be used to protect others or to treat someone who has capacity but refuses (though “unwise” ≠ lacking capacity).
🧩 Mental Health Act (MHA)	Patient has a mental disorder (including delirium due to physical illness) and there are risks to their health/safety or to others.	Authorises detention/assessment/treatment for the mental disorder (and some closely related physical health needs).	Does not authorise treatment for unrelated physical conditions (use MCA/common law for those).

✅ Core Principles (teach & remember)

🧪 Capacity is decision-specific and time-specific; don’t assume global incapacity.
🎯 Patients may make unwise choices; disagreement with clinicians ≠ incapacity.
👐 Use the least restrictive option that achieves safety and benefit.
📝 Document: capacity assessment (understand/retain/weigh/communicate), risks, legal basis (Common law, MCA, or MHA), and why it’s proportionate.
🤝 Seek senior/psychiatry advice early if the legal route is unclear or risks are high.

🛠️ Practical “At-the-Bedside” Steps

⏱️ Is it an emergency? If life/limb at immediate risk and capacity unknown → act under Common law, reassess once safe.
🧠 Can they decide? Assess capacity for the specific decision (information, risks, alternatives).
💡 If capacity lacking → use MCA best interests; consider LPA, advance statements, family views; restrain only if necessary & proportionate.
🧩 If mental disorder drives risk to self/others → consider MHA (speak with psychiatry); treat physical problems via MCA/common law as appropriate.
🔁 Review frequently: capacity can improve (e.g., after analgesia, delirium treatment, rehydration).

📊 What we often miss

👀 Capacity is overestimated in practice; studies suggest ~30% of acute medical inpatients and >40% psychiatric inpatients lack capacity for key decisions.
🧩 Delirium = mental disorder for MHA purposes, but don’t forget the MCA for physical treatment decisions.
🧭 If you can’t justify the legal route in one sentence, pause and phone a friend (senior/psych/legal).

🧷 Quick Safety Notes

🔒 Restraint must be necessary, proportionate, and recorded (aim for least restrictive; continuous observation when used).
📣 Communication: simplify information, use aids/interpreters, optimise hearing/vision—this may restore capacity.
👪 Involve family/LPA/IMCA early; they inform best interests but don’t replace proper assessment.

References

Patients who refuse treatment – BMJ

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Patients who refuse treatment or lack capacity

🧭 Frameworks (UK)

✅ Core Principles (teach & remember)

🛠️ Practical “At-the-Bedside” Steps

📊 What we often miss

🧷 Quick Safety Notes

References

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