Trafford Capacity Assessment & Best Interests Pack...Contents of the Pack Capacity Assessment Guidance Capacity Assessment Document Generic Best Interest Decision Form DNAR Best Interest

Trafford Capacity Assessment &

Best Interests Pack

June 2016

Contents of the Pack

Capacity Assessment Guidance

Capacity Assessment Document

Generic Best Interest Decision Form

DNAR Best Interest Decision Form

Information, advice, guidance and support regarding Mental Capacity and Best Interest Decisions in Trafford

Trafford DoLS Team, Trafford Council, - 0161 912 2036 [email protected]

Ms. Gilli Painter, Named Professional for Safeguarding Adults, Greater Manchester West Mental Health NHS Foundation Trust (Trafford) [email protected] Ms. Lesley Shaw, Lead Nurse for Vulnerable Adults, University Hospital South Manchester NHS Foundation Trust - 0161 291 2382 [email protected] M. Corrine Power, Named Nurse for Vulnerable Adults, Central Manchester University Hospitals NHS Foundation Trust (Trafford) [email protected] Dr. Mark Jarvis, Executive Clinical Director, NHS Trafford [email protected] Dr. George Kissen Medical Director, NHS Trafford - 0161 873 6084, [email protected] Ms. Julie Ryder, Named Nurse for Vulnerable Adults, Central Manchester University Hospitals NHS Foundation Trust - 0161 276 1234 [email protected] Mr. Phil Spilsted Lead Nurse for Vulnerable Adults for Learning Disability Services in Trafford - 01244 397 643

mailto:[email protected]







Capacity Assessment Guidance

The MCA sets out the five ‘statutory principles’ – these are the values that underpin the legal requirements in the Act and are founded in the Human Rights Act. These principles should be adhered

to when undertaking any assessment of capacity.

The five statutory principles are:

1 A person must be assumed to have capacity unless it is established that they lack capacity. 2 A person is not to be treated as unable to make a decision unless all practicable steps to help

him/her to do so have been taken without success. 3 A person is not to be treated as unable to make a decision merely because he/she makes an

unwise decision. 4 An act done or a decision made under this Act for or on behalf of a person who lacks

capacity must be done, or made, in his/her best interests. 5 Before the act is done, or the decision is made, regard must be had to whether the purpose

for which it is needed can be as effectively achieved in a way that is less restrictive of the

person’s rights and freedom of action. The MCA also introduces a new criminal offence of ill treatment or neglect of a person who lacks

capacity. A person found guilty of such an offence may be liable to a fine and/or imprisonment for a

term of up to five years. For further information and guidance please refer to the MCA Code of Practice. Decisions not covered by the best interests principles - The following decisions cannot be made in a person’s best interests as they are covered by other legal processes and require the person to have capacity, and / or court proceedings, to address: • to vote, • to marry or divorce (including civil partnerships), • to consent to sexual relations, • to consent to fertility treatment, • to make a decision to place a child up for adoption.

Assessing Capacity for the Level 1 Competency Framework

The process below can be completed when considering if a capacity assessment is required. The form on the next

page can be completed by staff to record their decisions and evidenced based practice under section 1 on the

competency framework.

The process is designed to help you establish an individual’s decision-making capacity, and takes you

through the following steps:

STEP 1: Determine whether an assessment of capacity is required or appropriate at this point in time.

Part 1. Does the person have an

impairment of, or a

disturbance in the

functioning of the mind or brain?

Please provide details Outcome

Yes

No

If you have answered NO to part 1 you should assume that the person has capacity to make the

decision. Please proceed to the conclusion to record this outcome.

Part 2. Is the impairment temporary, fluctuating or permanent?

If the impairment is

temporary or fluctuating

can the decision be

delayed until the

individual’s decision

making ability has

improved?

Please provide details

If you have answered YES to part 1 and you are not able to delay the decision to allow for the

recovery of capacity then you should proceed to Step 2 below.

STEP 2: Determine the time frame in which you need to undertake this

assessment.

Please specify a date or time frame within which this decision needs to be made.*

*It is important to establish this as it informs you how long you have to gather the relevant information

necessary for the person to be able to make a decision, as well as the requirement to maximise capacity

where possible. The Mental Capacity Act Code of Practice (s2.7) states that the level of support depends on

personal circumstances, the kind of decision that has to be made and the time available to make the

decision. If a decision can be delayed to allow for additional support then the appropriateness of doing

this should be considered.

STEP 3: Planning and Preparation Stage*

1. Please provide details

What information is

required for the person to

make an informed

decision?

Is there a choice or are

there alternatives?


How do you plan to present the information to the

person (e.g. verbal, written, diaries, visual etc.?)

How are you going to

manage any sensory or cognitive difficulties that may be present?


Are there particular times

of the day when the person understands or concentration is better?

Are there particular locations where the person

may feel more at ease?

4. Please provide details Who can help at the

preparation stage e.g. gathering relevant information relating to the

decision?

Can anyone assist to help

the person make a decision

or express their view (e.g. advocate, carer, and interpreter)?

*In order for an accurate assessment to be undertaken, it is important that the individual is presented with

adequate information about the decision, including choices and alternatives, in a way that is understandable, and in an environment that maximises understanding and communication. This section helps you to think

about how to do this before meeting with the person.

STEP 4: The 4-part statutory Mental Capacity Test*

1. Does the person have an

understanding of the

relevant information

relating to the decision?

This includes why they

have to make the decision, options available, consequences of deciding

one way or another or making no decision at all?

Please provide evidence supporting the outcome, including person’s responses and quotations where

appropriate.

Outcome

Yes

No

2. Is the person able to hold the information in their mind long enough to use it to make an effective

decision?

Please provide evidence supporting the outcome, including person’s responses and quotations where appropriate.

Outcome

Yes

No

3. Is the person able to weigh

up the information and use it to arrive at a decision?


appropriate.

Outcome

Yes

No

4. Can the person

communicate his / her decision (e.g. talking, sign

language, other form of communication)?


appropriate.

Outcome

Yes

No

*The statutory test from the Mental Capacity Act (2005) is designed to establish whether the impairment or disturbance is sufficient enough that the individual lacks capacity to make that particular decision at the time it needs to be made. All four parts must be assessed. Guidance on addressing these areas can be found in the MCA

2005 Code of Practice s4.14 to s4.25.

29

STEP 5: Take into account additional factors beyond the skills of the individual

Are there additional factors beyond the cognitive and communication skills of the individual which you

believe are affecting the person’s ability to make a free and balanced decision? This may include

external influences such as coercion or threats from others. Please provide details Has this resulted in

your opinion in

impairment in the

person’s capacity to

make this decision?

Yes

No

STEP 6: Conclusion*

Having taken ‘reasonable’ steps to establish capacity, I consider on the balance of probabilities, that the

person DOES have capacity to make this decision

Having taken ‘reasonable’ steps to establish capacity, I consider on the balance of probabilities, that the

person DOES NOT have capacity to make this decision

* The MCA 2005 Code of Practice (s 4.10) refers to the level of proof required for claiming that a person lacks

capacity. An assessor must be able to show, “on the balance of probabilities, that the individual lacks capacity to

make a particular decision, at the time it needs to be made (section 2(4)). This means being able to show that it is more likely than not that the person lacks capacity to make the decision in question.”

Signature of person/s assessing:

Post Title of person/s assessing:

Date:

If the person has been assessed as lacking capacity and the decision is not to be deferred then it will be necessary to make a Best Interests Decision on behalf of that individual. If the decision is complex i.e. 2 + on the competency framework please ensure you are a suitable qualified and experienced practitioners to be able complete this and proceed to Trafford’s Capacity Assessment form on page 40

Capacity Assessment Form Information When NOT to use this form: Do not use this form for small decisions that affect a person’s daily routine, for example:

what the person wears;

how they use their weekly benefits to buy necessities;

when they take their meals.

if the service provision (care package) on discharge from hospital is the same as when the person was admitted to hospital a ‘capacity assessment’ will not need to be carried out.

If you can’t support the person to take their own decisions in these routine areas and you need to decide things for them, you should note what you have done and why in the nursing care plan, support plan, social care plan or equivalent. Do not use this form when…there is someone empowered to make the decision, for example an attorney (appointed by the person when they had capacity) or a deputy appointed by the Court of Protection. Check! What areas is the attorney or the person’s deputy empowered to make decisions about? 1) Health & Welfare only, 2) Property & Finances only or 3) Health & Welfare AND Property & Finances. This is important to know and to check out. Whenever possible you will want to see copies of documents or orders. Remember, you may still need to use this form to determine that a person lacks capacity to make specific decisions which will enable Enduring Powers for Finances or Lasting Powers for Health & Well Being to begin. For example, if there is a serious medical decision to be made, but the deputy or attorney is only empowered to act on the person’s behalf for finances and property. In that circumstance an assessment of capacity would still be required as this is a health and welfare decision.

When to use this form: Use this form when key decisions and actions are taken on a person’s behalf because they do not have the capacity to decide for themselves. ‘Key decisions’ means significant decisions that go beyond a person’s daily routine or way of life. For example, decisions about:

minor clinical treatment, dentistry, ophthalmics or surgery, even if the decision may be not to treat the person a capacity assessment and best interest decision IS STILL REQUIRED.

the use of person’s money for more than their usual necessities

obtaining or disposing of possessions of significant value

spending short periods away from their home

limiting activities (like smoking or drinking) that the person would normally choose to do

bringing new people into the person’s life (like an advocate or volunteer). Also use this form for big, life-changing decisions, for example:

Moving to a different home or living somewhere else

Having major clinical treatment, dentistry or surgery, even if the decision may be not to treat the person capacity assessment and best interest decision IS STILL REQUIRED.

Disposing of significant assets.

Preventing someone from leaving a hospital or care home who needs treatment

Do Not Attempt Resuscitation (DNAR) Decisions These decisions will usually involve a wider range of people in the decision-making process, sometimes at a Best Interest Meeting. This form should then be used in conjunction with the Best Interest Decision document or the DNAR Best Interest Decision Document

All sections within the form will expand automatically as you type – all forms must be typed. DO NOT handwrite the form, there is insufficient room to add the information needed.

Capacity Assessment Form

Embedding the philosophy of “Make no decision about me without me” into practice

Section 1. Information about the Adult:

Name of adult: NHS Number:

Date of Birth: Sex: Female Male

Address: Post Code:

Mobile Number:

Ethnicity: First Language:

GP details, including address and contact number:

Section 2. Communication & reasonable adjustment

Are there any communication difficulties? Yes No If yes, tell us about them here:

Does the adult at risk require an interpreter? Yes No If yes, tell us about this here:

Does the adult require a Speech and Language Therapist?

Yes No If yes, tell us about this here:

Does the adult at risk require any other reasonable adjustment or support to communicate?


Section 3. Legal Powers of others to act on behalf of the adult:

If you answer yes to any of the questions 3a – 3f, you must ask to see original documents to check their validity. If the documents aren't available, telephone the Court of Protection to check. If the decision is urgent, there is no need to wait to see the documents – but the person’s representative must be made aware that documents will need to be verified after the event. Make the person’s representative aware that providing misleading information, or misusing legal powers, may result in arrest and prosecution.

3a) Does the person have an old Enduring Power of Attorney? (this will only become an effective only after the person has been assessed as lacking capacity to make decisions about their property or finances)

Yes No Don’t know If yes, tell us about the person here: Name: Relationship: Contact details:

3b) Does the person have a new Lasting Power of Attorney for Finances/Property? (can be activated before loss of capacity)


3c) Does the person have a new Lasting Power of Attorney for Health & Welfare? (effective only after the person has been assessed as lacking capacity to make specific decisions about health and/or welfare)


3d) Does the person have a legal Advance Decision to refuse medical treatment? (Explicit, witnessed,

dated and signed)

Yes No Don’t know If yes, is a copy available? Yes No (a copy will need to be seen)

3e) Does the person have a Court Appointed Deputy?


3f) Is the person subject to an existing Guardianship Order?

Yes No Don’t know If yes, tell us about the person here: Name:

Relationship: Contact details:

Section 4. Tell us about the type of decision, and the specific decision to be made. You can only ask the person to make one decision at a time. TICK ONLY ONE BOX.

Treatment Decision e.g. Clinical/Medical/Surgical Treatment, Medication

associated decisions, Nursing Treatment, Therapy treatments,

Podiatry, Dentistry...

Example: Susan has been asked to decide if she will have an ingrowing toenail removed.

Tell us about the specific decision you are asking the person to make:

Care Decision

e.g. Nursing Care, Care delivered by Support Workers, Home Care, Day Care, Care delivered by family members or unpaid

carers... You would assess for a care decision where

someone was consistently refusing care to their detriment

which my lead to allegations of harm or constitute neglect.

Example: Susan has been asked to decide if she will allow the care assistants to help her change position regularly to prevent pressure area breakdown


Accommodation Decision

e.g. Deciding to go into a Care Home, Moving from one Care Home to another, Accepting or relinquishing a tenancy...

Example Susan wants to accept a tenancy agreement to be able to live in alternative accommodation.


Property or Finance Decision

e.g. Gifting money, selling property, selling shares or realising other assets, making large withdrawals of cash...

Example: Susan has said she wishes to give her friend ten thousand pounds from her inheritance.


Risk/Danger Decision e.g. Wanting to go outdoors without support, travelling on public transport from one city to another, taking a flight...

Example: Susan wishes to go shopping to the Trafford Centre alone


Adult Safeguarding Decision

e.g. Deciding if an investigation should take place after a disclosure or identification of safeguarding concerns...

Example: Susan has disclosed she is being financially abused by another resident in her street. Her decision is if she wants this investigated under the adult safeguarding procedures.


Legal Decision

e.g. Making a Will...

Example: Susan has decided she wishes to make a will


Other decision not listed


Section 5. Independent Mental Capacity Advocates (IMCA)

Does the person require an IMCA Yes No

If yes, tell us about this here:

Date and time IMCA requested Date: Time:

You must complete ALL of sections 6, 7, 8,9,10 and 10a

Please record the discussion that took place during the assessment in the

next section.

Section 6. Providing and understanding information

Have you provided the person with information about the decision, in a way that helps them to understand and in formats that are accessible to them? This could be verbal information, written information, easy read or pictorial information, dvd, mp4 file or by accessing web pages. It is for you to agree with the person how much information they would like and in what format.

Yes, I have provided the person with information in formats

accessible to them Tell us about the information provided here:

To continue with the assessment you must provide the person with information about the decision in formats that are accessible to them. Please provide the person with information.

Was the person able to understand the information relevant to the decision provided?

Yes

Tell us how you were able to determine this here:

No, the person was not able to understand the information

Please tell us why here:

Section 7. Retaining the information

Has the person been able to retain the information in their mind long enough to make a decision? The Mental Capacity Act does not say how long “long enough” is. This a judgement decision for you as the assessor.

Yes


No, the person was not able to retain the information for

long enough to be able to make a decision. Please tell us why here:

Section 8. Weighing the information

Has the person used or weighed the information as part of the decision making process? The person will need to be able demonstrate to you that they understand the pros and cons of the decision being made.

Yes


No, the person was not able to weigh the information as part

of the decision making process. Please tell us why here:

Section 9. Communicating their decision

Has the person been able to communicate their decision to you in?

This point only applies if the person has not been unable to communicate their decision to you in any way.

Yes Tell us how you were able to determine this here:

No, the person was not able to communicate their decision

to me Please tell us why here:

Section 10. Does the person have a disturbance in the function of the mind or brain? e.g. the person has Dementia, a Learning Disability, Confusion secondary to infection, the person is intoxicated, the person has been using illicit substances - you don't need a diagnosis here, it is enough to say the person is presenting as confused. This is your space to say why you believe there is reason to doubt the persons "presumed capacity".

No, the person does not have an impairment or disturbance in the function of their mind or brain

You have ticked No, and therefore must stop the assessment. In

order to proceed the person must have an impairment or disturbance of their mind or brain.

Yes, the person does have an impairment or disturbance in the function of their mind or brain

Please tell us what the impairment or disturbance is here:

Section 10a. Does the impairment or disturbance mean that the person is unable to make a specific decision when they need to? The person CAN make the specific decision even though there is an impairment or disturbance in the function of their mind or

brain

The person CAN NOT make the specific decision due to the impairment or disturbance in the function of their mind or brain

Section 11. In your opinion, is the impairment or disturbance permanent or temporary? an example being drunk is temporary, Alzheimer’s disease is permanent, a Urinary Tract

Infection is temporary, Acquired Brain Injury could be permanent.

Temporary

You have clicked temporary, can the decision wait until the impairment or disturbance resolves?

Yes - then stop the assessment and wait.

No - tell us below why the decision can't wait

Permanent

Please tell us why below:

You have now concluded your assessment and will need to make a decision

about whether the person can make the specific decision.

Remember, you are only being asked to have reasonable grounds for believing that what you are deciding if the

person does, or does not have the capacity, at this material time, to make the decision.

Section 12. Outcome of this Mental Capacity Assessment

The person lacks capacity I have completed my assessment. I confirm that I have assessed the person named in this form and determined that they lack capacity relating to the specific decision named in section four of this form. In accordance with the requirements of the Mental Capacity Act, 2005 I will now co-ordinate the Best Interest Process, recording my actions on the generic Best Interest Decision Form or the specific Do Not Attempt Resuscitation (DNAR) Best Interest Decision Form.

The person does not lack capacity I have completed my assessment. I have determined that the person named in this form has the mental capacity to make their own decision relating to the specific decision named in section four of this form. The person’s decision will now be accepted as valid in accordance with the Mental Capacity Act, 2005.

Section 13. Details of the person completing form and reaching a decision

Name: Job title:

Based at e-mail:

Base Telephone Mobile number

Section 13a. Date assessment commenced and completed

Date commenced Date completed

Generic Best Interests Form

Best Interest Decision Form Embedding the philosophy of “Make no decision about me without me” into practice




Address: Post Code:

Tel.no: Mobile Number:



Who is the person’s nominated representative? Name: Name:

Has the person’s representative been contacted? Yes No

Are they willing to engage in the decision making process

Yes No

Section 2. What is the decision to be made in the person’s best interest?

Please tell us the specific decision here:

Section 2a. Regaining capacity

Is it likely that the person will regain capacity?

Yes No

If you have answered yes to this question, can the decision wait until the person regains capacity? If yes, then wait! If not then please tell us why in the box below, then continue with the process:

Section 2b. Least Restrictive Option

Is this the least restrictive option for the person?

Yes

If this is the least restrictive option, please tell us why below:

No If it is not the least restrictive option, please tell us why below:

Section 3. Independent Mental Capacity Advocates (IMCA) If the person is unbefriended, meaning they have no nominated representative and there is nobody willing to act as such or the nominated representative does not want to be part of the decision making process (but is not objecting to it) or the person’s nominated representative is alleged to have harmed, exploited or abused the person you should appoint an IMCA. IMCA Referral forms can be found here

http://www.traffordpct.nhs.uk/Library/Your_Health/Safeguarding_Adults/Trafford%20Spot%20Purchase%20IMCA%20Referral%20Form%20-%20Screening%20team.doc

Does the person require an IMCA

Yes No

If yes, tell us why here:

Date and time IMCA requested

Date: Time:

Section 4. Tell us here about other people consulted as part of this

decision making process – not every decision requires a meeting!

The people listed below: where consulted as part of a discussion Attended a best interest meeting

See appendix 1 for a balance sheet tool

Person 1:

Role/Representing:

Contact number

e-mail

Consulted Invited Attended Apologies

Person 2 Role/Representing: Contact number

e-mail


Person 3. Role/Representing: Contact number

e-mail



e-mail



e-mail



e-mail



e-mail



e-mail



e-mail



e-mail


Section 5.

Question 1 What is the justification for the proposed care, treatment, decision or action?

Question 2 Are there any risks relating to proposed care, treatment or decision?

Question 3 Are there any risks related to not carrying out the proposed care, treatment or decision?

Question 4 Are the persons past or present wishes/feelings regarding the treatment or decision known?

Question 5 Are there any beliefs and or values that would be likely to influence the decision, if he/she had the capacity?

Question 6 What are the views of the other, relevant people in the person’s life?

Question 7

Are there any disputes between any party about what is in the person’s best interests?

No, proceed with Best Interest Decision

Yes, a decision will need to be made by the Best Interest Assessor (the person completing this form) whether the decision can be delayed or whether action needs to be taken at once, key considerations are relief of pain, protection from harm/abuse or

exploitation and the preservation of life. Please tell us here the nature of the dispute: Dispute resolution should take the following forms: Local dispute resolution meeting chaired by the local Designated Nurse for Safeguarding & Vulnerable Adults or a Named Lead Safeguarding Professional. Where local dispute resolution fails, the matter can be referred to the Court of Protection for a judgement. NB: The party that refers to the Court of Protection are usually liable for the costs of the case.

Section 6. Outcome of Best Interest discussion/meeting Please tell us the outcome of your discussions here and reasonable beliefs with regard to Best Interests:

Yes No

Where the Court of Protection is not involved professionals, carers, relatives and others can only be expected to have reasonable grounds for believing that what they are doing, or deciding, is in the best interests of the person concerned. They must be able to demonstrate objective reasons as to why they believe they are acting in the person's best interests and they must have considered all relevant circumstances.

Section 7. Declaration I, the undersigned, believe this to be a fair representation of the discussions that took place. Those consulted agree that we have reasonable grounds for believing that what we are doing, or deciding, is in the best interests of the person concerned at this point in time.

Name of person completing this document:

Job title of person completing this document

Contact details of person completing this document

Date document completed

Balance Sheet Tool The balance sheet tool should be used where there are two or more available options, the basic structure would be:

BENEFITS OF A

BENEFITS OF B

PLUS BURDENS OF B

PLUS BURDENS OF A

Whichever side of the balance is in significant credit is best. Note, however, that you are not looking at which list has the most factors. Each factor will have a different weight. Hence you could use different fonts in the balance sheet to identify the different weight attached to the considerations. For example ‘this font’ indicates equal weight, ‘italics’ indicates less than equal weight, ‘bold’ indicates more than equal weight, and ‘bold and underlined’ indicates particularly weighty considerations. Every case is different and will involve different considerations below is an example. Please see the example on the next page. Example An 80 year old female with a diagnosis of dementia, physically well, very active and mobile but without mental capacity to make care, treatment, risk or financial decisions or to litigate. She was constantly asking to go home and had tried to leave the care home. The balance sheet approach can be used in this complex case with the following outcomes:

BENEFITS OF OWN HOME (A)

BENEFITS OF CARE HOME (B)

1. Continues to remain in a familiar place.

2. She does not feel unsafe. 3. She wants to be independent. 4. She wonders why she is in a hotel

1. Regular meals/hydration. 2. Prompting with medication. 3. Prompting with personal

care/hygiene. 4. Pressure/skin area

and not at home. 5. More family contact and

maintaining community contacts.

6. Increased care package. 7. This is where she is happiest.

support/treatment. 5. Physical safety improved. 6. Staff available 24/7 to deal with

crisis. 7. On-going reassurance for her

anxieties. 8. Improved dignity. 9. Release strain on family

members. 10. Anti-depressants and anti-

psychotics can be administered. 11. She enjoys the company of

others. 12. Care and support may slow her

decline. 13. Less need for her to contact

emergency services. 14. Reduced possibility of

exploitation/cold callers.

PLUS BURDENS OF CARE HOME (B) PLUS BURDENS OF OWN HOME (A)

8. Likely to be affected by not being in own home.

9. Loss of independence. 10. Inevitable short term

anger/distress. 11. Stronger possibility of depression. 12. She may just give up. 13. Problems with contact and

community activities.

15. Not eating or drinking enough. 16. Insufficient/irregular medication. 17. Deteriorating personal hygiene. 18. Deteriorating pressure areas, 19. Risks of wandering/falls. 20. Increased psychological distress. 21. Community/family support has

failed.

DNAR Best Interest Decision Form

Guidance for Responsible Clinicians and Do Not Attempt Resuscitation Best Interest Decision Form

This form must only be used in conjunction with the Trafford Mental Capacity Assessment Form

This document has been produced to support and record decision making in DNAR decisions, where it has been determined that an adult lacks capacity to make such a decision at the material time the decision is required. This form is intended to replace the generic best interest decision form and is to be used only when DNAR decisions are required.

Responsibility for making a DNAR decision Responsibility for a DNAR decision rests with the most senior healthcare professional responsible for the patients care, defined in this document as the Responsible Clinician. When a DNAR decision is made it should be recorded clearly by the Responsible Clinician, together with the reasons for it and the names and designation of those involved in the discussion and decision. If no discussion takes place either with the patient or with those close to them, the reasons for this should be recorded in the patient’s record.

Mental Capacity Act and professional considerations In line with the Mental Capacity Act DNAR decisions cannot be made about a person based only on their condition, behaviour, age or appearance (including learning disability or mental ill health). This also means that whilst people's quality of life might form part of the decision making process, it is important that decisions are made based on the person's own perception (or those who know the person well) of the quality of their life and that judgements are not made about what constitutes quality of life based on the decision maker's own views.

When assessing whether attempting CPR may benefit the patient, the Responsible Clinician must not be unduly influenced by any of their own or others pre-existing (negative or positive) views about living with a particular condition or disability. The key issue to consider is not the Responsible Clinician’s view of the patient’s disability or level of recovery that can reasonably be expected following CPR, but an objective assessment of what is in the best interests of the patient, taking account of all relevant factors, particularly the patient’s own views.

Reviewing a DNAR decision DNAR decisions must be reviewed by the Responsible Clinician and must always occur when there are changes in the person’s condition or their wishes. NHS providers and Contractors may put in place further safeguards within local

policies with respect to how often the order is reviewed. When a DNAR order is put in place on admission, the BMA, Resuscitation Council and RCN Guidance recommends that this is reviewed at the earliest opportunity

Complete all sections of this form with as much information as you are able. All sections within the form will expand automatically as you type – all forms must be typed. DO NOT handwrite the form, there is insufficient room to add the information needed. Please be aware: You must only complete this form where you have already completed a mental capacity assessment and the person has been found unable to make a decision at that time regarding future attempts to resuscitate them. This form will replace the standard Best Interest Decision Form and must only be used when considering DNAR, all other treatment decisions must be made using standard documentation.

Points to highlight within the care record:

The physical, emotional and psychological impact on the person

Expressed preferences of the person about CPR and or a decision not to resuscitate

Views of their family or friends but also their perception of what decision the person would have made if they could

The least restrictive option

Relevant legal or medical guidance

Where the Court of Protection is not involved professionals, carers, relatives and others can only be expected to

have reasonable grounds for believing that what they are doing, or deciding, is in the best interests of the

person concerned. They must be able to demonstrate objective reasons as to why they believe they are acting in the

person's best interests and they must have considered all relevant circumstances.

Do Not Attempt Resuscitation Best Interest Decision Form to be used only in conjunction with the Trafford Capacity Assessment Form

The Mental Capacity Act 2005 Code of Practice (5.31) states that, “All reasonable steps which are in the person’s best interests should be taken to prolong their life. There will be a limited number of cases where treatment is futile, overly burdensome to the patient or where there is no prospect of recovery. In circumstances such as these, it may be that an assessment of best interests leads to the conclusion that it would be in the best interests of the patient to withdraw or withhold life sustaining treatment, even if this may result in the patient’s death.”




Address: Post Code:

Tel.no: Mobile Number:


Are there any communication difficulties? Yes No If yes, tell us about them here:

Does the adult at risk require an interpreter? Yes No If yes, tell us about this here:

Does the adult at risk require any other reasonable adjustment or support to communicate?



Tell us about any existing physical health difficulties here:

Does the adult at risk have an Advance Decision to refuse treatment in place?

Yes No Not known

Who is the person’s nominated representative? Name: Name:

Has the person’s representative been contacted? Yes No Date: Time: By Whom?

Are they willing to engage in the decision making process?

Yes No

Section 2. Independent Mental Capacity Advocates (IMCA) If the person is unbefriended, meaning they have no nominated representative and there is nobody willing to act as such or the nominated representative does not want to be part of the decision making process (but is not objecting to it) or the person’s nominated representative is alleged to have harmed, exploited or abused the person you should appoint an IMCA. IMCA Referral forms can be found here

Does the person require an IMCA

Yes No


Date and time IMCA requested Date: Time: By Whom?

Section 3. Tell us here about the Responsible Clinician

Who is the Responsible Clinician (this is the most senior supervising health professional)

Name: Job title: Contact Number: e-mail address: Base:

http://www.traffordpct.nhs.uk/Library/Your_Health/Safeguarding_Adults/Trafford%20Spot%20Purchase%20IMCA%20Referral%20Form%20-%20Screening%20team.doc

Section 4. Tell us here about other people consulted as part of this

decision making process

The people listed below: where consulted as part of a discussion Attended a best interest meeting

Person 1: Role/Representing: Contact number

e-mail Consulted Invited Attended Apologies



















Section 5. Questions for the Responsible Clinician

Why has a Do Not Attempt

Resuscitation (DNAR) order been put

in place?

What risk and/or burdens will the

person face if Cardio-pulmonary

resuscitation (CPR) is performed?

What is the chance of CPR revival for the person if they have a cardio respiratory arrest?

With respect to any risks or burdens from CPR on the person how will this affect their daily life including any psychological, emotional and physical factors that need to be considered?

If the person would have increased needs if CPR were performed could these be looked after in their current environment and/or how would the person react to a change in needs?

Are there known illnesses or medical problems that will impact on the outcome of a decision to perform CPR?

What is the overall condition of the person’s health and what effect will performing CPR have on this i.e. is it likely the person will have more physical health or care needs?

Has the person’s faith, beliefs or culture been considered in terms of levels of medical intervention and to what level the person would want these to be considered?

When will the DNAR order be reviewed and by whom?

Section 6. Questions for the person’s representative

Has the person expressed their preference, wishes, views or feelings either in the past or now about CPR?

Yes No


Has the person expressed a preference in the past or now about the levels of medical intervention?

Yes No


Does the person have any concept or understanding of death?

Yes No


Does the person practice any religion or does their culture stipulate any specific process in terms of how they should be cared for before and/or after death?

Yes No


Section 7. Is there any dispute regarding the best interest decision?

Are there any disputes between any party about what is in the persons best interests?

No, proceed with Best Interest Decision

Yes, a decision will need to be made by the Best Interest Assessor (the person completing this form) whether the decision can be delayed or whether action needs to be taken at once, key considerations are relief of pain, protection from harm/abuse or exploitation and the preservation of life . Please tell us here the nature of the dispute: Dispute resolution should take the following forms: Local dispute resolution meeting chaired by the local Designated Nurse for Safeguarding & Vulnerable Adults or a Named Lead Safeguarding Professional. Where local dispute resolution fails, the matter can be referred to the Court of Protection for a judgement. NB: The party that refers to the Court of Protection are liable for the costs of the case.

I the undersigned, am the Responsible Clinician and believe this to be a fair representation of

the discussions that took place.

Those that I have consulted agree that we have reasonable grounds for believing that what we

are deciding, is in the best interests of the person concerned at this point in time.

This decision will be subject to regular review, which will be defined and recorded in the

persons care record.

Type your name here

Sign your name here (if printed copy)

Job title:

Date and time completed: Date: Time:

Documents

Trafford Capacity Assessment & Best Interests Pack...Contents of the Pack Capacity Assessment Guidance Capacity Assessment Document Generic Best Interest Decision Form DNAR Best Interest