Advance Care Planning: Advance Statements including Advance Decisions to Refuse Treatment (ADRT), & Lasting Powers of Attorney (LPA) 1.

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1 SECTION: 1 PATIENT CARE POLICY AND PROCEDURE NO: 1.30 NATURE AND SCOPE: SUBJECT: POLICY - TRUSTWIDE ADVANCE CARE PLANNING: ADVANCE STATEMENTS INCLUDING ADVANCE DECISIONS TO REFUSE TREATMENT (ADRT), AND LASTING POWERS OF ATTORNEY (LPA) This policy sets out structures to enable staff to support patients in future care planning and support those who have already set out their wishes for a time when they may lack capacity. DATE OF LATEST RATIFICATION: FEBRUARY 2018 RATIFIED BY: EXECUTIVE LEADERSHIP TEAM IMPLEMENTATION DATE FEBRUARY 2018 REVIEW DATE: JANUARY 2021 ASSOCIATED TRUST POLICIES AND PROCEDURES: Consent to Examination or Treatment Mental Capacity Act ISSUE 7 FEBRUARY 2018

2 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST ADVANCE CARE PLANNING: ADVANCE STATEMENTS AND ADVANCE DECISIONS TO REFUSE TREATMENT& LASTING POWERS OF ATTORNEY 1.0 Introduction 2.0 Policy Principles 3.0 The Mental Capacity Act 2005 CONTENTS 4.0 Advance Statements (Statements of Wishes and Feelings, Mental Health Act Code of Practice) 5.0 Advance Decisions to Refuse Treatment (ADRT) 6.0 Advance Decisions to Refuse Life-Sustaining Treatment. 7.0 Lasting Powers of Attorney (LPA) 8.0 The Mental Health Act 1983 and ADRTs 9.0 Source Documents 10.0 Duties 11.0 Training 12.0 Target Audience 13.0 Equality Impact Assessment 14.0 Review Date 15.0 Consultation 16.0 Monitoring Compliance 17.0 Legislation Compliance 18.0 Champion and Expert Writer Appendix 1 Appendix 2 Appendix 3 Process for Resolution of Conflict Where Donees of LPAs Do Not Agree to a Place of Discharge Which the Trust Deems Suitable Equality Impact Assessment Screening Tool Record of Changes ISSUE 7 FEBRUARY

3 NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST ADVANCE CARE PLANNING: ADVANCE STATEMENTS TO INCLUDE ADVANCE DECISIONS TO REFUSE TREATMENT (ADRT), AND LASTING POWERS OF ATTORNEY 1.0 INTRODUCTION 1.1 It is a general principle of law and medical practice that people have a right to consent to or refuse treatment. This general rule applies to all patients who have capacity to make decisions about a particular treatment regime, including in some circumstances those detained under the Mental Health Act 1983 ( the MHA ) 1.2 Adults have the right to say in advance that they want to refuse treatment if they lose capacity in the future, or make arrangements for someone else to make decisions for them, in the event that they lose capacity. 1.3 This policy aims to set out the legal principles concerning the key instruments which can be used by patients to ensure their wishes are met in the future, i.e. advance statements which may include Advance Decisions to Refuse Treatment (ADRT), and Lasting Powers of Attorney (LPA). 1.4 Advance care planning (ACP) is a voluntary process of discussion about future care between an individual and their care providers, irrespective of discipline. If the individual wishes, their family and friends may be included. It is recommended that with the individual s agreement this discussion is documented, regularly reviewed, and communicated to key persons involved in their care. An ACP discussion might include: An advance statement An Advance Decision to Refuse Treatment (ADRT) A Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision, or other types of decision, such as appointing a Lasting Power of Attorney. 1.5 An advance statement concerns an individual s choices about what they would like to happen should they come to lack capacity. An advance statement can include preferences about medical treatment (such as what works best for the person), or preferences about any other aspect of personal care or financial decision making. It is relevant (but not legally binding) in ascertaining the individual s best interests, when they have lost capacity to make decisions. 1.6 An Advance Decision to Refuse Treatment (ADRT) may be part of an advance statement. An ADRT concerns only the anticipatory refusal of specific medical treatment in specified circumstances at a time when a person lacks capacity to make that decision. This mechanism allows individuals to refuse medical treatment. It does not allow individuals to demand treatment, nor to refuse basic care. 1.7 A Lasting Power of Attorney (LPA) is a method by which an individual (the donor) can appoint someone to make decisions (the donee) regarding personal welfare (including medical care) and/or financial matters (known as property and affairs). (1.1), and the donee must take into account advance statements (1.2) in their assessment of the individual s best interests. 1.8 All three of these methods provide important opportunities for patients to express their choice, preferences and requirements in respect of the care and treatment they will receive in the future when they lack capacity. As such they are an important part of the modern partnership that needs to exist between patients/their representatives and those providing their care. 2.0 POLICY PRINCIPLES ISSUE 7 FEBRUARY

4 2.1 Patients must be offered a formal opportunity to voluntarily take an active part in planning for their care. 2.2 This will contribute to a balanced partnership between individuals and health and social care professionals. Openness and a willingness to discuss the advantages and disadvantages of particular treatment options will facilitate the development of trust and mutual understanding this will also enable all parties to avoid conflicts and treatment disputes in the future. 2.3 Modern health services promote partnership between individuals who use the services and health professionals. This partnership aims to improve the experience for all involved and potential outcomes. 3.0 THE MENTAL CAPACITY ACT The Mental Capacity Act ( MCA ) provides a statutory framework for making decisions about the care and welfare for people who permanently or temporarily lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they may lack capacity in the future. 3.2 The legal framework provided by the MCA is supported by a Code of Practice ( The Code ), which provides guidance and information about how the MCA works in practice. Those clinicians who make decisions in relation to those who lack capacity must have regard to the Code. 4.0 ADVANCE STATEMENTS (Statements of Wishes and Feelings, Mental Health Act Code Of Practice 2015 Chapter and Mental Capacity Act Code Of Practice 5.0) 4.1 An advance statement concerns an individual s choices about what they would like to happen should they lose capacity. A statement can include preferences about medical treatment (such as what works best for the person), or preferences about any other aspect of personal care or financial decision making including preferred place of care or death. The advance statement may include refusal of medical treatment. NOTE: Such refusal has the status of an ADRT and is subject to the law relating to ADRTs (see below). Sometimes practitioners will conclude that an ADRT does not exist, or is not valid and/or applicable but that an expression of the person s wishes does exist and/or has been recorded in writing. This will inform any best interests decision that needs to be made. 4.2 Advance statements enable the patient to express views now about their care or treatment at a time when they may lack capacity. For example, an advance statement may contain information about what treatment works well for a patient and what treatment they might like to have. It identifies views and preferences on a large range of medical, social care and personal issues which must be taken into account where appropriate to the decision being made about the best interests of the patient. This may include cultural and religious beliefs. It can also be specified who should be contacted and given information. Another example may include instructions about the care of pets. A statement does not have to be set out on formal paperwork although the Trust does provide access to an advance statement document in its mental health recovery pack, or the Preferred Priorities for Care document which could be used. In addition there are advance statement documents which the Trust provides which may be useful for people who have a learning disability both of which are available on the Trust Intranet The law requires that advance statements are taken into account by decision makers on behalf of someone who lacks capacity. Advance statements (other than statements that amount to an ADRT) are not legally binding although service providers should make every ISSUE 7 FEBRUARY

5 effort to comply with a reasonable request and there must be a note in the running records as to why this may not be possible if the resulting action does not concur with the advance statement. This must then be discussed with the patient when they regain capacity. 4.4 It is important to establish with patients whether or not they wish to make an advance statement (the process is entirely voluntary) and if they do to ensure that this is clearly recorded in the person s shared health and social care record. This should become a routine procedure of care planning and reviewed regularly. 4.5 Trust employees are referred to paragraphs in Chapter 5 of the Mental Capacity Code of Practice and Chapter 9 of the Mental Health Act Code of Practice 2015 for further guidance in relation to advance statements. 5.0 ADVANCE DECISIONS TO REFUSE TREATMENT (ADRT) (Mental Capacity Act Code of Practice Chapter 9 and Mental Health Code of Practice 2015 Chapter ) 5.1 An advance decision to refuse treatment (ADRT) can be made by those aged 18 or over, who have the capacity to do so. 5.2 An ADRT concerns the anticipatory refusal of specific medical treatment at a time when a person lacks capacity to make that decision. This method allows individuals to refuse medical treatment. It does not allow individuals to demand specific treatment, nor to refuse actions that are needed to keep them comfortable (also referred to as basic care ). In addition, nobody can ask for and receive procedures that are against the law (for example, help with committing suicide). The statutory framework for ADRTs is in sections 24 to 26 of the MCA, supported by Chapter 9 of the MCA Code. 5.3 It is important for practitioners to bear in mind the following key points with regard to ADRTs: 5.4 A valid and applicable ADRT will normally be binding if it meets the MCA requirements (see paragraphs 5.6 and 6.1 below). Where a patient is detained under the Mental Health Act this rule is subject to the provisions of that Act where the treatment refused is for a mental disorder (see paragraph 8 below). 5.5 An ADRT does not need to be evidenced in writing unless it relates to refusal of life sustaining treatment. It is recommended that an ADRT should be recorded in writing wherever possible however. An ADRT can be withdrawn at any time, either orally or in writing, while the patient still has the capacity to do so. An oral withdrawal of an ADRT should be clearly documented in the patient s health and social care records. 5.6 An ADRT: Must state precisely what treatment is to be refused (which can be stated in layperson s terms). A statement giving a general desire not to be treated is not enough. Must set out the circumstances when the refusal should apply. It is helpful to include as much detail as possible. Will only apply at a time when the person lacks capacity to consent to or refuse the specific treatment and all of the named circumstances are satisfied. 5.7 A patient can be treated where a clinician is not satisfied that the ADRT exists and/or is both valid and applicable. Where there is some doubt about the validity or applicability of an ADRT (i.e. the decision one way or the other is finely balanced) or there is a dispute between the patient s family and the treating clinician, legal advice will need to be sought pending an application to the Court of Protection. Alternatively, where there is a valid and applicable ADRT relating to treatment for mental disorder, assessment and detention under the Mental Health Act may be appropriate. In cases of uncertainty when emergency ISSUE 7 FEBRUARY

6 treatment is required the clinician should proceed with treatment and carefully document their actions. 5.8 An ADRT must be recorded prominently in the patient s health and social care record and at care reviews. The existence of an ADRT and details of its contents must be recorded on the appropriate patient data system such as SystmOne or RIO where the data system allows. There is no particular format that must be used (i.e. no formal paper work). A patient may have set out an ADRT on note paper or another non formal format, this is acceptable. It is the content that is important rather than the appearance. The Trust also provides accessible ADRT documentation for - but not limited to - patients with a learning disability who have capacity at the time when the ADRT is created To establish whether an advance decision is valid and applicable, practitioners must try to find out if the person: Has done anything that clearly goes against their advance decision. Has withdrawn their decision. Has subsequently conferred the power to make that decision on an attorney (via a LPA), or Would have changed their decision if they had known more about the current circumstances An ADRT can be altered, either orally or in writing. If the patient wishes to amend an existing ADRT to include a refusal of life-sustaining treatment, that amendment must comply with the requirements for ADRTs relating to life-sustaining treatment The term patient in this context, includes all those above the age of 18 years who may be patients of the Trust or may describe themselves as patients or clients. This includes older people - for example over the age of 65 years - and those with a learning disability An ADRT will override any consent given by the donee of a Personal Welfare Lasting Power of Attorney if the Lasting Power of Attorney document was made before the advance decision. Equally, if a Personal Welfare Lasting Power of Attorney was created after an ADRT, the advance decision would be invalid if the attorney was granted the power to make the decision relating to that treatment. In this situation, the Attorney can choose not to follow the advance decision Clinicians involved with the patient may comment on the person s capacity to make an ADRT if asked to do so. A clinician may, if asked to do so, sign the ADRT as a witness to the patient s signature In contentious cases, the Trust practitioner may not wish to act as a witness in order to ensure that a clear line is drawn between what the patient wishes to do, and the Trust feels is appropriate. 6.0 ADVANCE DECISIONS RELATING TO LIFE-SUSTAINING TREATMENT, 6.1 If the ADRT relates to life-sustaining treatment, it must: Be in writing. o This need not be the person making the ADRT. It can be written by someone else under the direction of the patient who must sign it and be witnessed by another person. All persons must be in the room at the same time. ISSUE 7 FEBRUARY

7 o A photocopy or electronic copy of the signed document is acceptable. Be witnessed and signed by that witness. State clearly that the decision applies even if life is at risk. 6.2 Some practitioners may disagree in principle with a patient s decision to refuse lifesustaining treatment. They do not have to act against their beliefs. But they must not simply abandon patients or act in a way that adversely affects their care. 6.3 ADRTs relating to life sustaining treatment are most applicable to physical healthcare treatment such as, but not limited to, cardio pulmonary resuscitation, chemotherapy, antibiotics, artificial nutrition/hydration. Where such valid and applicable ADRTs have been written when the patient has capacity they are likely to be binding notwithstanding any later contact with mental health services. Special care must be taken to ensure that they are not a driven by a manifestation of a mental disorder such as a desire to self-harm. 7.0 LASTING POWERS OF ATTORNEY (LPA) MCA Code Chapter A Lasting Power of Attorney ( LPA ) is a legal process by which an individual (the donor) can formally appoint someone else to make decisions (the donee/attorney) regarding personal welfare (including medical care) and/or financial matters (property and affairs). An LPA will be drafted when the patient has capacity and can be registered at any time before they are relied upon by the donee/attorney. 7.2 The document may also indicate what practical arrangements the individual may wish to have addressed if admitted to hospital, for example care of dependents, safeguarding their home and possessions. 7.3 The opportunity to execute an LPA is open to individuals aged 18 or above including older people and those with a learning disability (who have capacity at the time the power is executed). The patient may at any time, when he / she has capacity to do so, revoke the LPA. The LPA attorney must exercise his/her powers under the LPA subject to the best interests requirements of the MCA. A personal welfare attorney cannot refuse consent to life-sustaining treatment unless such authority is expressly given. The attorney can only exercise personal welfare decisions when the patient lacks capacity. 7.4 Patients should routinely be asked if they have arranged an LPA. This should be noted on the health and social care records and recorded in RIO/SystmOne. Information as to the nature of the LPA must be included. It is important to see a copy of the document and know whether the Lasting Power of Attorney has been registered with the Office of the Public Guardian (OPG). Registration could take a number of weeks - an unregistered Lasting Power of Attorney is ineffective. Where there are doubts as to the existence of an LPA, form OPG 100 is used to request this information from the OPG. Only someone who has personal welfare power of attorney can be a decision maker on welfare matters. Although someone who has only property and affairs power of attorney will not be a decision maker for issues relating health and welfare, it may still be appropriate to consult them about decision making relating to the patient. 7.5 Regulation 8 allows for 2 categories of people to be given an LPA Certificate. i) Category A is a person chosen by the donor, who has known the person for a period of at least 2 years. ii) Category B is someone who, on account of their professional skills and expertise who reasonably considers that he / she is competent to make the judgements necessary to certify the matters set out in Schedule 1 of Mental Capacity Act. Specifically, Schedule 1, Paragraph 2 (1) (e) requires that the Certificate that a ISSUE 7 FEBRUARY

8 person completes outlines that, in their opinion, at the time when the donor executes the instrument: (a) (b) (c) The donor understands the purpose of the instrument and the scope of the authority conferred under it. No further undue pressure is being used to induce the donor to create a Lasting Power of Attorney and There is nothing else which will prevent a Lasting Power of Attorney from being created by the instrument. 7.6 Persons Who May Provide an LPA Certificate The following are examples of persons within category B. A registered healthcare professional; A Barrister, Solicitor or Advocate called or admitted in any part of the United Kingdom; A registered Social Worker; or An independent Mental Capacity Advocate. 7.7 A person is disqualified from giving an LPA Certificate in respect of any instrument intended to create a lasting power of attorney if that person is; A family member of the donor; A donee of that power; A donee of Any other lasting power attorney, or; An enduring power of attorney, which has been executed by the donor (whether or not it has been revoked); A family member of a donee within sub-paragraph(b); A Director or employee of a Trust Corporation acting as a donee within sub-paragraph (b); 7.8 The Trust agrees in principle for its professionally registered health and social care staff to provide certificates for Lasting Power of Attorney. 7.9 In cases of disagreement between Trust practitioners and donees of Power of Attorney, attempts should be made to come to an agreement about a planned course of action. In some cases it will be clear that the donee has the final decision making ability. In other cases there will be disagreement on a course of action which may have serious consequences for the patient. Legal advice should be sought without delay Appendix 1 deals with the process where donees of LPAs object to discharge to a place which the Trust considers acceptable. 8.0 THE MENTAL HEALTH ACT 1983 AND ADRTs 8.1 Whilst the primary reason for a patient s admission to Trust mental health services as a patient will be to receive treatment for their mental health needs, it is recognised that patients may wish to make an ADRT or have made an ADRT relating to treatment for their ISSUE 7 FEBRUARY

9 mental disorder. Where a patient is an informal inpatient, a valid and applicable ADRT relating to treatment for a mental disorder will be binding on clinicians. There is an assumption in law that a person has capacity to make their own decisions even if they are subject to detention in hospital, guardianship, or Community Treatment Order. 8.2 Part 4 of the MHA generally means the person can be treated for mental disorder without their consent (Note: see below for provisions relating to Electro Convulsive Therapy (ECT and for Part 4A provisions relating to patients on a Community Treatment Order)). The patient can be given treatment for their mental disorder, even if they have made an ADRT to refuse such treatment. If the clinician does not follow an ADRT, they must record in the patient s notes why they have decided not to do so. 8.3 A patient may have made an ADRT relating to ECT. Section 58A of the MHA sets out rules relating to detained patients, ADRTs and ECT. These ADRTs require the scrutiny of a Second Opinion Appointed Doctor and will be binding if valid and applicable. The emergency provisions of Section 62 apply if it is necessary to administer ECT pending the arrival of the SOAD. Section 62 can only be used if treatment with ECT is immediately necessary to save the patient s life or immediately necessary to prevent a serious deterioration of his condition (MHA s 62 (1) (a) (b)). 8.4 Part 4A of the Mental Health Act concerns consent to treatment by community patients (patients subject to a Community Treatment Order). An adult community patient who lacks capacity may not be given treatment if to do so would conflict with a valid and applicable ADRT (section 64D) unless it is emergency treatment (section 64G). 8.5 Patients may make or have already made, an ADRT relating to physical healthcare which is unrelated to their mental disorder. These ADRTs, if valid and applicable, will be binding whether or not the patient is detained under the Mental Health Act or is a community patient. 9.0 SOURCE DOCUMENTS 9.1 Mental Capacity Act Mental Capacity Act Code of Practice. 9.3 Mental Health Act 1983 (as amended). 9.4 Mental Health Act Code of Practice General Medical Council (2010): Treatment and Care towards the end of life 9.6 Department of Health (2007): Best Practice in Managing Risk 9.7 Department of Health (2008): Refocusing the Care Programme Approach 10.0 DUTIES 10.1 The primary responsibility for ensuring this policy is adhered to rests with all staff making decisions and performing acts in connection with personal care, healthcare or treatment of a person who lacks capacity to consent to these acts Secondary responsibility lies with managers of services to ensure that all staff are aware of the requirements of this policy and the implications of it for their practice. ISSUE 7 FEBRUARY

10 11.0 TRAINING 11.1 Training on advance planning will be an integral part of Mental Capacity Act and Mental Health Act training. Training on advance care planning is also available from the End of Life trainers TARGET AUDIENCE 12.1 All staff involved in direct patient care and in contact with adult patients and transitions services for young persons EQUALITY IMPACT ASSESSMENT 13.1 This policy has been assessed using the Equality Impact Assessment Screening Tool. The assessment concluded that the policy would have no adverse impact on, or result in the positive discrimination of, any other diverse groups detailed. These include the strands of disability, ethnicity, gender, identify, age, sexual orientation, religion / belief, social inclusion and community cohesion REVIEW DATE 14.1 This policy will be reviewed in 3 years or in light of organisational or legislative changes CONSULTATION 15.1 Leadership Council (LC) and Mills & Reeve Solicitors (version 1 and new amendments paragraphs and Appendix) MONITORING COMPLIANCE 16.1 The use of advance statements will form part of annual audits such as but not limited to Mental Capacity Act /Mental Health Act and Care Programme Approach, CQUINN - as appropriate within each division. The outcome of any audit will be considered within each division and action plans developed and implemented as necessary by individual Directorates. Ongoing monitoring will be undertaken by Local Clinical Governance Groups who will confirm that all agreed actions have been completed and reporting processes undertaken LEGISLATION COMPLIANCE 17.1 This policy is based on and developed around the Mental Capacity Act 2005, the Mental Capacity Act Code of Practice, the Mental Health Act 1983 (as amended) and the Mental Health Act Code of Practice CHAMPION AND EXPERT WRITER 18.1 The Champion of this policy is Dr Julie Hankin, Executive Director: Clinical Governance and Medical Affairs. The Expert Writer is Michael Sergeant, MHA/MCA/DOLS Lead (Local Services) ISSUE 7 FEBRUARY

11 APPENDIX 1 PROCESS FOR RESOLUTION OF CONFLICT WHERE DONEES OF LPAS DO NOT AGREE TO A PLACE OF DISCHARGE WHICH THE TRUST DEEMS SUITABLE Patient has been deemed medically fit for discharge but has been found to lack capacity to consent to future care arrangements. The patient has one or more persons who are directed to act as a donee on their behalf, via a Lasting Power of Attorney (either for Health & Welfare, for Financial Affairs or both). In order to identify a suitable discharge placement and agree a care plan, a best interests meeting should be arranged to discuss all of the available options. Invite Local Authority representatives and LPA s. There may well be more than one meeting before all are in agreement with the way forward. A suitable placement should then be identified more than one can be identified for consideration. Ideally a solution will be reached through negotiation. However, if there is dispute as to where the patient should be discharged, identify any concerns from the LPA s and consider the reasons for any objections. Advise the LPA s that they may want to seek legal advice in the event of disagreement. Identify a date for proposed discharge from hospital when a suitable placement becomes available. If funding has been agreed by the commissioners, and a suitable placement becomes available, work with the commissioners and new placement to discharge the patient to the placement. In circumstances where the donee of the LPA is not in agreement, the LA/CCG should seek to agree on an interim basis to enable the patient to move out of an acute bed into a more suitable environment. The donee can then continue further discussions with commissioners as to long term placements once the patient has been discharged from the Trust s care. If a placement is available but the LPA is for financial matters and is unwilling to pay, discussions should be had with commissioners as to whether they will fund the placement on an interim basis whilst discussions remain ongoing. If the Trust is unable to discharge the patient, the Trust may then seek to service notice on the Local Authority under Schedule 3 of the Care Act ISSUE 7 FEBRUARY

12 Treatment (ADRT), & Lasting Powers of Attorney (LPA) 1.30 APPENDIX 2 EQUALITY IMPACT ASSESSMENT (EIA) SCREENING TOOL Name of policy/procedure/strategy/plan/function etc being assessed: Brief description of policy/procedure/strategy/plan/ function etc and reason for EIA: ADVANCE CARE PLANNING: ADVANCE STATEMENTS INCLUDING ADVANCE DECISIONS TO REFUSE TREATMENT (ADRT), AND LASTING POWERS OF ATTORNEY (LPA) This policy sets out structures to enable staff to support patients in future care planning and support those who have already set out their wishes for a time when they may lack capacity. Names and designations of EIA group members: Michael Sergeant MHA/MCA Lead Local Services Division Jaswinder Basi CPA & MHA Manager. Julie Harris MHA Team Leader List of key groups/organisations consulted Leadership Council Data, Intelligence and Evidence used to conduct the screening exercise Mental Health Act Code of Practice. Chapter 1 Guiding Principles. Least Restrictive Option and Maximising Independence ISSUE 7 FEBRUARY

13 Treatment (ADRT), & Lasting Powers of Attorney (LPA) 1.30 Equality Strand Race Does the proposed policy/procedure/ strategy/ plan/ function etc have a positive or negative (adverse) impact on people from these key equality groups? Please describe This policy aims to have a positive impact on any member of the wider community. Consequently the Trust as a public authority must, in the exercise of its functions, have due regard to the need to a) eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010 in regard to the nine protected characteristics in the Equality Act 2010 (age, disability gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex, sexual orientation). Are there any changes which could be made to the proposals which would minimise any adverse impact identified? What changes can be made to the proposals to ensure that a positive impact is achieved? Please describe Have any mitigating circumstances been identified? Please describe Areas for Review/Actions Taken (with timescales and name of responsible officer) N/A N/A Expert Writer to review in 3 years Gender Incl. Transgender Disability Incl. Mental Health and LD The policy must be read in the context of the statement of guiding principles found in Chapter 1 of the Mental Health Act Code of Practice As Race As Race N/A Expert Writer to review in 3 years As Race. However, as mental health is classified as a disability under the Disability Discrimination Act this policy promotes consistency of mental health N/A N/A Expert Writer to review in 3 years ISSUE 7 FEBRUARY

14 Treatment (ADRT), & Lasting Powers of Attorney (LPA) 1.30 issues. N/A Expert Writer to review in 3 Religion/Belief As Race As Race years As Race As Race N/A Expert Writer to review in 3 Sexual Orientation years As Race As Race N/A Expert Writer to review in 3 Age years Social Inclusion* 1 years As Race As Race N/A Expert Writer to review in 3 Community Cohesion* 2 As Race As Race N/A Expert Writer to review in 3 years Human Rights * 3 years As Race As Race N/A Expert Writer to review in 3 * 1 for Social Inclusion please consider any issues which contribute to or act as barriers, resulting in people being excluded from society e.g. homelessness, unemployment, poor educational outcomes, health inequalities, poverty etc * 2 Community Cohesion essentially means ensuring that people from different groups and communities interact with each other and do not exclusively live parallel lives. Actions which you may consider, where appropriate, could include ensuring that people with disabilities and non-disabled people interact, or that people from different areas of the City or County have the chance to meet, discuss issues and are given the opportunity to learn from and understand each other. * 3 The Human Rights Act 1998 prevents discrimination in the enjoyment of a set of fundamental human rights including: The right to a fair trial, Freedom of thought, conscience and Religion, Freedom of expression, Freedom of assembly and association and the right to education Conclusions and Further Action (including whether a full EIA is deemed necessary and agreed date for completion) This policy has been assessed using the Equality Impact Assessment Screening Tool. The assessment concluded that the policy, properly followed, would have no adverse impact on any of the nine protected characteristics in the Equality Act 2010 (age, disability gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex, sexual orientation). Screening Tool Consultation End Date Tuesday 2 January 2018 Name of Equality and Diversity (E&D) Group Equality and Diversity Sub-Committee of Board of Directors Approving EIA (i.e. Directorate E&D Group, Divisional E&D Forum or Trustwide E&D Steering Group) Name of Responsible Officer Name and Contact Details (tel. , postal) Michael Sergeant Mental Health Act/Mental Capacity Act Lead (Local Services) michael.sergeant@nottshc.nhs.uk Postal: Mental Health Act Department, Duncan Macmillan House, Porchester Road, Mapperley, Nottingham NG3 6AA ISSUE 7 FEBRUARY

15 APPENDIX 3 Policy/Procedure for: ADVANCE CARE PLANNING: ADVANCE STATEMENTS INCLUDING ADVANCE DECISIONS TO REFUSE TREATMENT (ADRT), AND LASTING POWERS OF ATTORNEY Issue: 07 Status: Author Name and Title: APPROVED Michael Sergeant, MHA/MCA/DOLS Lead (Local Services) Issue Date: 26 FEBRUARY 2018 Review date: JANUARY 2021 Approved by: EXECUTIVE LEADERSHIP TEAM (14/02/2018) Distribution: Normal RECORD OF CHANGES DATE AUTHOR POLICY DETAILS OF CHANGE 01/06/10 J Craig 22/05/2013 M Sergeant/ G Finn 25/02/2015 M Sergeant 8.11 (Issue 2) 1.30 (Issue 3) 1.30 (Issue 4) 06/09/2016 M Sergeant 1.30 (Issue 5) Changes throughout the document to maintain compliance with the Mental Health Act 1983 (as amended) and the Mental Capacity Act. Minor changes throughout the document. Part 5 and 6 order reversed. Part 8.0 rewritten. Policy changed from Section 8 MHA Legislation to Section 1 Patient Care as it has wider scope than mental health services. References to 2015 MHA Code Minor amendments only. Obsolete links removed. New link at 5.8. Policy Champion updated. 18/12/2017 M Sergeant 1.30 Additions at 7.9, 7.10 and Appendix 1. APPENDIX ISSUE 7 FEBRUARY