Consent and shared decision-making

Why this matters on day one

Montgomery changed the legal test from what a reasonable doctor would disclose to what a reasonable patient in this position would want to know. That makes exploring the individual patient's priorities a legal requirement, not just good manners.

The sequence

1. 1Capacity first. Presume it. Assess only if there is reason to doubt. Understand, retain, weigh, communicate — all four, for this decision, at this time.
2. 2Explore before explaining. Ideas, concerns and expectations. What matters to them — function, independence, being home, avoiding hospital? The material risks are the ones that matter to THIS patient, which you cannot know without asking.
3. 3Present the real options. Including doing nothing. Benefits, risks, likelihood, and the consequences of each in terms they can use. Use absolute numbers, not relative risk.
4. 4Check and document. Ask them to tell you back. Document what you discussed, the specific risks named, the alternatives, questions asked, and the decision. A signed form is evidence a conversation happened, not that it was adequate.
5. 5Respect refusal. A capacitous adult may refuse anything, including life-saving treatment, and need not justify it. An unwise decision is not incapacity.

What goes wrong

• Taking consent for a procedure you cannot perform and do not understand.
• Reciting a standard risk list without finding out what this patient cares about.
• Treating the signature as the consent.
• Concluding a patient lacks capacity because they disagree with you.
• Not offering "no treatment" as a genuine option.