Wirral Community NHS Trust Consent Form 4
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1 Wirral Community NHS Trust Consent Form 4 Form for adults who are unable to Consent to investigation or treatment Patient details (or pre-printed label) Patient's surname/family name Patients first names Date of birth. Responsible health professional.. Job title. NHS number (or other identifier).. Male Female Special requirements (E.g. other language/other communication method) To be retained in patient's notes
2 Patient identifier/label All sections to be completed by health professional proposing the procedure A Details of procedure or course of treatment proposed. (NB see guidance to health professionals overleaf for details where court approval must first be sought) B Assessment of patient's capacity I confirm that the patient lacks capacity to give or withhold consent to this procedure or course of treatment because: The patient is unable to comprehend and retain information material to the decision; and/or The patient is unable to use and weigh this information in the decision-making process; or The patient is unconscious Further details (excluding where patient unconscious): for example how above judgements reached; which colleagues; what attempts made to assist the patient make his or her own decision and why these were not successful. C Assessment of patient's best interests To the best of my knowledge, the patient has not refused this procedure in a valid advance directive. Where possible and appropriate, I have consulted with colleagues and those close to the patient, and I believe the procedure to be in the patient's best interests because: (Where incapacity is likely to be temporary, for example if patient unconscious, or where patient has fluctuating capacity) The treatment cannot wait until the patient recovers capacity because: D Involvement of the patient's family and others close to the patient The final responsibility for determining whether a procedure is in an incapacitated patient's best interest lies with the health professional performing the procedure. However, it is good practice to consult with those close to the patient (e.g. spouse/partner, family, carer, supporter or advocate) unless you have good reason to believe that the patient would not have wished particular individuals to be consulted, or unless the urgency of their situation prevents this. "Best interests" go far wider than "best medical
3 interest", and include factors such as the patient's wishes and beliefs when competent, their current wishes, their general well-being and their spiritual and religious welfare. (To be signed by a person close to the patient, if they wish) I/We have been involved in a discussion with the relevant health professionals over the treatment of (Patient s name). I/We understand that he/she is unable to give his/her consent, based on the criteria set out in this form. I/We also understand that treatment can lawfully be provided if it is in his/her best interests to receive it. Any other comments (including concerns about decision) Name Relationship to patient Address (if not the same as patient) Signature Date.. If a person close to the patient was not available in person, has this matter been discussed in any other way (e.g. over the telephone?) Yes No Details: Signature of health professional proposing treatment The above procedure is, in my clinical judgement, in the best interests of the patient, who lacks capacity to consent for himself or herself. Where possible and appropriate I have discussed the patient's condition with those close to him or her, and taken their knowledge of the patient's views and beliefs into account in determining his or her best interests. I have/have not sought a second opinion. Signature Date Name (PRINT).. Job title
4 Where second opinion sought, s/he should sign below to confirm agreement: Signature Date Name (PRINT).. Job title.
5 Guidance to health professionals (to be read in conjunction with consent policy) This form should only be used where it would be usual to seek written consent but an adult patient (18 or over) lacks capacity to give or withhold consent to treatment. If an adult has capacity to accept or refuse treatment, you should use the standard consent form and respect any refusal. Where treatment is very urgent (for example if the patient is critically ill), it may not be feasible to fill in a form at the time, but you should document your clinical decisions appropriately afterwards. If treatment is being provided under the authority of Part IV of the Mental Health Act 1983, different legal provisions apply and you are required to fill in more specialised forms (although in some circumstances you may find it helpful to use this form as well). If the adult now lacks capacity, but has clearly refused particular treatment in advance of their loss of capacity (for example in an advance directive or "living will"), then you must abide by that refusal if it was validly made and is applicable to the circumstances. For further information on the law on consent, see the Department of Health's Reference guide to consent for examination or treatment ( When treatment can be given to a patient who is unable to consent For treatment to be given to a patient who is unable to consent, the following must apply: the patient must lack the capacity ('competence') to give or withhold consent to this procedure AND The procedure must be in the patient's best interests. Capacity A patient will lack the capacity to consent to a particular intervention if he or she is: unable to comprehend and retain information material to the decision, especially as to the consequences of having, or not having the intervention in question; and/or Unable to use and weigh this information in the decision-making process. Before making a judgement that a patient lacks capacity you must take all steps reasonable in the circumstances to assist the patient in taking their own decisions (this will clearly not apply if the patient is unconscious). This may involve explaining what is involved in very simple language, using pictures and communication and decision-aids as appropriate. People close to the patient (spouse/partner, family, friends and carers) may often be able to help, as may specialist colleagues such as speech and language therapists or learning disability teams, and independent advocates or supporters.
6 Capacity is 'decision-specific': a patient may lack capacity to take a particular complex decision, but be quite able to take other more straightforward decisions or parts of decisions. Best interests A patient's best interests are not limited to their medical interests. Other factors which form part of the best interest s decision include: the wishes and beliefs of the patient when competent their current wishes their general well-being their spiritual and religious welfare Two incapacitated patients, whose physical condition is identical, may therefore, have different best interests. Unless the patient has clearly indicated that particular individuals should not be involved in their care or unless the urgency of their situation prevents it you should attempt to involve people close to the patient (spouse/partner, family and friends, carer, supporter or advocate) in the decision-making process. Those close to the patient cannot require you to provide particular treatment which you do not believe to be clinically appropriate. However they will know the patient much better than you do, therefore are likely to be able to provide valuable information about the patient's wishes and values. Second opinions and court involvement Where treatment is complex and/or people close to the patient express doubts about the proposed treatment, a second opinion should be sought, unless the urgency of the patient's condition prevents this. Donation of regenerative tissue such as bone marrow, sterilisation for contraception purposes and withdrawal of artificial nutrition or hydration from a patient in PVS must never be undertaken without prior High Court approval. High Court approval can also be sought where there are doubts about the patient's capacity and best interests.
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