PLAB 2 Capacity Assessment Station: How to Approach, Mark Scheme & Free Practice
A patient telling you they want to stop treatment is one of the most demanding ethics stations in PLAB 2. In eight minutes you must find out why they are refusing, check their understanding of what refusal means, assess capacity without turning the conversation into an interrogation, and respect a decision you may personally disagree with - all while keeping the relationship warm enough that the door stays open. The station is built on the Mental Capacity Act 2005 and GMC decision-making guidance, and it rewards listening far more than persuading. This guide walks through the structure that scores well, the four-limb capacity test woven into natural conversation, and the safety-critical lines you must not cross.
What the station is testing
The station is marked across three domains - data gathering, clinical management and interpersonal skills - plus safety-critical checks: capacity must be assessed using the four-limb Mental Capacity Act test rather than assumed absent because the patient is refusing; a capacitous refusal must be respected, never overridden or worked around with pressure or deception; a senior must be involved before anything changes; and the patient must leave knowing they can change their mind and will not be abandoned. Coerce the patient or ignore a valid refusal and Clinical Management collapses to Clear Fail.
Hold these differentials in your head
Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.
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Capacitous refusal of life-extending treatmentThe core station. The patient understands, retains and weighs the information and communicates a clear, settled choice - often driven by treatment burden and a wish to be at home. Your job shifts from persuasion to respect: acknowledge the decision, offer supportive and palliative alternatives, involve a senior and document.
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Refusal driven by fear or misunderstandingThe patient believes something factually wrong - that treatment is futile, that side effects are permanent, that they are dying imminently. This is reversible: gently correct the misunderstanding with honest information, then re-check the decision. A choice built on wrong facts is not yet an informed refusal.
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Depression clouding judgementLow mood, hopelessness or passive death wishes can masquerade as a considered refusal. Screen mood and suicidal thinking in every refusal station. If depression is driving the decision, the priority becomes assessing and treating the mood disorder before accepting the refusal at face value.
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Delirium or acute confusionFluctuating attention, disorientation or an acute illness affecting cognition means the patient may fail the understand or retain limbs. Capacity is decision-specific and time-specific: treat the reversible cause, reassess later, and in the meantime act in the patient's best interests with senior input.
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Pressure from family or othersA valid decision must be the patient's own. Ask directly, and if possible alone with the patient, whether anyone has influenced them. If the refusal reflects coercion rather than their own settled wish, it is not a free choice and needs senior and possibly safeguarding involvement.
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Jehovah's Witness refusing blood productsA capacitous adult refusing blood on religious grounds must be respected even if death may result. Explore what they will accept (cell salvage, non-blood alternatives), avoid any hint of pressure, involve seniors early and document precisely which products are refused.
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Advance decision to refuse treatment in placeIf the patient now lacks capacity but made a valid and applicable advance decision under the Mental Capacity Act, it is legally binding. Check it covers the current situation and, for life-sustaining treatment, that it is written, signed, witnessed and states it applies even if life is at risk. Escalate to a senior before acting.
Step-by-step approach
This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.
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1. Open without an agenda
The patient can tell within seconds whether you have come to listen or to talk them round. Come to listen.
- Greet, introduce yourself with name and grade, confirm the patient's identity.
- Settle them comfortably - offer a chair, sit at their level, do not stand over the bed.
- Open broadly: "I understand you've been thinking about your treatment. Can you tell me what's on your mind?"
- Then be quiet and let them talk. The opening minute belongs to the patient.
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2. Explore the refusal before any persuasion
Reasons first. You cannot respond to a decision you do not yet understand, and the mark scheme rewards exploration heavily.
- Clarify exactly what they want to stop - one treatment, all treatment, or something in between.
- Ask what the treatment has been like for them: side effects, repeated admissions, time lost.
- Draw out ideas, concerns and expectations - what do they think is happening, what do they fear, what matters most to them now?
- Ask about home, family and what a good day looks like. The real reason for refusal often lives here.
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3. Screen for reversible influences
Before accepting any refusal, check nothing treatable is driving it. This block contains a safety-critical item.
- Screen mood sensitively: "How have your spirits been through all this?"
- Ask directly about hopelessness and any thoughts of harming themselves - a refusal must not be suicidality in disguise.
- Ask about pain and other uncontrolled symptoms that might be colouring the decision.
- Check the decision is their own: "Has anyone been putting pressure on you, or is this entirely your choice?"
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4. Correct misunderstandings honestly
An informed refusal needs accurate facts. Correct errors plainly, without spin in either direction.
- Ask what they understand the treatment is doing before you explain anything.
- If they have a fact wrong - the prognosis, the purpose of a drug, the likelihood of side effects - correct it gently and clearly.
- Do not exaggerate benefits to change their mind or soften risks to seem kind. The GMC expects honesty in both directions.
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5. Weave the four-limb MCA test into the conversation
The Mental Capacity Act test is understand, retain, weigh, communicate. Evidence each limb through natural dialogue - never as a quiz.
- Understand - "Just so I know we're on the same page, what's your understanding of what the treatment does for you?" Their own words evidence this limb.
- Retain - return to a point later in the conversation and see whether they still hold it. You do not need a memory test.
- Weigh - "Talk me through how you've balanced this - what made staying at home matter more than the treatment?" A reasoned trade-off, even one you disagree with, evidences weighing.
- Communicate - a clear, consistent statement of the choice completes the test. Any means of communication counts.
- Remember the Act's starting point: capacity is presumed, and an unwise decision is not evidence of incapacity.
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6. Explain the consequences of refusal without threat
The patient must know what refusal means. Say it once, plainly, and never as leverage.
- State the likely consequences in plain English: what stopping treatment means for the illness, and what could happen with a future complication.
- Check they have understood and can play it back to you.
- No scaremongering, no "you'll die if you do this" delivered as a warning shot. One honest explanation, then move on.
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7. Respect the decision explicitly and offer alternatives
If the patient has capacity, the refusal stands. Saying so out loud is a heavily weighted moment.
- Say it in terms: "This is your decision to make, and I will respect it."
- Offer what they will accept - palliative and supportive care, symptom control, care at home, district nursing.
- Explore middle ground where it exists, such as finishing the current course while planning a different approach.
- Offer to involve family in a joint conversation if the patient wishes, and raise advance care planning supportively.
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8. Involve seniors, document, and keep the door open
You do not change the plan alone at FY2 level, and the patient must never feel abandoned by their choice.
- State that you will discuss with your senior and the relevant team (oncology, palliative care) before anything is stopped.
- Say you will document the conversation and the capacity assessment.
- Safety-net: they can change their mind at any time, nothing is closed off, and the team will keep looking after them either way.
- Summarise, invite final questions, thank them and close warmly.
Common pitfalls
- Equating the refusal itself with lack of capacity. The Mental Capacity Act presumes capacity, and an unwise decision is not evidence it is absent - assess properly before concluding anything.
- Lecturing or persuading before you have explored. Candidates who launch into the benefits of treatment in the first two minutes lose data-gathering and interpersonal marks together.
- Running the capacity test as a quiz: "Can you repeat back what I just said?" Evidence the four limbs through natural conversation instead.
- Forgetting to screen mood and suicidal thinking. A refusal driven by untreated depression is a safety-critical miss.
- Coercing, guilt-tripping or overstating risks to change the patient's mind. Pressure and deception are safety-critical fails, however well-intentioned.
- Accepting the refusal without offering alternatives - palliative care, symptom control and support at home turn "stopping treatment" into a positive plan.
- Not involving a senior. Stopping active treatment on the spot as the junior doctor, without escalation or documentation, fails the management domain.
- Closing without keeping the door open. The patient must hear that they can change their mind and will not be abandoned.
Frequently asked questions
Can a patient really refuse life-saving treatment in PLAB 2?
Yes. Under the Mental Capacity Act 2005, an adult with capacity can refuse any treatment, including treatment that would save or extend their life, and that refusal is legally binding. The station tests whether you assess capacity properly, explain the consequences honestly, and then respect the decision rather than override it. Trying to work around a capacitous refusal is a safety-critical fail.
How do I assess capacity without making it feel like a test?
Fold the four limbs into the conversation you would have anyway. Asking the patient to explain their understanding in their own words covers understanding; returning to a point later checks retention; asking how they balanced the options against what matters to them evidences weighing; and a clear, consistent statement of the choice covers communication. You never need to announce that you are testing them.
What if I think the patient is making the wrong decision?
An unwise decision is not the same as an incapacitous one - the Act says so explicitly. Your role is to make sure the choice is informed, free from pressure and not driven by something reversible like depression or a misunderstanding. Once those are excluded, disagreeing with the outcome does not entitle you to keep pushing. Say plainly that you respect the decision, then focus on what care they will accept.
Do I still need to involve a senior if the patient clearly has capacity?
Yes, and saying so out loud is a weighted item. As the junior doctor you do not stop chemotherapy or discharge a patient off active treatment on your own - you tell the patient you will discuss with your senior and the relevant teams, document the conversation and the capacity assessment, and arrange follow-up. It also reassures the patient the decision is being taken seriously, not just accepted to end the conversation.