Standard Operating Procedure 3 (SOP 3) Template Advance Decision To Refuse Treatment &Advance Statement The Mental Capacity Act 2005 (MCA) provides the legal framework to empower and protect people over the age of 16 who may lack capacity to make some decisions for them. The MCA 2005 provides for certain ways that an individual may influence what happens to them should they ever be unable to make a particular decision in the future. For individuals over the age of 18, one of these is to be able to make an Advance Decision to refuse medical treatment (ADRT) setting out their wishes and feelings in respect to treatment. According to the House of Lords Select Committee; Advance Decisions to refuse treatment are essential means of allowing individuals to determine their care in the event that they lose capacity. As with other aspects of the Act, the general public cannot benefit from this opportunity if they are not made aware of it. (para.199). As such Black Country Partnership Foundation Trust are committed to ensure the Mental Capacity Act 2005 is embedded across the Trust, with that the awareness of Advance Decisions is key to help promote individual with the principle to take an active role in planning their care and treatment. Communication is the key to the provision of safe and effective care and is essential to all aspects of this policy Linked with the Mental Capacity Act Advance decision to Refuse Treatment and Advance decisions and The Mental Capacity Act (2005) Trust Policy. Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services Who does the procedure apply to? (staff roles and responsibilities) All Staff involved in the care and treatment of patients. This should be document in the patient s notes. There should be a flag on the OASIS system, and it should be discussed in MDT and any patient care decisions. When should the procedure be applied? Whenever a patient is admitted, it is part of the admission to ascertain if there is an Advance decision to refuse treatment in place (ADRT) or and advance statement. The flow chart informs staff the procedures set out for this. How to carry out this procedure (step step-by-step information) Below are flow charts, and templates to be used for advance decisions and advance statements. MCA- Advance Decisions & Advance Statements Page 1 of 12 Version 1.1 July 2018
Advance decision flow chart. Does the Patient have an Advance decision/statement in place? YES DON T KNOW NO Efforts should be made to locate any advance decision/statement. However emergency treatment must not be delayed in order to look for an advance decision, if there is not clear indication that one exists or its validity and/or applicability. If patient lacks capacity, decision should be made in best interests. As described in the MCA or the MHA. See MCA BCPFT policy.. Advanced decision/statement flag to be added. Recorded in admission notes/copy kept on file. Contact GP is unable to attain a copy. Speak with relatives/carers about any advance decision/statements. All staff to be aware that (VALID) Advance DECISION is legally binding. All staff to be aware of difference between Advance decision and advance statement. All Out of Hours/Duty Doctors are to be alerted to the Advance Decision. Ensure this is discussed as part of Treatment plan and in Multi-disciplinary meetings. Review this with the patient regularly and document this. If it is withdrawn ensure FLAG on oasis is taken off system. If the patient is transferred / discharged ensures the information is disseminated accordingly. Any concerns with the validity of the Advance decision, staff are directed to speak with: Responsible Clinician. Multi-disciplinary team. Safeguarding Mental Capacity Act Lead/ and or Safeguarding. Who in turn will liaise with the Trust Solicitor for legal advice on complex situations MCA- Advance Decisions & Advance Statements Page 2 of 12 Version 1.1 July 2018
Advance decision Checklist The checklist below has been adapted from NHS National End of Life Care Programme. It is a useful tool, in helping you determine if an advance decision is valid and applicable, and legally binding. Should after following the flow chart, it become apparent the advance decision is NOT legally binding. You must still take into account the patient s wishes and feelings when assessing their best interests, if they are unable to make the decision themselves. If you have any doubt at all about the YES/NO regarding any of the questions below, please seek advice from your Manager/Matron/Medical team/senior Medical team. Prior to using the checklist, make sure 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 Answer Yes/No 1 Does the person have the capacity to Yes: The person has capacity to make the give consent to or refuse treatment on decision him or herself. The advance him or herself, with appropriate decision is not applicable. Ask what she /he support where necessary want to do. IS THE ADVANCE DECISION VALID? 2 Has the person withdrawn the advance decision? (This can be done verbally or in writing) No: continue with checklist. 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. 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 Has the person done anything that is clearly inconsistent with the advance decision remaining his/her fixed decision? IS THE ADVANCE DECISION APPLICABLE? 5 (a) Does the advance specify (b) (c) Which treatment the person wishes to refuse? (d) Is the treatment in question that specified in the advance decision? No: continue with checklist. YES: This is not a valid advance decision. The done(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: 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 records the reasons. No: The advance decision is valid. Continue with the checklist. YES: to both (a) and (b): Continue with the checklist. No: This is not an applicable advance decision. 6 If the Advance decision has specified YES: Continue with the checklist. MCA- Advance Decisions & Advance Statements Page 3 of 12 Version 1.1 July 2018
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? 7 Are there reasonable grounds for believing that circumstances exist which the person did not anticipate when they originally made the advance decision. Could this have affected his/her decision had they anticipated them? No: This is not an applicable advance decision. YES: Is 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 this would have affected his/her decision had she/she anticipated them, and record your reasoning. 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? 11 Is the advance decision: In writing AND Signed by the person making it or somebody else on their behalf at their direction AND Signed by a witness responsible for witnessing the signature, not the decision. No: Continue with checklist. YES: Continue with the checklist. No: This is not a binding advance decision to refuse the specified lifesaving treatment. YES: Continue with 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 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 life sustaining treatment. Adapted from: NHS National End of life Care Programme Improving end of life care. Advance decisions to refuse treatment A Guide for health and social care professionals. Advance Decision to Refuse Treatment MCA- Advance Decisions & Advance Statements Page 4 of 12 Version 1.1 July 2018
(ADRT) Adapted from NHS England https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/advance-decisions-to- Refuse-Treatment-Guide.pdf My name Address If I become unconscious, these are distinguishing features that could identify me: Date of birth: NHS no (if known): Hospital no (if known): Telephone Number: What is this document 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 decision I have made. Advice to the carer reading this document: Please check Please do not assume that I have lost my mental capacity before any actions are taken. I might need help and time to communicate when the time comes to need to make a decision. If I have lost capacity for a particular decision check that my advance decision is valid and applicable to the circumstances that exist at the time. If the professionals are satisfied that the advance decision is valid and applicable this decision becomes legally binding and must be followed, including checking that it is has not been varied or revoked by either me verbally or in writing since it was made. Please share this information with people who are involved in my treatment and need to know about it. Please also check if I have an advance statement about my preferences, wishes, feelings and my values and beliefs that might be relevant to this decision. This advance decision does not refuse the offer of provision of basic care, support and comfort. Important note to the person making this advance decision: If you wish to refuse a treatment that is (or may be) life sustaining you must state in the boxes I am refusing this treatment even if my life is at risk as a result. Any advance decision that states that you are refusing life sustaining treatment must be signed and witnessed on page 6. My Name NHS no (if known) MCA- Advance Decisions & Advance Statements Page 5 of 12 Version 1.1 July 2018
My Advance decision to refuse treatment. I wish to refuse the following specific treatments: In these circumstances: My Signature (nominated Person Date of Signature My Name NHS no (if known) Witness Name of witness Witness Signature Telephone of witness: Date: Person to be contacted to discuss my wishes: Name MCA- Advance Decisions & Advance Statements Page 6 of 12 Version 1.1 July 2018
Address I have discussed this with (e.g. name of healthcare professional) Profession/job title: Date: Contact details: I give my permission for this document to be discussed with my relatives/carers Yes (please circle one) No My General Practitioner is: Name: Telephone: Address: Optional Review comment Date/time: Signature of Person named 1: Witness Signature: My Name NHS no (if known) MCA- Advance Decisions & Advance Statements Page 7 of 12 Version 1.1 July 2018
The following list identifies which people have a copy and have been told about this advance decision to refuse treatment (ADRT) Name Relationships Telephone Number Further Information (optional) I have written the 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 may find it useful, for example to inform any clinical assessment it is becomes necessary to decide what is in my best interests. Advance Statement Template An advance statement is not legally binding but those making a best interests decision on your behalf should Take its contents into account, when you cannot tell them what you would like. TEMPLATE FOR ADVANCE STATMENT Advance statement for care and treatment MCA- Advance Decisions & Advance Statements Page 8 of 12 Version 1.1 July 2018
Name: DOB: Date: I declare that I my wishes for my care, wishes and preferences, are as follows: My wishes regarding medication and treatment are as follows: When unwell in the past the following has worked well for me: I prefer to be cared for at: (e.g. Care home/home/hospice/hospital) My religious/spiritual cultural believes which I would like taken into account are as follows: I would like the following people to be told immediately that I have been admitted to hospital: I do not want the following people to be informed: MCA- Advance Decisions & Advance Statements Page 9 of 12 Version 1.1 July 2018
I have dependent children whom are : (Names and DOB) Provision for their care are with: (Name the people whom will be taking care of your children) I have pets at home and they can be cared for by: My favourite foods are: (For example I only eat Halal food, or I am a vegetarian, or gluten intolerant and or any food allergies. I give permission for the following people to have keys to my home to help with things I need and require attending to: (Give names of the trusted people) Where Staffs are directed to go to the Mental Capacity Act (2005) Policy, Mental Capacity Act Advanced decision and Advance statement policy. The Mental Capacity Act (2005). Safeguarding Mental Capacity Act lead. Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust s Mandatory & Risk Management Training Needs Analysis for MCA- Advance Decisions & Advance Statements Page 10 of 12 Version 1.1 July 2018
further details on training requirements, target audiences and update frequencies Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Please refer to overarching policy Data Protection Act and Freedom of Information Act Please refer to overarching policy MCA- Advance Decisions & Advance Statements Page 11 of 12 Version 1.1 July 2018
Standard Operating Procedure Details to be completed by Corporate Governance Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-MHA-SOP-06-3 Revised Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed N/A Executive Director of Nursing, AHPs and Governance MCA and DoLs Lead Mental Health Legislation Forum n/a Month/year SOP was approved July 2018 Next review due July 2021 Disclosure Status B can be disclosed to patients and the public Review and Amendment History - to be completed by Corporate Governance Version Date Description of Change 1.1 July 2018 1.0 April 2013 New SOP for BCPFT Updated information and new design of forms/templates to be completed. MCA- Advance Decisions & Advance Statements Page 12 of 12 Version 1.1 July 2018