# Situation: The nurse works in the mental health program of a provincial hospital that also supports the rural health units in its area. The program follows the Mental Health Act (Republic Act [RA] 11036). A 27-year-old man with schizophrenia was brought in by his father. He is now calm, can state the risks and benefits of a proposed long-acting injectable antipsychotic, and agrees to it. His father says, 'He is mentally ill, so I should be the one to sign.' Whose written consent should the nurse make sure is obtained?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630168  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: The nurse works in the mental health program of a provincial hospital that also supports the rural health units in its area. The program follows the Mental Health Act (Republic Act [RA] 11036).

A 27-year-old man with schizophrenia was brought in by his father. He is now calm, can state the risks and benefits of a proposed long-acting injectable antipsychotic, and agrees to it. His father says, 'He is mentally ill, so I should be the one to sign.' Whose written consent should the nurse make sure is obtained?

## 보기

1. Both, since a client with a mental illness needs a cosigner
2. The psychiatrist's, as the injection is a medical decision
3. The client's own, as he is presumed to have capacity **✔ 정답**
4. The father's, as the relative who brought him in

**정답: 3**

## 해설

RA 11036 presumes that every person has legal capacity irrespective of the nature of a mental health condition, and requires the service user's written informed consent before treatment. Substitute consent through a legal representative applies only when decision-making capacity is impaired, which is not the case here.

## 심화 해설

Core Legal Principle Under RA 11036

The Mental Health Act establishes a presumption of legal capacity for all persons, regardless of whether they have a mental health condition. A diagnosis of schizophrenia does not, by itself, remove a person’s right to make decisions about their own treatment. The law requires the service user’s own written informed consent before any treatment is initiated, including long-acting injectable antipsychotics.

Informed consent is valid only when the person has the capacity to understand the nature, risks, benefits, and alternatives of the proposed treatment, and makes a voluntary choice. In this scenario, the client is calm, can state the risks and benefits of the proposed long-acting injectable antipsychotic, and agrees to it. These are direct clinical indicators that decision-making capacity is intact at this moment. Therefore, the client’s own written consent is the legally required and ethically appropriate consent to obtain.

Why the Father Cannot Sign Instead

Substitute consent through a legal representative is a narrowly defined exception under RA 11036. It applies only when a service user’s decision-making capacity is actually impaired—meaning the person cannot understand relevant information, appreciate the consequences of a decision, or communicate a choice. Key point! The father’s statement that “he is mentally ill, so I should sign” reflects a common misconception that a psychiatric diagnosis automatically equates to incapacity. It does not.

Capacity is decision-specific and time-specific. A person may have impaired capacity during an acute psychotic episode but regain capacity once stabilized. Here, the client is calm and demonstrates understanding of the proposed treatment, which satisfies the functional test of capacity. The mere presence of a family member who brought the client to the facility does not confer legal authority to consent on the client’s behalf.

Clinical Significance of the Client’s Own Consent for LAI Antipsychotics

Long-acting injectable antipsychotics are a major treatment option in schizophrenia, but their use depends heavily on the client’s acceptance of the route of administration. Withdrawal of consent is a recognized outcome in clinical trials comparing long-acting injectable and oral antipsychotics. Meta-analyses of randomized controlled trials have specifically examined the risk of discontinuation due to withdrawal of consent, which reflects the client’s active refusal to continue the assigned treatment.

When a client provides their own informed consent for a long-acting injectable antipsychotic, the treatment alliance is strengthened, and the risk of later withdrawal of consent may be reduced compared to a decision imposed by others. If the father were allowed to sign without the client’s genuine agreement, the client might later refuse subsequent injections, leading to treatment interruption and relapse. The legal requirement for the client’s own consent is therefore not merely a procedural formality—it is clinically protective.

Differential Reasoning for the Options

| Option | Analysis |
| --- | --- |
| 1. Both, since a client with a mental illness needs a cosigner | Incorrect. RA 11036 does not require a cosigner for a person with capacity. Requiring a cosigner would undermine the presumption of capacity and the client’s autonomy. |
| 2. The psychiatrist’s, as the injection is a medical decision | Incorrect. The psychiatrist recommends and administers the treatment, but the decision to accept or refuse belongs to the service user. The psychiatrist’s signature documents the medical order, not the client’s consent. |
| 3. The client’s own, as he is presumed to have capacity | Correct. The client demonstrates capacity and agrees to the treatment. RA 11036 requires the service user’s own written informed consent. |
| 4. The father’s, as the relative who brought him in | Incorrect. Bringing the client to the facility does not make the father a legal representative. Substitute consent is reserved for situations of impaired capacity, which is not present here. |

Watch out! In exam questions involving mental health and consent, the presence of a psychiatric diagnosis is often used as a distractor. Always assess the client’s functional capacity—understanding, appreciation, reasoning, and communication of a choice—rather than assuming incapacity from the diagnosis alone. A calm client who can state the risks and benefits of a proposed treatment and agrees to it has the capacity to provide their own informed consent.

## 임상 시나리오

Consent Under RA 11036Capacity is presumed, not lost by diagnosis
A diagnosis of schizophrenia does not automatically remove the right to consent. The Mental Health Act presumes legal capacity for every person regardless of mental health condition.

Obtain the service user's own written informed consent when the client is calm, can state risks and benefits, and agrees to the proposed long-acting injectable antipsychotic.

CautionSubstitute consent by a legal representative applies only when decision-making capacity is actually impaired. A family member's statement that the client is mentally ill is not grounds to sign for him.

## 핵심 개념

- **Presumption of legal capacity** — RA 11036 principle that every person is assumed capable of making decisions regardless of mental health condition.
- **Informed consent** — Voluntary agreement to treatment after understanding nature, risks, benefits, and alternatives.
- **Substitute consent** — Consent given by a legal representative only when the service user's decision-making capacity is impaired.
- **Decision-making capacity** — Ability to understand relevant information, appreciate consequences, and communicate a choice.
- **Long-acting injectable antipsychotic** — Antipsychotic medication administered by injection with prolonged duration of action.

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