Policies, Procedures, Guidelines and Protocols

Transcription

1 Policies, Procedures, Guidelines and Protocols Document Details Title Advanced Decision to Refuse Treatment Policy and Procedure (previously known as Living Wills) Trust Ref No Local Ref (optional) Main points the document covers Advanced refusal of treatment and process to accommodate such decision, including legal requirements Who is the document All appropriate staff aimed at? Author Deputy Director of Nursing & Quality A. Coleman Approval Process Approved by Quality & Safety Operational Group (Committee/Director) Approval Date 18 Aug 2014 Initial Equality Impact No Screening Full Equality Impact No Assessment Lead Director Director of Nursing & Operations Category Sub Category Review date Aug 2017 Distribution Who the policy will be All Trust Staff distributed to Method Trust Intranet Document Links Required by CQC Yes (Outcomes 4 & 7) Required by NHSLA No Other Amendments History No Date Amendment 1 14 Aug 2014 Format to achieve SCHT standard policy style 2 Update contact websites and telephone numbers 3 Update Patient Information Leaflet 4 5 1

2 CONTENTS 1 Introduction 3 2 Duties What is an Advanced Decision Advance Decisions to refuse life-sustaining treatment. 5 5 Legal status of an Advanced Decision 5 6 What is a valid Advanced Decision Storage of an Advanced Decision 7 8 Role of the Health Professional 7 9 Do Advanced Decisions apply in an emergency Mental Health 9 11 Children Ambulance Service Patient s Responsibilities Lasting Powers of Attorney Consultation and Approval Process Dissemination Monitoring Relationships with other policies or legal requirements References. 12 Appendices Appendix A - Code of Practice-Emergency Guidelines-Advance Decisions Appendix B - Advanced Decision Checklist Appendix C - Advanced Decision template Appendix D - Advanced Decision notification card Appendix E - Advanced Decision patient leaflet Advanced Decisions Policy Aug 2014 AAC Page 2

3 Advance Decisions Policy 1.0 Introduction 1.1 An adult who has competence or capacity (these terms are interchangeable for the purpose of this policy and refer to the ability to make decisions) is able to make decisions for themselves, including decisions about how they wish to be treated in the future. 1.2 The Mental Capacity Act 2005 (MCA), which came into full effect in October 2007, extended the ways in which people using services can plan ahead for a time when they may lack capacity. This included codifying Advance Decisions into law and introducing Lasting Powers of Attorney for health and welfare, through which treatment decisions can be made on behalf of a mentally incapacitated individual. 1.3 An Advance Decision enables someone aged 18 years or over, who has capacity, to refuse specified medical treatment for a time in the future when they may lack the capacity to consent to or refuse that treatment. 1.4 An Advance Decision to refuse treatment must be valid and applicable to current circumstances. If it is, it has the same effect as a decision that is made by a person with capacity and is legally binding: health care professionals must follow the decision. 1.5 Providing care or treatment for people who have made an Advance Decision is a complex area and it is advisable to refer to Chapter 9 of the Mental Capacity Act (2005) Code of Practice for more detailed guidance. This is available at This policy should be read in conjunction with the multi agency Mental Capacity Act Guidance and the Trust s policy for Consent to Examination or Treatment, both of which are available on the intranet site. 1.7 The policy addresses the following: What is an Advance Decision? Advance Decisions to refuse life-sustaining treatment What is the legal status of an Advance Decision? What is a valid Advance Decision? Storage of Advance Decisions What is the role of the health professional? Do Advance Decisions apply in an emergency? Mental Health Children Ambulance Service Patient Responsibilities Lasting Powers Of Attorney Code of Practice Emergency Guidelines Advance Decisions Advanced Decisions Policy Aug 2014 AAC Page 3

4 2.0 Duties 2.1 Director of Nursing & Operations The Director of Nursing & Operations is responsible for overseeing the implementation and impact of this policy and for making recommendations for change (through the management structure). 2.2 Managers & Service Leads Managers and Service Leads should use this policy to help them discuss the procedure when dealing with an Advanced Decision issue. 2.3 Staff All staff, whilst performing their duties on behalf of SCHT, should be of this policy and act accordingly. aware 3.0 What is an Advance Decision? 3.1 An Advance Decision is a mechanism whereby people with capacity give instructions about what is to be done if they should subsequently lose the capacity to make or communicate appropriate decisions. An advance decision to refuse treatment (previously known as a living will or advance directive) is a decision to refuse a particular medical treatment in specified circumstances. This can include the choice to refuse treatment even if doing so might put the patient s life at risk. 3.2 The fundamental aim of an Advance Decision is to provide a means for the patient to continue to exercise autonomy. 3.3 A patient cannot demand treatment be given if it is not clinically indicated through an Advance Decision. However if an indication is given of a request for treatment, this may be important for a patient making their wishes and feelings known. 3.4 An Advance Decision may be written down or a clear oral statement. Although oral Advance Decisions are valid there are obvious advantages to a patient recording their views and decisions in writing. 3.5 Where individuals have discussed their wishes with the health care team and made clear their expectations in terms of certain interventions, these verbal wishes should be noted in the medical record if the individual clearly wants them to be taken into account. Even where there is doubt about the validity and applicability of oral Advance Decisions, verbal wishes should be used in the decision-making process when ascertaining what would be in the patient s best interests. 3.6 An Advance Decision must be in writing where it relates to life-sustaining treatment. Advanced Decisions Policy Aug 2014 AAC Page 4

5 3.7 Any Advance Decision is superseded by a competent contemporaneous decision by the individual concerned, or by the decision of an attorney appointed under a Lasting Power of Attorney with the authority to make that particular decision, where they were appointed after the date when the Advance Decision was made (see section 13 for information about Lasting Powers of Attorney). 4.0 Advance Decisions to refuse life-sustaining treatment 4.1 The MCA sets out formalities for Advance Decisions that refuse life-sustaining treatment. An Advance Decision to refuse life-sustaining treatment must fulfil the following additional requirements: It must be in writing, which includes being written on the person s behalf or recorded in their medical notes It must be signed by the maker in the presence of a witness who must also sign the document. It can also be signed on the maker s behalf at their direction if they are unable to sign it for themselves It must be verified by a specific statement made by the maker, either included in the document or within a separate statement, that says that the Advance Decision is to apply to the specified treatment even if life is at risk. If there is a separate statement this must also be signed and witnessed. 4.2 Staff will not incur liability for providing treatment in a patient s best interests if they are not satisfied that a valid and applicable Advance Decision exists. If they are satisfied that an Advance Decision exists which is valid and applicable, then not to abide by it could lead to a legal claim for damages or a criminal prosecution for assault. 4.3 If staff reasonably believe that there is a valid and applicable Advance Decision then they will not be held liable for the consequences of abiding by it and not providing treatment. Staff should clearly record how they came to their conclusions. 5.0 What is the legal status of an Advance Decision? 5.1 Legal cases have shown beyond doubt that when an informed and competent patient has made an anticipatory choice which is clearly established and applicable in circumstances, doctors would be bound by it (BMA 1995). 5.2 The principle of Advance Decisions was codified in law by the Mental Capacity Act in October Advance Decisions that are valid and applicable in the circumstances are legally binding. 5.3 Any health professional who knowingly acts in disregard of a valid and applicable Advance Decision would be likely to be held guilty of assault. Advanced Decisions Policy Aug 2014 AAC Page 5

6 5.4 Conversely, a Health Professional who acts in good faith in accordance with an apparently valid Advance Decision would not be considered negligent should the Advance Decision then be proved to be invalid. 5.5 The Mental Capacity Act states that patients should not be able to refuse basic care and hygiene through an Advance Decision. Basic care means those procedures which are essential to keep an individual comfortable. It is generally accepted that this includes warmth, shelter, food, water and pain relief. However, nutrition and hydration should not be given to a person who indicates opposition, and invasive measures such as tube feeding should not be instituted contrary to a clear Advance Decision. 6.0 What is a valid Advance Decision? 6.1 In order for an Advance Decision to be valid, the following must apply: It must be made by a person who is 18 years old or over and who has the mental capacity to make it It must specify, in medical or lay terms, the treatment to be refused. The patient must be aware of the likely consequences of a refusal of treatment It must specify the circumstances in which the refusal would apply. 6.2 The Decision would become invalid if: It is withdrawn by the patient The patient acts inconsistently with the Decision since the time of making it* The patient subsequently appoints a Lasting Power of Attorney with the power to make the specified decision A refusal may be invalid if, for example, the treatment options have materially changed since the patient lost capacity. 6.3 Additional common law criteria for validity of an Advance Decision to refuse treatment include: The patient has been offered sufficient, accurate information to make an informed decision The circumstances that have arisen are those that were envisaged by the patient The patient is not subjected to undue influence in making the decision*. Advanced Decisions Policy Aug 2014 AAC Page 6

7 6.4 The additional requirements outlined in Section 3 also apply when the Advance Decision relates to life-sustaining treatment. (*Healthcare professionals should act based on the best evidence available to them.) 6.5 The checklist at Appendix A can be used to assess the validity of an Advance Decision. 6.6 Advance Decisions made before the MCA came into full effect in October 2007 are still valid if they meet the provisions of the Act. Most Advance Decisions refusing life sustaining treatments made before October 2007 are unlikely to meet the specific requirements of the Act and should be reviewed in line with these requirements. 6.7 If there is doubt about whether an Advance Decision is valid or not, a declaration should be sought from the Court of Protection Storage of Advance Decisions 7.1 The onus to ensure that the decision is properly drafted is on the patient. Appendix B provides an example Advance Decision template that patients can use to put together their Advance Decision. It is important to note that this is just an example and there is no set format for Advance Decisions. The British Medical Association recommends that a patient should carry a card, informing people of the existence of the Decision, and give a copy of the Decision to the appropriate health professionals. A card that could be used by patients is included as Appendix C. 7.2 Patients are advised to make relatives and friends aware of the existence of an Advance Decision. 7.3 Patients should not send a copy to the Trust as there is no way of storing it or sharing it with all health professionals concerned or the hospitals the patient may be admitted to. Patients may wish to inform their GP, who then can document it on an Advance Decisions Register (if they hold a register) or in the patient s medical record. 8.0 What is the role of the health professional? 8.1 Should a patient enquire about an Advance Decision, health professionals should provide the patient with a copy of the Advance Decision Information Leaflet available at Appendix D. 8.2 Ideally Advance Decisions should be drafted with appropriate discussion with health professionals and, if appropriate relatives rather than by patients in isolation. Advanced Decisions Policy Aug 2014 AAC Page 7

8 8.3 If asked to witness an Advance Decision, health professionals should be aware that it may later be assumed they verified that the patient had capacity at the time of making the decision. Health professionals who act as a witness and have no reason to believe that the patient suffers from impaired capacity may specifically add a note to the patient s notes to that effect. If there is any reason to doubt that the patient understands the implications of the decision, an assessment of capacity is advisable. Checklists for assessing capacity and making best interests decisions are available as part of the multi-agency Mental Capacity Act guidance, accessible via the Trust intranet. 8.4 If a health professional cannot act in accordance with an Advance Decision for ethical reasons, he/she should ask someone else to deal with the patient s treatment. The wishes of the patient as expressed in the Advance Decision, assuming it is valid, should be followed. 8.5 A patient cannot require a health professional to take a positive step which could cause the patient s death and such a request in an Advance Decision is invalid. 8.6 In an emergency, or where there is doubt about the existence or validity of an Advance Decision, doctors should provide treatment that is immediately necessary to stabilise or to prevent a deterioration in the patient s condition until the existence or applicability of the Advance Decision can be established. 8.7 It is always very important for the health professional to document the treatment of a patient in accordance with an Advance Decision. Furthermore, it is important for that health professional to discuss the Advance Decision with the relatives and friends of the patient. Those discussions should also be documented in the patient notes. 8.8 It is important that relatives are made aware of the legal status of Advance Decisions. If relatives oppose implementation of an Advance Decision, they should be given the opportunity to discuss the issues with an appropriate member of staff. Staff who object to following the patient s instructions should inform their manager immediately. In these circumstances, staff will be asked to hand over the care of the patient. 8.9 Should any of the above issues arise it is advised that the health professional completes a Datix entry. 9.0 Do Advance Decisions apply in an emergency? 9.1 A health professional must provide treatment in the patient s best interests, unless they are satisfied that there is an Advance Decision that is: Valid Applicable in the circumstances 9.2 Health professionals should not delay emergency treatment to look for an Advance Decision if there is no clear indication that one exists, or if there are real doubts about the validity or applicability of the decision. If it is clear that a Advanced Decisions Policy Aug 2014 AAC Page 8

9 person has made one that is likely to be relevant, health professionals should assess its validity and applicability as soon as possible. Sometimes the urgency of treatment decisions will make this difficult. 9.3 If treatment has been initiated in good faith and an Advance Decision is subsequently discovered which is clearly relevant to the current circumstances and fulfils the criteria for validity set out in section 5, the Advance Decision should be followed. 9.4 If it is unclear whether the individual intended an Advance Decision to apply in all circumstances of impaired capacity, including an apparently unforeseen situation (for example a patient with a degenerative illness losing capacity as the result of a car accident), the advice about assessing validity should be followed see section 5 and Appendix A. 9.5 See also Section 14 Code of Practice, emergency guidelines Mental Health 10.1 A patient detained under the Mental Health Act 1983 (MHA) can make an Advance Decision if they are competent at the time of making the particular decision. However, Advance Decisions can be overridden by the provisions in Sections 58, 62 and 63 of the MHA for treatment of the mental disorder for which they have been detained. In these particular circumstances, patient consent is not required by the Act and therefore the Advance Decision will not be applicable. However, where possible, a patient s Advance Decision or preferences should be considered as part of the treatment plan An Advance Decision to refuse other forms of treatment for which consent is required is still valid. Being subject to guardianship or after-care under supervision does not affect an Advance Decision in any way See chapter 9 of the Mental Capacity Act (2005) Code of Practice for further guidance on Advance Decisions to refuse treatment. Chapter 13 of the Code of Practice gives information about the interface between the Mental Capacity Act and Mental Health Act Children 11.1 In the case of a young person under the age of 18, they are unable to make a valid Advance Decision, although their wishes should be taken into account and accommodated if possible. The Advance Care Plans for Children should guide the practitioner to the child / young person s wishes. However, they can be overruled by a court or a person with parental responsibility. The Children s Act 1989/2004 emphasises that the views of minors should be sought and taken into account in matters that affect their welfare Ambulance Service 12.1 During the transfer of patients by the Ambulance Service, the following should be adhered to: Advanced Decisions Policy Aug 2014 AAC Page 9

10 An Advance Decision that is valid and applicable to subsequent circumstances in which the patient lacks capacity is legally binding An Advance Decision is valid if made voluntarily by an appropriately informed person with capacity Therefore, ambulance staff should respect the wishes in such a document In the pre-hospital emergency environment, there may be situations where there is doubt about the validity of the Advance Decision. If ambulance staff are not satisfied that the patient had made a prior and specific request to refuse treatment, they should continue to provide all clinical care in the normal way See also Section 8 Do Advance Decisions apply in an emergency? 13.0 Patients Responsibilities 13.1 It is the patient s responsibility to inform the health professional that they have made an Advance Decision. However, staff should ask sensitively whether the patient has one Ideally, Advance Decisions should be drafted with appropriate discussion with health professionals rather than by patients in isolation. Medical advice can lead to a better informed declaration but it is important for any adviser to help patients clarify their own wishes rather than influence them It is recommended that Advance Decisions are reviewed on a regular basis, the Alzheimer s Society suggests every six months. This will ensure that the decision remains valid and up to date Lasting Powers of Attorney 14.1 The Mental Capacity Act 2005 (MCA) replaced the Enduring Power of Attorney (EPA) with the Lasting Power of Attorney (LPA). A Lasting Power of Attorney is a legal document that allows someone to give one or more people the authority to make specified decisions on their behalf. Under an LPA, the person given the authority (attorney or donee) can make decisions that are as valid as if made by the person giving the authority (the donor). A person must be aged 18 years or over to appoint an LPA There are two types of LPA. The Lasting Power of Attorney for property and financial affairs covers decisions relating to finances. The health and welfare LPA covers decisions about health and personal welfare, including decisions about medical treatment. The donor can choose one person or several to make different kinds of decisions on their behalf. An attorney can be given the power to make decisions about life-sustaining treatment When a person makes an LPA they must have the capacity to understand the importance of the document and the power they are giving to another person. Advanced Decisions Policy Aug 2014 AAC Page 10

11 14.4 To be valid, the LPA must be written on a statutory form and must be registered with the Office of the Public Guardian Donors can have their LPA registered while they are still capable or attorneys can apply to register it Health and welfare LPAs can only be used once the individual has lost capacity People appointed as attorneys under an LPA must act in the best interests of the person for whom they are making decisions and must follow the principles set out in the MCA and accompanying Code of Practice When a health professional has a significant concern relating to decisions taken under the authority of an LPA about serious medical treatment, the case can be referred for adjudication to the Court of Protection For additional information see the Office of the Public Guardian website: Consultation and Approval Process 15.1 Consultation Consultation will be through appropriate Trust staff Approval The Operational Quality & Safety Group will approve this policy and its approval will be notified to the Quality & Safety Committee Dissemination 16.1 This policy will be disseminated by the following methods: Directors within their area of responsibility Staff via Inform and Datix system Publication on the Trust Intranet site Awareness raised by Managers and Service Leads at staff meetings 17.0 Monitoring 17.1 An exception report as appropriate will be provided by the Risk Manager to identify the number of occasions the policy has been applied and reviewed to ensure a satisfactory outcome. Advanced Decisions Policy Aug 2014 AAC Page 11

12 17.2 Any Service User feedback, complaint or information from PALS or through the Patient & Carer Forum which relates to none compliance with the standards in this policy 17.3 This Policy will be reviewed as indicated. Any comments, queries or suggested amendments should be addressed to Deputy Director of Nursing & Quality 18.0 Relationships with other policies or legal requirements Mental Capacity Act Consent to Examination and Treatment 19.0 References Advance decisions and proxy decision-making in medical treatment and research: Guidance from the BMA s Medical Ethics Department, British Medical Association, June 2007 UK Ambulance Service Clinical Practice Guidelines (2006), Joint Royal College Ambulance Liaison Committee (JRCALC) & Ambulance Service Association (ASA), October 2006 Advance Decisions to refuse treatment: A guide for health and social care professionals, The National Council for Palliative Care & NHS End of Life Care Programme, September 2008 Mental Capacity Act 2005, Department for Constitutional Affairs & Department of Health, April 2005 Mental Capacity Act 2005 Code Of Practice, Department for Constitutional Affairs, April 2007 The Mental Capacity Act 2005: Guidance for Health Professionals, British Medical Association, March 2007 Websites: Alzheimer s Society NHS National End of Life Care Programme Advanced Decisions Policy Aug 2014 AAC Page 12

13 Appendix A Code of Practice Emergency Guidelines Advance Decisions Does the patient have capacity? No Is there an Advance Decision? No Yes Yes Consider patient s known preferences Follow good practice procedures for giving information and obtaining consent Is it a clear & applicable refusal of treatment? Yes No Assess and act in the patient s best interests Is it valid? (See Appendix A) No Yes Is the patient pregnant? No Is it an emergency? No Postpone treatment decision Yes No Yes Will following a refusal endanger a viable fetus? No Does refusal address current emergency circumstances? Yes Yes Apply to court Is there evidence of a changed opinion? No Follow Decision refusing treatment Yes Give emergency treatment Advanced Decisions Policy Aug 2014 AAC Page 13

14 Appendix B Advance Decision Checklist The following checklist can be used to assess whether an Advance Decision to refuse treatment is legally binding. If you conclude that the decision is not legally binding, it should not be ignored. You should still take it into account as evidence of the person s wishes when assessing their best interests, if they are unable to make the decision for themselves. If you have any doubt about whether to answer yes or no to any of the questions within the checklist, seek advice from your clinical lead. If necessary, seek legal advice. Before using this checklist, make sure that you have identified the treatment for which a decision is required. Always assume the person has capacity to consent to or refuse treatment. You are required to maximise the person s capacity and facilitate communication. QUESTION 1. Does the person have capacity to give consent to or refuse treatment him or herself, with appropriate support where necessary? ANSWER YES/NO YES: The person has capacity to make the decision him or herself. The advance decision is not applicable. Ask what s/he wants to do. NO: Continue with checklist IS THE ADVANCE DECISION VALID? 2. Has the person withdrawn the advance decision? (This can be done verbally or in writing) 3. Since making the advance decision, has the person created a lasting power of attorney (LPA) giving anybody else the authority to refuse or consent to the treatment in question? 4. Are there reasonable grounds for believing that circumstances exist which the person did not anticipate at the time of making the advance decision and which would have affected his/her decision had s/he anticipated them? YES: This is not a valid advance decision. Make sure that you have identified and recorded the evidence that the person withdrew the advance decision. NO: Continue with checklist YES: This is not a valid advance decision. The donee(s) of the LPA must give consent to or refuse the treatment. The LPA decision must be in the person s best interests. NO: Continue with checklist YES: If such reasonable grounds exist, this will not be an applicable advance decision. It is important to identify the grounds, discuss this with anybody close to the person, and identify why they would have affected his/her decision had s/he anticipated them, and record your reasoning. NO: Continue with checklist Advanced Decisions Policy Aug 2014 AAC Page 14

15 5. Has the person done anything that is clearly inconsistent with the advance decision remaining his/her fixed decision? IS THE ADVANCE DECISION APPLICABLE? 6. (a) Does the advance decision specify which treatment the person wishes to refuse?* (b) Is the treatment in question that specified in the advance decision? 7. If the advance decision has specified circumstances in which it is to apply, do all of those circumstances exist at the time that the decision whether to refuse treatment needs to be made? (N.B. It is possible for a person to decide that the advance decision should apply in all circumstances) ANSWER YES/NO YES: This is not a valid advance decision. It is important to identify what the person has done, discuss this with anybody close to the person, explain why this is inconsistent with the advance decision remaining his/her fixed decision, and record your reasons. NO: The advance decision is valid. Continue with checklist YES: To both (a) and (b): Continue with the checklist NO: This is not an applicable advance decision YES: Continue with the checklist NO: This is not an applicable advance decision LIFE SUSTAINING TREATMENT 8. Is the decision both valid and applicable according to the criteria set out above? 9. In your opinion is the treatment in question necessary to sustain the person s life? 10. Does the advance decision contain a statement that it is to apply even if the person s life is at risk? 11. Is the advance decision: In writing AND Signed by the person making it or by somebody else on his/her behalf and at his/her direction AND Signed by a witness? YES: Continue with the checklist NO: This is not a binding advance decision to refuse the specified life-sustaining treatment. YES: Continue with the checklist NO: This is a binding advance decision to refuse the specified non-life-sustaining treatment. It must be respected and followed. YES: Continue with the checklist NO: This is not a binding advance decision to refuse the specified life-sustaining treatment. YES TO ALL: This is a binding advance decision to refuse the specified lifesustaining treatment. It must be respected and followed. NO TO ANY: This is not a binding advance decision to refuse the specified lifesustaining treatment. * NB It is possible to use layman s language to specify both treatment and circumstances Advanced Decisions Policy Aug 2014 AAC Page 15

16 Reference: Advance Decisions to refuse treatment: A Guide for Health and Social Care Professionals, NHS End of Life Care Programme and The National Council for Palliative Care, September 2008 Advanced Decisions Policy Aug 2014 AAC Page 16

17 Appendix C My Advance Decision to Refuse Treatment My Name Any distinguishing features in the event of unconsciousness Address Date of Birth Telephone Number What is this document is for? This advance decision to refuse treatment has been written by me to specify in advance which treatments I don t want in the future. These are my decisions about my healthcare, in the event that I have lost mental capacity and cannot consent to or refuse treatment. This advance decision replaces any previous advance decision I have made. Advice to the reader I have written this document to identify my advance decision. I would expect any Healthcare Professional reading this document in the event I have lost capacity to check that my advance decision is valid and applicable, in the circumstances that exist at the time. Please Check Please do not assume I have lost capacity before any actions are taken. I might need help and time to communicate. If I have lost capacity please check the validity and applicability of this advance decision. This advance decision becomes legally binding and must be followed if professionals are satisfied it is valid and applicable. Please help to share this information with people who are involved in my treatment and care and need to know about this. Please also check if I have made any other statements about my preferences or decisions that might be relevant to my advance decision. This advance decision does not refuse the offer and/or provision of basic care, support and comfort. 17

18 My Name My advance decision to refuse treatment I wish to refuse the following specific treatments: In these circumstances: (Note to the person making this statement: If you wish to refuse a treatment that is or may be life-sustaining, you must state in the box above that you are refusing that treatment even if your life is at risk as a result. An advance decision refusing life-sustaining treatment must be signed and witnessed.) Advanced Decisions Policy Aug 2014 AAC Page 18

19 My Signature (or nominated person) Witness Date of Signature Witness Signature Name Telephone Address Date Person to be contacted to discuss my wishes: Name Relationship Address Telephone I have discussed this with: (e.g. name of Healthcare Professional) Profession / Job Title: Contact Details Date I give permission for this document to be discussed with my relatives / carers YES NO (please circle one) My General Practitioner is: (Name) Address Telephone Optional Review Comment Date / Time Maker s Signature Witness Signature Advanced Decisions Policy Aug 2014 AAC Page 19

20 The following list identifies which people have a copy and have been told about this Advance Decision to Refuse Treatment (and their contact details) Name Relationships Telephone Number Further Information (Optional) I have written the following information that is important to me. It describes my hopes, fears and expectations of life and any potential health and social care problems. It does not directly affect my advance decision to refuse treatment but the reader might find it useful. Reference: NHS National End of Life Care Programme Advanced Decisions Policy Aug 2014 AAC Page 20

21 Appendix D I have an Advance Decision I of have written an Advance Decision. A copy can be obtained from My GP s name is Dr Tel no Signature Date / / Advanced Decisions Policy Aug 2014 AAC Page 21

22 Appendix E Policy Review June 2014 AAC

23 Chaperone Policy 1 June 2014