A frail 79-year-old who declines surgery for a facial tumour, and a daughter who disagrees

Capacity is decision-specific and time-specific. I would be assessing her ability to decide about treatment of this facial lesion, not whether she can manage her affairs. An MMSE of 22 does not answer the question.

The four-part test (Mental Capacity Act 2005 in England and Wales):

1. Can she understand the relevant information - the diagnosis, the options (surgery, radiotherapy, biopsy only, active monitoring with wound care), and the consequences of refusing?
2. Can she retain it long enough to decide?
3. Can she weigh it and use it - does she compare options, or is her refusal a fixed, unconsidered position?
4. Can she communicate her decision by any means?

What would make me defer rather than conclude:

• She is unwell with a treated urinary tract infection - delirium on top of mild cognitive impairment is very plausible and is reversible. Deferring a few days costs little except time.
• She cannot hear me properly. Without her hearing aid, any assessment of her understanding is invalid. I would arrange a quiet room, her aid, an interpreter if needed, and a written summary of options in large print.
• Time of day, pain, and whether her daughter is dominating the consultation all matter. I would see her alone or with an independent advocate present, and repeat the assessment on a second occasion.

If, after all that, she can explain in her own words that she knows the lesion may grow or spread but that she does not want surgery on her face, she has capacity and her refusal is binding. Documenting her actual words is far stronger evidence than writing 'has capacity'.

I accept the refusal, document it, and offer a plan that respects it while reducing harm.

Options to put to her:

• Radiotherapy - no cutting, but typically multiple daily visits over several weeks, which is a real burden for a woman with carers twice a day, and late effects on the cheek are possible. If she will accept it, it is a genuine alternative to surgery.
• Biopsy only or curettage - a smaller procedure; a biopsy is worth offering because if this is a squamous cell carcinoma rather than a basal cell carcinoma, the prognosis and the options change, and she may find a small diagnostic procedure acceptable even if excision is not.
• Topical therapy - imiquimod or 5-fluorouracil are only sensible for superficial basal cell carcinoma, not for a 2.4 cm ulcerated nodular lesion; I would not oversell them.
• Active wound care - emollient, non-adherent dressing, management of bleeding, and review. This is a legitimate plan, not a failure of care, and should be written down as such.
• Safety-netting and a route back: if the lesion becomes painful, malodorous or bleeds uncontrollably, she can return and we revisit.

The daughter:

• Acknowledge her distress and her fear of watching the lesion grow, and thank her for bringing her mother.
• Explain, without being condescending, that her mother has demonstrated capacity and that the decision is hers; I cannot 'make her see sense'.
• Confirm with the patient's consent what I can share with the daughter, and offer the daughter a separate conversation about what to expect, wound care and carer support.
• If the daughter continues to push for treatment against her mother's wishes, this becomes a safeguarding matter about potential coercion, and I would involve the appropriate adult safeguarding route while keeping the relationship as constructive as possible.

Anticoagulation: apixaban does not need stopping for a biopsy or minor procedure; for any bleeding I would use local pressure and, if truly necessary, discuss peri-procedural management with the anticoagulation team rather than stopping it unilaterally and risking a stroke.

Process:

1. Record which specific element of the test she fails, in her own words as far as possible.
2. Establish whether there is a valid advance decision refusing treatment, or an attorney or deputy with authority for health and welfare; the daughter holds neither. Without either, the decision is a best-interests decision made by the treating clinician, after consultation.
3. Consult the daughter and the carers about her values, her previous views about her face and about hospitals, her tolerance of dressings, and what matters to her.
4. Hold a best-interests meeting with dermatology, oncology/radiotherapy, the GP and the family, and consider a second clinical opinion for a decision of this consequence.
5. Choose the least restrictive option that achieves the purpose, and record the reasoning, not just the conclusion.
6. Consider an independent mental capacity advocate if there is no one appropriate to consult, and consider deprivation-of-liberty issues if she needs to be in hospital or a care home for treatment.

What drives the choice between surgery and radiotherapy:

• Life expectancy and frailty - a woman with multiple comorbidities and limited mobility may gain little from a treatment requiring daily radiotherapy attendances over weeks.
• Histology - a biopsy is even more important now; a basal cell carcinoma can reasonably be managed conservatively in a frail patient, whereas a squamous cell carcinoma or a poorly differentiated tumour behaves differently and may justify more intervention.
• Logistics and distress - surgery can often be done in one day under local anaesthetic; radiotherapy requires repeated hospital travel with carers, which may be more burdensome than an operation.
• Cosmesis and late effects - radiotherapy to the cheek can give good early cosmetic results but poorer long-term tissue quality in someone who might live another decade.
• Anticoagulation and anaesthetic risk - apixaban with AF means a considered perioperative plan, but it is not a bar to local excision.
• Her known wishes, even if she now lacks capacity to decide, carry real weight and should shape the recommendation.