Consent Form 4 - Heart of England NHS Foundation Trust

HT_0709_consent 1
Assessment of patient’s best interests
Consent Form 4
As far as is reasonably possible, I have considered the person’s past and present wishes and feelings (in particular
Adults who lack the capacity to consent to investigation or treatment
Patient details (or pre-printed label)
Patient’s surname/family name ............................................... Patient’s first names ....................................................
Date of Birth............................................................................. Male Female NHS number ............................................................................. PID ................................................................................
Responsible health professional.......................................................................................................................................
Job title ..................................................................................... Registration number...................................................
Special requirements.........................................................................................................................................................
if they have been written down) and any beliefs and values that would likely influence the decision in question.
As far as possible, I have consulted other people (those involved in caring for the patient, interested in their
welfare or the patient has said should be consulted) as appropriate. I have considered the patient’s best interests
in accordance with the requirements of the Mental Capacity Act and believe the procedure to be in their best
interests because:.......................................................................................................................................................
Where the lack of capacity is likely to be temporary, for example if patient is unconscious, or where patient has
fluctuating capacity, complete the following section:
The treatment cannot wait until the patient recovers capacity because:....................................................................
...........................................................................................................................................................................................
(eg other language/other communication method)
Involvement of the patient’s family and others close to the patient
Name of proposed procedure or course of treatment (include brief explanation if medical
The final responsibility for determining whether a procedure is in an incapacitated patient’s best interests lies
term not clear): .................................................................................................................................................................
with the health professional performing the procedure. However, it is good practice to consult with those close
...........................................................................................................................................................................................
Assessment of patient’s capacity (in accordance with the Mental Capacity Act)
to the patient (eg spouse/partner, family and friends, carer, supporter or advocate) unless you have good reason
to believe that the patient would not have wished for particular individuals to be consulted, or unless the
urgency of their situation prevents this. “Best interests” go far wider than “best medical interests”, and include
I confirm that the patient lacks capacity to give or withhold consent to this procedure or course of treatment
factors such as the patient’s wishes and beliefs when competent, their current wishes, their general well-being
because of an impairment of the mind or brain or disturbance affecting the way their mind or brain works (for
and their spiritual and religious welfare.
example, a disability, condition or trauma, or the effect of drugs or alcohol) and they cannot do one or more of
the following:
To be signed below by a person or persons close to the patient, if they wish:
•
understand information about the procedure or course of treatment
I / We have been involved in a discussion with the relevant health professionals over the treatment of
•
retain that information in their mind
.............................................................(patient’s name). I / We understand that he / she is unable to give his / her
•
use or weigh that information as part of the decision-making process, or
own consent, based on the criteria set out in this form. I / We also understand that this treatment can lawfully
•
communicate their decision (by talking, using sign language or any other means)
be provided as it is in his/her best interests to receive it.
Further details of this assessment: (for example how above judgements reached, which colleagues consulted,
Any other comments (including any concerns about decision):......................................................................................
what attempts were made to assist the patient to make his or her own decision and why these were not
.............................................................................................................................................................................................
successful):...........................................................................................................................................................................
Name.................................................................... Relationship to patient........................................................................
Advance decision to refuse medical treatment
Address (if not the same as patient)............ ....................................................................................................................
Signature..................................................................................Date...................................................................................
This patient has/has not (delete as appropriate) made an advanced decision to refuse medical treatment.
If a person close to the patient is not available in person, has this matter been discussed in any other way (eg
Where an advance decision to refuse medical treatment has been made, please document the details of the
over the telephone)?
Yes
No
treatment to be refused here: ..........................................................................................................................................
............................................................................................................................................................................................
Independent Mental Capacity Advocate (IMCA)
Where, to the best of your knowledge, the patient has not refused this procedure in a valid Advance Decision,
For decisions about serious medical treatment, where there is no one appropriate to consult other than paid
please continue to the next section.
No
Record full details of the conversations, and the outcome, in the patient’s medical records
Lasting Power of Attorney/ Court Appointed Deputy
If the patient has authorised an attorney to make decisions about the procedure in question under a Lasting
Signature of health professional proposing treatment
Power of Attorney or a Court Appointed Deputy has been authorised to make decisions about the procedure in
The above procedure is, in my clinical judgement, in the best interests of the patient, who lacks capacity to
question, they have authority to make decisions in the patient’s best interests.
consent for himself or herself. Where possible and appropriate I have discussed the patient’s condition
Signature of attorney or deputy:
with those close to him or her, and taken their knowledge of the patient’s views and beliefs into account in
I have been authorised to make decisions about the procedure in question under a Lasting Power of Attorney
determining his or her best interests.
/ as a Court Appointed Deputy (delete as appropriate). I have considered the relevant circumstances relating to
the decision under the heading ‘Assessment of patient’s best interests’ and believe the procedure to be in the
patient’s best interests. Any other comments (including the circumstances considered in assessing the patient’s
Signature.....................................................................................Date...............................................................................
Name (PRINT)..............................................................................Job Title........................................................................
best interests): ................................................................................................................
....................................................
Where a second health professional’s opinion is sought, he/she should sign below to confirm agreement:
.............................................................................................................................................................................................
Signature.....................................................................................Date...............................................................................
Name:............................................................................................................................. Date............................................
Name (PRINT)..............................................................................Job Title........................................................................
Address:...............................................................................................................................................................................
Signature:…….………………………………........................................................................................................................
Copy accepted by patient: yes / no (please ring)
YELLOW COPY: CASE NOTES WHITE COPY: PATIENT
HWZ0007S
Guidance to health professionals
(to be read in conjunction with consent policy)
What a consent form is for
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 1 if they choose to have treatment. 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 made a valid
advance decision to refuse treatment that is applicable to the proposed treatment then you must abide by that refusal.
For further information on the law on consent, see Department of Health’s Reference guide to consent for examination
or treatment (www.doh.gov.uk/consent).
When treatment can be given to a patient who lacks the capacity
to consent
All decisions made on behalf of a patient who lacks capacity must be made in accordance with the Mental Capacity
Act 2005. More information about the Act is given in the Code of Practice. Treatment can be given to a patient who is
unable to consent if:
•
•
the patient lacks the capacity to give or withhold consent to this procedure AND
the procedure is in the patient’s best interests.
Capacity
A person lacks capacity if they have an impairment or disturbance (for example, a disability, condition or trauma, or the
effect of drugs or alcohol) that affects the way their mind or brain works which means that they are unable to make a
specific decision at the time it needs to be made. It does not matter if the impairment or disturbance is permanent or
temporary.
You must take all steps reasonable in the circumstances to assist the patient in taking their own decisions. 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
(as distinct from an IMCA as set out below) or supporters. Sometimes it may be necessary for a formal assessment to be
carried out by a suitably qualified professional.
Capacity is ‘decision-specific’; a patient may lack capacity to take a particular complex decision, but be able to take
other more straight-forward decisions or parts of decisions. Capacity can also fluctuate over time and you should
consider whether the person is likely to regain capacity and if so whether the decision can wait until they regain
capacity.
and applicable Advance Decision refusing the specific treatment. The Mental Capacity Act requires that
a health professional must consider all the relevant circumstances relating to the decision in question,
including, as far as possible:
•
•
•
the person’s past and present wishes and feelings (in particular if they have been written down)
any beliefs and values (e.g. religious, cultural or moral) that would be likely to influence the
decision in question and any other relevant factors
the other factors that the person would be likely to consider if they were able to do so.
When determining what is in a person’s best interests a health professional must not make assumptions
about someone’s best interests merely on the basis of the person’s age or appearance, condition or any
aspect of their behaviour. If the decision concerns the provision or withdrawal of life-sustaining treatment
the health professional must not be motivated by a desire to bring about the person’s death.
The Act also requires that, as far as possible, health professionals must consult other people, if it is
appropriate to do so, and take into account of their views as to what would be in the best interests of the
person lacking capacity, especially anyone previously named by the person lacking capacity as someone to
be consulted and anyone engaging in caring for patient and their family and friends.
Independent Mental Capacity Advocate (IMCA)
The Mental Capacity Act introduced a duty on the NHS to instruct an Independent Mental Capacity
Advocate (IMCA) in serious medical treatment decisions when a person who lacks capacity to make a
decision has no one who can speak for them, other than paid staff. IMCAs are not decision makers for
the person who lacks capacity. They are there to support and represent that person and to ensure that
decision making for people who lack capacity is done appropriately and in accordance with the Act.
Lasting Power of Attorney and Court Appointed Deputy
A person over the age of 18 can appoint an attorney to look after their health and welfare decisions,
if they lack the capacity to make such decisions in the future. Under a Lasting Power of Attorney (LPA)
the attorney can make decisions that are as valid as those made by patients themselves when they have
capacity. The LPA may specify limits to the attorney’s authority and the LPA must specify whether or
not the attorney has the authority to make decisions about life-sustaining treatment. The attorney can
only, therefore, make decisions as authorised in the LPA and must make decisions in the person’s
best interests.
The Court of Protection can appoint a deputy to make decisions on behalf of a person who lacks capacity.
Deputies for personal welfare decisions will only be required in the most difficult cases where important
and necessary actions cannot be carried out without the court’s authority or where there is no other
way of settling the matter in the best interests of the person who lacks capacity. If a deputy has been
appointed to make treatment decisions on behalf of a person who lacks capacity then it is the deputy
rather than the health professional who makes the treatment decision and the deputy must make
decisions in the patient’s best interests.
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. The Court of Protection deals with serious decisions affecting personal welfare matters, including
healthcare, which were previously dealt with by the High Court. Cases involving:
A person is unable to make a decision if they cannot do one or more of the following things:
•
•
•
•
•
Understand the information given to them that is relevant to the decision.
Retain that information long enough to be able to make the decision.
Use or weigh up the information as part of the decision-making process.
Communicate their decision - this could be by talking or using sign language and includes simple muscle
movements such as blinking an eye or squeezing a hand.
Best interests
Treatment may be provided in an incapacitated adult’s best interests provided that the patient has not made a valid
•
•
•
decisions about the proposed withholding or withdrawal of artificial nutrition and hydration
(ANH) from patients in a permanent vegetative state (PVS)
cases involving organ, bone marrow or peripheral blood stem cell (PBSC) donation by an adult
who lacks capacity to consent
cases involving the proposed non-therapeutic sterilisation of a person who lacks capacity to
consent to this (e.g. for contraceptive purposes) and
all other cases where there is a doubt or dispute about whether a particular treatment will be in a
person’s best interests (include cases involving ethical dilemmas in untested areas)
should be referred to the Court for approval. The Court can be asked to make a decision in cases where
there are doubts about the patient’s capacity and also about the validity or applicability of an advance
decision to refuse treatment.
HT_0709_consent 1
Assessment of patient’s best interests
Consent Form 4
As far as is reasonably possible, I have considered the person’s past and present wishes and feelings (in particular
Adults who lack the capacity to consent to investigation or treatment
Patient details (or pre-printed label)
Patient’s surname/family name ............................................... Patient’s first names ....................................................
Date of Birth............................................................................. Male Female NHS number ............................................................................. PID ................................................................................
Responsible health professional.......................................................................................................................................
Job title ..................................................................................... Registration number...................................................
Special requirements.........................................................................................................................................................
if they have been written down) and any beliefs and values that would likely influence the decision in question.
As far as possible, I have consulted other people (those involved in caring for the patient, interested in their
welfare or the patient has said should be consulted) as appropriate. I have considered the patient’s best interests
in accordance with the requirements of the Mental Capacity Act and believe the procedure to be in their best
interests because:.......................................................................................................................................................
Where the lack of capacity is likely to be temporary, for example if patient is unconscious, or where patient has
fluctuating capacity, complete the following section:
The treatment cannot wait until the patient recovers capacity because:....................................................................
...........................................................................................................................................................................................
(eg other language/other communication method)
Involvement of the patient’s family and others close to the patient
Name of proposed procedure or course of treatment (include brief explanation if medical
The final responsibility for determining whether a procedure is in an incapacitated patient’s best interests lies
term not clear): .................................................................................................................................................................
with the health professional performing the procedure. However, it is good practice to consult with those close
...........................................................................................................................................................................................
Assessment of patient’s capacity (in accordance with the Mental Capacity Act)
to the patient (eg spouse/partner, family and friends, carer, supporter or advocate) unless you have good reason
to believe that the patient would not have wished for particular individuals to be consulted, or unless the
urgency of their situation prevents this. “Best interests” go far wider than “best medical interests”, and include
I confirm that the patient lacks capacity to give or withhold consent to this procedure or course of treatment
factors such as the patient’s wishes and beliefs when competent, their current wishes, their general well-being
because of an impairment of the mind or brain or disturbance affecting the way their mind or brain works (for
and their spiritual and religious welfare.
example, a disability, condition or trauma, or the effect of drugs or alcohol) and they cannot do one or more of
the following:
To be signed below by a person or persons close to the patient, if they wish:
•
understand information about the procedure or course of treatment
I / We have been involved in a discussion with the relevant health professionals over the treatment of
•
retain that information in their mind
.............................................................(patient’s name). I / We understand that he / she is unable to give his / her
•
use or weigh that information as part of the decision-making process, or
own consent, based on the criteria set out in this form. I / We also understand that this treatment can lawfully
•
communicate their decision (by talking, using sign language or any other means)
be provided as it is in his/her best interests to receive it.
Further details of this assessment: (for example how above judgements reached, which colleagues consulted,
Any other comments (including any concerns about decision):......................................................................................
what attempts were made to assist the patient to make his or her own decision and why these were not
.............................................................................................................................................................................................
successful):...........................................................................................................................................................................
Name.................................................................... Relationship to patient........................................................................
Advance decision to refuse medical treatment
Address (if not the same as patient)............ ....................................................................................................................
Signature..................................................................................Date...................................................................................
This patient has/has not (delete as appropriate) made an advanced decision to refuse medical treatment.
If a person close to the patient is not available in person, has this matter been discussed in any other way (eg
Where an advance decision to refuse medical treatment has been made, please document the details of the
over the telephone)?
Yes
No
treatment to be refused here: ..........................................................................................................................................
............................................................................................................................................................................................
Independent Mental Capacity Advocate (IMCA)
Where, to the best of your knowledge, the patient has not refused this procedure in a valid Advance Decision,
For decisions about serious medical treatment, where there is no one appropriate to consult other than paid
please continue to the next section.
No
Record full details of the conversations, and the outcome, in the patient’s medical records
Lasting Power of Attorney/ Court Appointed Deputy
If the patient has authorised an attorney to make decisions about the procedure in question under a Lasting
Signature of health professional proposing treatment
Power of Attorney or a Court Appointed Deputy has been authorised to make decisions about the procedure in
The above procedure is, in my clinical judgement, in the best interests of the patient, who lacks capacity to
question, they have authority to make decisions in the patient’s best interests.
consent for himself or herself. Where possible and appropriate I have discussed the patient’s condition
Signature of attorney or deputy:
with those close to him or her, and taken their knowledge of the patient’s views and beliefs into account in
I have been authorised to make decisions about the procedure in question under a Lasting Power of Attorney
determining his or her best interests.
/ as a Court Appointed Deputy (delete as appropriate). I have considered the relevant circumstances relating to
the decision under the heading ‘Assessment of patient’s best interests’ and believe the procedure to be in the
patient’s best interests. Any other comments (including the circumstances considered in assessing the patient’s
Signature.....................................................................................Date...............................................................................
Name (PRINT)..............................................................................Job Title........................................................................
best interests): ................................................................................................................
....................................................
Where a second health professional’s opinion is sought, he/she should sign below to confirm agreement:
.............................................................................................................................................................................................
Signature.....................................................................................Date...............................................................................
Name:............................................................................................................................. Date............................................
Name (PRINT)..............................................................................Job Title........................................................................
Address:...............................................................................................................................................................................
Signature:…….………………………………........................................................................................................................
Copy accepted by patient: yes / no (please ring)
YELLOW COPY: CASE NOTES WHITE COPY: PATIENT
HWZ0007S