CCFP priority topic 66 of 105
Mental Competency on the CCFP exam
8 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 22, 2026.
What the exam tests
Key features
The CFPC’s 8 key features for Mental Competency. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 8
Capacity for this decision
When an illness may impair thinking, judge capacity for the specific choice at hand.
CFPC skill Clinical reasoning, selectivity, communication, professionalismPhase History, diagnosis, investigation, treatment, referralSources CMPA
On the exam
A man with dementia must decide on an amputation, and his daughter wants it. Expect a short menu (pick several from a list).
Pick how to start the assessment.
Common mistakes
Taking the daughter's view because she holds power of attorney. Her agreement with the surgeon says nothing about whether he can decide for himself.
Approach
- Capacity belongs to one decision at one time. A patient may be unable to decide on one treatment yet able to decide on another.
- Tell him why you are asking these questions, and ask if you may go ahead.
- Fix what blocks talking first: hearing, vision, language or speech. Use an interpreter if needed.
- Family may help him talk, with his permission. They must not answer for him.
- His daughter decides only if he is found unable to. Until then, her wish does not settle it.
- Bring in others when unsure: psychiatry if depression or psychosis may drive the choice, or a second assessor.
Key feature 2 of 8
Subtle decline
When a well patient starts slipping at home, check thinking and daily function, and refer when needed.
CFPC skill Clinical reasoning, communication, selectivityPhase Physical, investigation, referral
On the exam
Her son says she repeats questions and has missed pills. Expect a short menu (pick several from a list) of assessments.
Pick the assessments to do today.
Common mistakes
Reassuring the son because she seems fine in the office. Or naming dementia from one test score without asking how she manages day to day.
Approach
- Get the story from someone who sees her every day, with her consent.
- Do a brief office test of thinking and memory.
- Ask how she manages pills, money, cooking, shopping, the phone and getting around.
- Look for causes you can treat: a new drug, low mood, poor hearing or poor vision.
- Ask about driving and safety at home.
- Refer to a memory clinic, geriatrics or occupational therapy when the picture is unclear.
Key feature 3 of 8
High-stakes choices
When a patient faces a weighty treatment choice, ask yourself whether capacity needs checking.
CFPC skill Clinical reasoningPhase Hypothesis generation, treatmentSources CMPA
On the exam
A man with dementia refuses an amputation his family wants. Expect one best answer.
Pick what decides whether his refusal stands.
Common mistakes
Doubting his judgment in general because he refuses. A refusal proves nothing; his capacity for this choice decides it.
Approach
- Think of capacity at every big choice: surgery or not, resuscitation, a move into care.
- A refusal does not prove incapacity. Capable patients may refuse treatment that is clearly needed.
- Do not judge whether you agree with the choice. Judge whether he can understand and weigh it.
- A signed form only records agreement. The consent is the discussion.
- The physician who will do the procedure is responsible for consent. Share what you know about his thinking.
- Record the talk: what you explained, his questions, and your view of his capacity.
Key feature 4 of 8
The four abilities
Test whether the patient can grasp the facts, apply them to themself, weigh them and decide.
CFPC skill Clinical reasoningPhase Diagnosis, investigationSources CMPA
On the exam
A man with dementia scored 17 on the Montreal Cognitive Assessment (MoCA) and must decide on an amputation. Expect a short menu (pick several from a list) of questions.
Pick the questions that test capacity.
Common mistakes
Asking the date, a clock drawing or recall of five words. He can miss the date yet grasp the operation, or score well yet not apply it to himself.
Approach
- Explain the problem, the treatment, other choices, and what happens with no treatment. Then ask open questions.
- Use his own words. If an answer shows a gap, explain again and check again.
- Clear answers to open questions count. Needing repeated yes-or-no prompts leaves you unsure.
- Look for depression or psychosis shaping the choice: hopelessness, guilt, or a belief that someone means harm.
- Depression or psychosis alone does not settle it. Decide whether it is shaping this choice.
- Write down his exact answers. If you stay unsure, lean toward capable: people are presumed capable.
| Ability | Ask | Not enough |
|---|---|---|
| Understand | What is wrong? What is the treatment? What else could you do? Can you say no? | Nodding to "Do you understand?" |
| Appreciate | What could happen to you if you have it? If you don't? | Knowing the facts but denying they apply to him |
| Reason | Why did you decide this way? | A reason driven by hopelessness or a false belief |
| Choose | What have you decided? | A different answer each time you ask |
Key feature 5 of 8
Cause, course, recheck
Once capacity is impaired, work out how bad, how fixable and how lasting it is, then plan rechecks.
CFPC skill Clinical reasoningPhase History, diagnosisSources CMPA, Choosing Wisely Canada
On the exam
New confusion a week after a new drug, in a man with dementia in long-term care. Expect a short menu (pick several from a list).
Pick the next steps, and what to skip.
Common mistakes
A urine test for his old bladder urgency, or a new MoCA to compare. Neither explains a change that began after a new drug.
Approach
- Ask when the change began, and what drug or illness came just before it.
- If he seems incapable, look first for causes you can treat, such as drug toxicity. Then assess again.
- Capacity can change over time. Reassess it as he changes.
- In long-term care, no urine dip or culture without clear signs of bladder infection. Bacteria without symptoms are common.
Key feature 6 of 8
Refuses assessment
When a patient will not take part in a capacity check, record it, keep caring, and come back to it.
CFPC skill Communication, professionalism, clinical reasoning, selectivityPhase Treatment, hypothesis generation, follow-upSources CMPA
On the exam
A man just out of delirium will not discuss his planned amputation. His foot is stable. Expect one best answer.
Pick the best next step.
Common mistakes
Turning to his daughter or cancelling surgery now. Refusing to talk shows neither capacity nor its lack. Once infection spreads, waiting is wrong too.
Approach
- Record that he declined, and what you explained.
- Keep giving care he accepts. Refusing one thing is not refusing all care.
- Set a time to try again. A follow-up visit can reopen the talk.
- Ask why. His reasons may point to another way forward.
- If waiting would cause harm, you still must decide on his capacity first. Only if he is found incapable does his substitute decision-maker decide. Follow your province's process.
- A substitute follows wishes he voiced while capable, then his best interests.
- Treat without consent only for severe suffering or an imminent threat to life or health, when no one can consent in time.
| Situation | Do | Avoid |
|---|---|---|
| Stable, no harm from waiting | Record the refusal, keep caring, plan a recheck | The substitute deciding now |
| Harm builds while you wait | Decide on his capacity; if incapable, involve the substitute | Waiting until he agrees to talk |
| Emergency, no one can consent in time | Do only what is needed now; respect known wishes | Treating beyond the emergency |
Key feature 7 of 8
Involuntary treatment
When someone must be held or treated against their will, start the legal process and support everyone through it.
CFPC skill Communication, professionalism, patient-centred approachPhase Treatment, follow-upSources CMPA
On the exam
A woman with psychosis says a neighbour is poisoning her and threatens him. Expect a short menu (pick several from a list).
Pick the steps to take today.
Common mistakes
Signing for assessment without examining her yourself. Or assuming the hold lets you treat her without consent: being held does not by itself remove capacity, and provinces differ.
Approach
- Know your province's mental health law. Most require a mental disorder plus danger to self or others. Some also allow likely serious decline.
- Examine the patient yourself, recently, before you sign an application for psychiatric assessment.
- A psychiatrist then examines her within a strict time limit and decides on a certificate. Certificates must be renewed.
- Unsure the criteria are met? Talk to a colleague.
- Record your findings and your reasons for the certificate.
- Tell her and her family why, what happens next, and that you remain her family doctor. In some provinces she can ask a review board to look at it.
- A held patient may still be capable of treatment decisions. Assess that separately.
Key feature 8 of 8
Driving and lost freedoms
When a rule takes away a freedom like driving, plan for the patient's grief and for your bond.
CFPC skill Patient-centred approachPhase TreatmentSources CMPA
On the exam
A man with dementia must stop driving and is angry. Expect a short menu (pick several from a list) of steps.
Pick what to do and say.
Common mistakes
Reporting without telling him, or not reporting because he promises to stop. One costs his trust; the other risks his safety and others'.
Approach
- Talk with him before you report. Warn him not to drive and explain the risk.
- Explain your legal duty. The licensing body, not you, decides on the licence.
- Where reporting is required, report even if he says he will stop.
- Record your assessment, the advice you gave and your reasons for reporting.
- Expect anger and grief at the lost freedom. Ask how he will get around, and who can help.
- If you expect an angry response, have a colleague or staff member join you.
- Book a follow-up to talk about the loss and keep the relationship.
| Where | Duty | Note |
|---|---|---|
| Most provinces and territories | Must report | Even if the patient says they will not drive |
| British Columbia | Must report if the patient keeps driving after your warning | Warn first |
| Alberta, Québec, Nova Scotia | May report | Québec: must report a patient who is a serious risk and keeps driving after a warning |
| Ontario | Must report listed conditions; may report others | Check the ministry's list |
Flashcards
Answer it first, then check.
KF 1He could not consent to surgery last month. Is he unable to consent now?
Not necessarily. Capacity is judged for each treatment at each time, not across the board. Source: CMPA
KF 2Her son reports missed pills and repeated questions. What two things do you assess?
Her thinking, with a brief office test, and her daily function: pills, money, cooking, shopping.
KF 3He signed the consent form. Is consent settled?
No. The form only records agreement. Consent is the discussion, with capacity for this choice. Source: CMPA
KF 4His MoCA is 17. Does that mean he cannot consent?
No. Ask whether he understands this choice and sees what it means for him. Source: CMPA
KF 5A long-term care resident with new confusion has no urinary symptoms. Urine culture?
No. Without clear signs of bladder infection, skip the dip and culture. Bacteria without symptoms are common. Source: Choosing Wisely Canada
KF 6He will not discuss surgery, and his foot is stable. What now?
Record the refusal, keep caring for his foot, and set a time to try again. Source: CMPA
KF 7She is held under mental health law. Can she refuse treatment?
It depends on the province. Being held does not by itself remove capacity, so assess it and check your province's law. Source: CMPA
KF 8He promises to stop driving. Do you still report him?
In most provinces, yes. The duty stands even if the patient says they will not drive. Source: CMPA
FAQ
Which legal test of capacity does the exam use?
The shared Canadian core: can the patient understand the facts of this choice, and see what they mean for them? Provinces word it differently, so marks go to the approach.
Can a child consent to treatment?
Often, yes. Maturity counts, not age. In Québec, a parent consents for a child under 14.
Does a low MoCA score mean the patient cannot consent?
No. The MoCA measures thinking in general. Capacity is about one decision. A low score is a reason to assess with care, not a verdict on the choice.
Who assesses capacity before surgery?
The physician who will do the procedure is responsible for consent, and capacity is part of it. As family doctor, you share what you know about the patient's usual thinking.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 22, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Consent and capacity resourcesCMPA
- Choosing Wisely recommendationsChoosing Wisely Canada