Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)12 – Advance Decisions Policy

Mental Capacity Act Policy practice guidance note

Advance Decision to Refuse Treatment and Advance Statements – V03

Date Issued Planned Review PGN No:

Issue 1 – Feb 2019

Issue 2 – Nov 2019

Feb 2022 MCA-PGN-02

Part of CNTW(C)34 – Mental Capacity

Act policy

Author/Designation Kerry Graham –Mental Health Legislation Development Lead

Responsible Officer

/ Designation Dr. R. Nadkarni –Executive Medical Director

Contents

Section Description Page No

1 Introduction 1

2 Definitions 1

3 Purpose 2

4 PART ONE - Advance Decisions 3

5 Making an Advance Decision to Refuse Treatment 5

6 Procedure for Advance Decision to Refuse Treatment 7

7 Inpatient Admission 9

8 PART TWO – Advance Statements 9

9 Making an Advance Statement 10

10 Procedure for Advance Statement 11

11 Inpatient Admission 13

12 Young Carers 13

13 Complaints 13

14 Training 14

15 Associated Documents 14

16 References 14

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Appendices – listed separate to PGN

Document No: Description

Appendix 1 Making an Advance Decision to Refuse Treatment Flowchart

Appendix 2 Advance Decision to Refuse Treatment Pro-forma

Appendix 3 Guidance on Completing an Advance Decision Pro-forma

Appendix 4 Advance Statement Flowchart

Appendix 5 Advance Statement Pro-forma

Appendix 6 LEAFLETS - Advance Decision to Refuse Treatment and Advance Statement Information

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1. INTRODUCTION 1.1. Usually a person is able to discuss care and treatment options when they are unwell

and a joint decision can be made about future care and treatment options. When an adult has capacity they can refuse treatment and it cannot be given without the person’s valid consent except for some circumstances under the Mental Health Act 1983.

1.2. Communication is the key to the provision of safe and effective care and is essential

to all aspects of this practice guidance note whether this is before capacity is lost and a person is considering their future, when capacity is diminished or fluctuating, and with relatives, carers, advocates and the care team when capacity is lost.

1.3. There are occasions when a person is unable on a temporary or permanent basis, to communicate their wishes and consent to or refuse treatment.

1.4. The Mental Capacity Act 2005 (the Act) provides the legal framework for acting and

making decisions on behalf of individuals who lack the mental capacity to make particular decisions for their self.

1.5. It includes many important provisions to protect the rights of those who lose capacity

to make decisions and provides several ways that people can influence what happens to them if they are unable to make particular decisions in the future including:

Advance Decisions to refuse medical treatment

Advance Statements - expressions of wishes and feelings

1.6 The presumption of capacity applies to any existing Advance Statement or Advance

Decision. The provisions of the Act are that an individual must be age 18 years or over to make an Advance Decision.

1.7 Staff should refer to Cumbria Northumberland, Tyne and Wear NHS Foundation Trust

(the Trust/CNTW) policy CNTW(C)34 - Mental Capacity Act as well as the Mental Capacity Act - Code of Practice (Control and click following links)

1.9 Staff need to be clear of the difference in the legal status of Advance Decisions and

Advanced Statements when they are working with service users. 2. DEFINITIONS 2.1 An Advance Decision is an actual refusal of all or some specified treatment and the

circumstances in which this would apply. A person has the right to refuse treatment for reasons that are “rational, irrational or for no reason” and is entitled to refuse treatment irrespective of the wisdom of that decision. A valid and applicable Advance Decision has the same effect as if a person had capacity and made a contemporaneous decision to refuse treatment. Advance Decisions to refuse treatment for mental disorder may not apply if the person who made the Advance Decision is or is liable to be detained under the Mental Health Act (MHA) 1983.

2.2 An Advance Statement is a statement of a person’s wishes, views and feelings. Such

wishes should be given the same consideration as wishes expressed at any other time.

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Clinicians must consider advance statements when determining what is in the patient’s best interests if the patient subsequently loses capacity. Some patients will deliberately state their wishes in advance about a variety of issues, including their medical treatment, how families and carers should be involved; the steps that should be taken in emergencies and what should be done if particular situations occur.

3 PURPOSE

3.1 The Trust support’s the use of Advance Decisions and Advance Statement to enhance

communication between service users, carers and staff.

3.2 This practice guidance note enshrines the principle that service users have the formal opportunity to take an active part in planning for their care. Encouraging patients to set out their wishes in advance is often a helpful therapeutic tool, encouraging collaboration and trust between patients and professionals. It is a way in which effective use can be made of patients’ expertise in the management of crises in their own conditions.

3.3 Modern mental health and learning disability services promote partnerships between individuals who use services and mental health and learning disability professionals. This practice guidance note aims to improve the experience and potential outcomes for all involved. The incorporation of Advance Decisions and Advance Statements into Trust practice guidance note will continue to develop this partnership approach.

3.4 Part 1 of this practice guidance note relating to Advance Decisions, will apply to all

service users of the Trust aged 18 years or over. Only people aged 18 years and over can make an Advance Decision to refuse medical treatment within the legislative framework.

3.5 Part 2 of this practice guidance note relating to Advance Statements will apply to all

service users over 16 years of age as a child under the age of 16 years may be able to consent to treatment if it is concluded that they have the capacity to make the decision, and are of sufficient understanding and intelligence to be capable of making up their own mind. This is sometimes referred to as ‘Gillick competence’. It would also be possible for someone with parental responsibility to record their wishes in an Advance Statement. Any wishes would of course need to be in the child’s best interest.

3.6 Clear recording and the appropriate circulation and regular review / update of any known Advance Statements or Advance Decision is then crucial to enable service users wishes and feelings to be appropriately considered and acted upon.

3.7 This practice guidance note concentrates on Advance Decisions and Advance

Statements as they are used in mental health and learning disability services. There is another important use of these in end of life care. This is described in the document ‘Deciding Right’ shown in Appendix 8 which is supported by the Trust.

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4 PART ONE: ADVANCE DECISIONS TO REFUSE TREATMENT 4.1 An Advance Decision to refuse treatment is preferably a written document where the content has been agreed through discussion and negotiation between the person making it and the people involved in their care and treatment, including where appropriate carers and family members. 4.2 It is a document that is owned by the service user and shared with Trust staff. It is not the property of the Trust or a document that the Trust requires staff to ensure is completed.

4.3 The person may use whatever format they wish, including verbal. Service users may

prefer not to make what they consider to be a legalistic document but instead talk to professionals about their wishes in relation to refusing treatment and have these recorded in their health records. Trust staff can also use the Trust proforma to produce a record and ask the service user to check the content and ensure that they agree with what is written and sign the form. Service users can also use the Trust proforma.

4.4 Refusal of life sustaining treatment must be in a written document; contain the words “even if life is at risk” and be signed and witnessed.

4.5 An Advanced Decision does not give an individual the right to demand specific treatment at the time of making it or in advance. 4.6 If a verbal or written advance refusal to treatment is thought to have previously been

made please refer to Mental Capacity Act (MCA) Code of Practice (CoP) 9.38 to 9.44 with regards to validity and applicability. This should be documented by those involved with the person at the earliest opportunity.

4.7 An Advance Decision to refuse treatment:

Must state precisely what treatment is to be refused – a statement giving a general desire not to be treated is not enough

Should set out the circumstances when the refusal should apply. It is helpful to include as much detail as possible including the reasons for refusing treatment e.g. particular side effects as this will support the validity of the decision. It is not a requirement to include reasons for refusing treatment

Will only apply at a time when the person lacks capacity to consent to or refuse the specific treatment

4.8 The provisions of the Advance Decision to refuse treatment will reflect the expressed

wishes of the individual in terms of refusing specific medical treatment and relapse management. In the General Medical Council’s booklet 'Seeking Patient Consent; The Ethical Considerations', it is advised that in obtaining informed consent for treatment, any associated serious or frequently occurring risk should be discussed. The Medical Defence Union recommends that these discussions be formally documented.

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4.9 In certain circumstances, described in MHA CoP Ch 24, the MHA Act allows patients to be given medical treatment for their mental disorder without their consent and even though they have made a valid and applicable advance decision to refuse the treatment. This only applies to patients who are detained under the Act and in certain circumstances patients on community treatment orders (CTOs), if they have been recalled to hospital by their responsible clinician where the certificate requirements are met.

4.10 Even where clinicians may lawfully treat a patient compulsorily under the Act, they

should, where practicable, try to comply with the patient’s wishes as expressed in an advance decision. They should, for example, consider whether it is possible to use a different form of treatment not refused by the advance decision. If it is not, they should explain why to the patient.

4.11 Except where the Act means that they need not, clinicians must follow all other

advance decisions made by their patients, which they are satisfied are valid and applicable, even if the patients concerned are detained under the Act or on CTOs. By definition, this includes all valid and applicable advance decisions made by detained and community patients to refuse treatment which is not for mental disorder.

4.12 Clinicians must always start from the assumption that a person had the mental

capacity at the time in question to make the advance decision. If a clinician is not satisfied that the person had capacity at the time they made the advance decision, or if there are genuine doubts about its validity or applicability, they can treat the person without fear of liability, so long as they comply with the other requirements of the MCA, including the requirement to act in the patient’s best interests.

4.13 Witnessing the person signature is not essential, except in cases where the person is

making an Advance Decision to refuse life sustaining treatment. But if the format used to record an advance decision includes a witness signature, the witness is witnessing the signature of the person making the advance decision to confirm that it is a document that the person has drawn up. It may be helpful to give a description of the relationship between the witness and the person making the Advance Decision. The role of the witness is to witness the persons signature, it is not to certify that the person has the capacity to make the Advance Decision – even if the witness is a healthcare professional or knows that person.

4.14 It is possible that a professional acting as a witness will also be the person who

assesses the person’s capacity. If so, the professional should also make a record of the assessment, because acting as a witness does not prove that there has been an assessment. The Trust proforma provides a section to assist with this recording.

4.15 It is viewed as good practice that the professional should liaise with the Responsible

Clinician or their deputy before signing any documentation as well as seeking support in the assessment of capacity if there are concerns identified.

4.16 Where the Advance Decision relates to end of life care the principals in ‘Deciding

Right’ will be followed, guidance is available at

http://www.northerncanceralliance.nhs.uk/deciding-right/

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5 MAKING AN ADVANCE DECISION TO REFUSE TREATMENT 5.1 An Advance Decision enables someone aged 18 years and over while still capable

to refuse specified medical treatment for a time in the future when they may lack the capacity to consent to or refuse that treatment.

5.2 It is up to individuals to decide whether they want to refuse treatment in advance.

They are entitled to do so if they want, but there is no obligation to do so. 5.3 Advance Decision to refuse treatment should be understood as an aid to rather than

a substitute for open dialogue between service users, carers, health and social care professionals. Open attitudes and a willingness to discuss the advantages and disadvantages of particular options can do much to establish trust and mutual understanding between all those involved.

5.4 It is important that Advance Decisions to refuse treatment are completed when an

individual feels best able to represent their wishes clearly and to record them/have them recorded formally after capacity has been assessed by health care professionals. (See pro-forma Appendix 1).

5.5 The proforma provided by the trust for service users to use if they wish, includes

additional sections not required by the act. It is the view of the trust that these additional and optional sections will support service users in demonstrating that the decision is valid.

The MCA does not require reasons for an Advance Decision to be given and states that a person is not to be treated as being unable to make a decision merely because they make an unwise decision. The 'reasons' box has been included in the Trust proforma because it may help service users to demonstrate that they have fully understood the treatment position and may make it easier for health professionals to be satisfied at a later date that the Advance Decision is valid. Professionals must not place undue importance on the 'reasons' box when trying to assess whether an Advance Decision is valid. The real issue is whether the person had capacity at the time to make the Advance Decision and there is a separate section dealing with this. Professionals do not have to make a value judgement of how valid or otherwise the reasons given are in order to decide on the validity of the Advance Decision

The MCA presumes capacity. However given that service users may well have fluctuating capacity, an assessment of capacity is included on the form for completion each time a new Advance Decision is made to bolster the rights of the service user by ensuring no doubts over their capacity at the time are raised later

The Pro-forma gives the option of documenting the fact that an Advance Decision has been retracted or modified. This is in order to avoid confusion over which document is current. However an Advance Decision (including one relating to life-sustaining treatment) can be withdrawn verbally. If this happens professionals should document it on the form immediately

5.6 An Advance Decision to refuse treatment is written to assist in future treatment rather

than written at a time of crisis. Reflection at an appropriate time after a crisis has

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occurred may provide an opportunity to identify the treatment that an Advance Decision to refuse treatment needs to cover.

5.7 Some people choose to make Advance Decisions while they are still healthy, even if

there is no prospect of illness. This might be because they want to keep some control over what might happen to them in the future. Others may think of an Advance Decision as part of their preparations for growing older (similar to making a will). Or they might make an Advance Decision after they have been told they have a specific disease or condition e.g. degenerative cognitive impairment.

5.8 An Advance Decision to refuse treatment needs to be written as clearly and

unambiguously as possible in order to avoid misinterpretation. It can be expressed in either medical terms or layman’s language i.e. written so that the service user understands it and so can anyone else who reads it.

5.9 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: it is binding on Healthcare professionals who must follow the decision.

5.10 Events Making an Advanced Decision Invalid:

The person withdrew the decision while they still had capacity to do so.

After making the Advance Decision, the person made a Lasting Power of Attorney (LPA) giving an attorney authority to make treatment decisions that are the same as those covered by the Advance Decision

The person has done something that clearly goes against the Advance Decision which suggests that they have changed their mind

5.11 An Advance Decision is Not Applicable if:

The proposed treatment is not the treatment specified in the Advance Decision

The circumstances are different from those that may have been set out in the Advance Decision

There are reasonable grounds for believing that there have been changes in circumstance, which would have affected the decision if the person had known about them at the time they made the Advance Decision

Advance Decisions to refuse treatment for mental disorder may not apply if the person who made the Advance Decision is or is liable to be detained under a Section of the Mental Health Act 1983 to which Part 4 applies

5.12 Health Care Professional’s will be protected from liability if they:

Stop or withhold treatment because they reasonably believe that an Advance Decision exists, and that it is valid and applicable

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Treat a person because having taken all practical and appropriate steps to find out if the person has made an Advance Decision to refuse treatment, they do not know or are not satisfied that a valid and applicable Advance Decision exists

5.13 Assistance in writing an Advance Statement will always be offered to those individuals

who have sensory impairments or who lack confidence in completing written forms. The provision of interpreter services will also be provided as required.

5.14 A capable individual has the right to make an Advance Decision to refuse treatment

when they feel it to be appropriate and to withdraw from it or negotiate a new or modified version at any time.

5.15 Information leaflets for Service Users, including leaflets in an accessible format, about

Advance Decision to refuse treatment will be readily available in a variety of locations:

Trust reception areas e.g. wards, community bases and hospital sites

Via user groups

On the Trust intranet and internet site

Advocacy services 6 PROCEDURE FOR ADVANCE DECISIONS TO REFUSE TREATMENT

6.1 As part of the assessment and care planning process with an individual the assessor

and an appropriate member of the care team or Care Coordinator will ensure the individual is aware of, and if appropriate, discuss the process of an Advance Decision to refuse treatment with the individual (and carer where appropriate), including identifying if there is an existing document or verbal Advance Decision. An information leaflet will be provided and the individual can then decide if/or when they might want to make or update an Advance Decision to refuse treatment.

6.2 An existing written Advance Decision that the service user does not want to rescind

or update does not need to be transferred onto the Trust pro-forma and should be identified as outlined in 8.6 and 8.7.

6.3 If the individual has an existing verbal Advance Decision this should be recorded in

their notes using the Trust pro-forma or a clear entry in their health record and be identified as outlined in 8 below.

6.4 Individuals can discuss and decide what treatment they want to refuse with either their Care Coordinator or Consultant or any member of their care team and/or their advocate, or by accessing support through a user group.

6.5 A Multi-Disciplinary/Care Coordination Review provides an opportunity to discuss and

review the Advance Decision to refuse treatment. This process should enable the individual to express their wishes and allow for family, carers or advocates to take a role in supporting the service user as well as bringing their unique understanding of the individuals’ needs to this process.

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6.6 There may be occasion where a service user in our care has made or wishes to make an Advance Decision to refuse a treatment for a physical condition and the management and care of which is outside the mental health care team’s area of expertise. In this event the most appropriate healthcare professional should advise and support the service user in its development.

6.7 When an Advance Decision to refuse treatment has been made this should be

indicated by either completing the tick box indicator on the Care Coordination care plan and on the individuals Care Coordination registration form (this may necessitate the completion of an updated registration form) or by an appropriate entry on the Multi-Disciplinary care plan and an entry on the electronic patient record.

6.8 The service users will retain the original Advance Decision to refuse treatment and be

supported in ensuring that a copy is given to all members of the Care Coordination/Multi-Disciplinary Team including the General Practitioner.

6.9 The service user’s Care Coordinator or an identified member of the multidisciplinary care team will with the service users consent, ensure that the existence of the Advance Decision is registered on the electronic patient record (RiO) via an appropriate alert and an electronic copy of the decision is recorded on RiO. The service users will be advised to make any personal arrangements to ensure that the document is readily available if needed e.g. on admission to hospital.

6.10 The process of identifying the existence of an Advance Decision to refuse treatment is through the electronic patient record and care planning process will facilitate the alerting of health and social care professionals who may not have current involvement with the service users care e.g. crisis assessment and treatment services.

6.11 An Advance Decision to refuse treatment should be reviewed with the individual and the Multi-Disciplinary/Care Coordination team every 6 months through the process of a Multi-Disciplinary Lead Professional/Care Coordination Review (unless another process is agreed). However an individual can review their Advance Decision to refuse treatment at any time involving the care team if they wish.

6.12 If the review results in changes to the Advance Decision to refuse treatment the updated document must be circulated (as indicated in point 3.6). It is the responsibility of each holder of the advance refusal of treatment to update their records with the new document.

6.13 If the review results in the withdrawal of the advance decision then each holder must be notified immediately and the entry on the electronic patient record updated. It is the responsibility of each holder of the advance refusal of treatment to update their records by clearly identifying that the document has been withdrawn.

6.14 If any concerns arise as to the legal effect of the Advance Decision to refuse treatment initial advice should be sought from the Mental Health Legislation Team.

6.15 Legal advice must be sought initially from the Mental Health Legislation Team of the Trust where it is proposed to treat the individual contrary to a refusal of treatment in

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the Advance Decision to refuse treatment, except where treatment is provided under the provisions of part 4 of the Mental Health Act.

7 INPATIENT ADMISSION 7.1 If the Individual is being admitted in Normal Working Hours:

The referring person (initial response team clinician, crisis team clinician, medical staff or community team clinician) and if possible the service user, will be expected to supply the admitting nurse on the ward with a copy of an individual’s Advance Decision to refuse treatment with the current Multi Disciplinary/Care Coordination assessment and risk profile

The admitting nurse should ask if the patient has made an advance decision 7.2 If the Individual is Being Admitted out of Normal Working Hours:

The initial response team clinician, crisis team clinician, medical staff or community team clinician will take reasonable steps (checking the patients’ medical record, asking the individual and their Family/Carer) to determine whether an Advance Decision to refuse treatment is in place, obtain a copy and take account of its contents

The ward will follow this up in normal working hours through contact with the Care Coordinator or Consultant or checking on the electronic patient record and where an Advance Decision to refuse treatment is in place this will be provided to the ward in addition to the Lead Professional/Care Coordination assessment and risk profile as part of the admission documentation

Out of Hours advice will also be obtained from the on call manager 8 PART TWO: ADVANCE STATEMENTS 8.1 An Advance Statement is an expression of a person’s wishes, feelings, beliefs and

values about their care and treatment should they not be able to communicate their wishes or have the capacity to make these decisions in the future.

8.2 It could be recorded on a Trust proforma, or be in another form e.g. a Wellness

Recovery Action Plan (WRAP), crisis contingency plan, care plans. 8.3 It is preferable that the content has been agreed through discussion and negotiation between the person making it and the people involved in their care and treatment including where appropriate carers and family members. 8.4 An Advance Statement identifies the individual’s care and treatment and how their

provision of care may be provided should that individual become mentally unwell and lose capacity whether this is temporary or permanent. For some service users it is aimed towards planning for a crisis/relapse/acute episode when the individual is unable to make their preference known.

8.5 An Advance Statement may cover numerous elements of care and treatment.

Additionally it will identify those trusted relatives, carers and advocates who may be

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contacted in an emergency and/or provide consultation to health professionals. The Advance Statement may also indicate what practical arrangements the individual may wish to have addressed if admitted to hospital, e.g. care of dependents, safeguarding their home and possessions. They also have a place to help provide a sensitive and compassionate management of death.

8.6 Whilst it does not have a basis in statutory law an Advance Statement should always be used to help find out what someone’s wishes and feelings might be as part of working out their best interests should they lose capacity. The provisions of the Advance Statement will reflect the expressed wishes of the individuals in terms of medical treatment and relapse management. 8.7 Patients should be made aware that expressing their preference for a particular form

of treatment or care in advance like this does not legally compel professionals to meet that preference. However, professionals should make all practicable efforts to comply with these preferences and explain to patients why their preferences have not been followed.

8.8 If a decision is made which disregards the service user’s Advance Statement the reasons for this must be documented in their record by the clinician making the decision. 8.9 If a service user wants to include an expressed wish not to receive a particular

treatment, or not to be treated at all, the Mental Capacity Act 2005 provides the statutory basis for refusal of treatment (as outlined in Part 1 of this practice guidance note).

9 MAKING AN ADVANCE STATEMENT 9.1 An Advance Statement can be made by anyone over the age of 16 years who at the time of making it has the capacity and competence to make it. 9.2 Advance Statements provide the potential to enhance and/or build on the

collaborative approach of Care Coordination/Care planning. They place an emphasis on establishing an accepted agreement between an individual, the other important people involved in their lives including family/carers, health and social care professionals.

9.3 Advance Statements should be understood as an aid to rather than a substitute for open dialogue between service users, carers, health and social care professionals. Open attitudes and a willingness to discuss the advantages and disadvantages of particular options can do much to establish trust and mutual understanding between all those involved. 9.4 It is up to individuals to decide whether they want to make an Advance Statement. They are entitled to do so if they want, but there is no obligation to do so. 9.5 It is important that Advance Statements are completed when an individual feels best able to represent their wishes clearly and to record them/have them recorded formally (see proforma appendix 2). An Advance Statement is written to assist in crisis planning rather than written at a time of crisis. Reflection at an appropriate

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time after a crisis has occurred may provide an opportunity to identify the issue/areas that an Advance Statement needs to cover. 9.6 Some people may think of an Advance Statement as part of their preparations for growing older (similar to making a will). Or they might make an Advance Statement after they have been told they have a specific disease or condition. Advance Statements need to be written as clearly and unambiguously as possible in order to avoid misinterpretation. Responsibilities should be understood by everyone referred to and should not be imposed on third parties where they have not given their agreement. 9.7 A capable individual has the right to make an Advance Statement when they feel it to be appropriate and to withdraw from it or negotiate a new or modified version at any time. 9.8 The fact that a patient has expressed their wishes about a particular matter in the past

is not a substitute for seeking their views on it when the situation actually arises, even if they are no longer in a position to think about their views as clearly as they did when they expressed their wishes previously. Everyone has the right to change their mind. In particular, where patients have the mental capacity to express a clear wish in the present, that wish should always be assumed to have overtaken their previous wishes, even if it is significantly different.

9.9 Information leaflets for Service Users about Advance Statements, including leaflets in an accessible format, will be readily available in a variety of locations:

Trust reception areas e.g. wards, community bases and hospital sites

Via user groups

On Trust intranet/internet site

Advocacy services 10 PROCEDURE FOR ADVANCE STATEMENTS 10.1 As part of the assessment and care planning process with an individual, the assessor

or Care Coordinator will discuss the process of Advance Statements with the individual (and carer where appropriate), including identifying if there is an existing Advance Statement and provide an information leaflet. The individual can then decide if/or when they might want to make or update an Advance Statement. An existing written Advance Statement that the service user does not want to rescind or update does not need to be transferred onto the Trust proforma and should be identified as outlined in 9.18.

10.2 Individuals can discuss and decide what they want included with either their Care

Coordinators and/or their advocate, or by accessing support through a user group. 10.3 Assistance in writing an Advance Statement will always be offered to those

individuals who have sensory impairments or who lack confidence in completing written forms. The provision of interpreter services will also be provided as required.

10.4 This should be followed by a full discussion with all those involved including health

and social care professionals, including needs that result from the individuals’ culture,

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ethnicity or disability. Any issues, which arise with respect to medical interventions, should be discussed with the psychiatrist and this will be documented in clinical records.

10.5 If the issue about medical intervention includes the individual wishing to refuse

treatment then the Advance Decision process should be used. 10.6 A Care Coordination/Multi-Disciplinary Team (MDT) review provides an opportunity

for this discussion and to have the Advance Statement agreed. This process should enable the individual to express their wishes and allow for family, carers or advocates to take a role in supporting the service user as well as bringing their unique understanding of the individuals’ needs to this process.

10.7 Once discussion has occurred and agreement reached the Advance Statement

should be recorded. If the Trust proforma is used this needs to be signed by the individual and witnessed by an appropriate person to validate the signature e.g. carer, advocate or health care professional.

10.8 When an Advance Statement has been made this should be indicated by completing

the relevant Lead Professional/Care Coordination/CPA documentation and an appropriate entry made in the individuals record with an alert entry advising where the information is located, ie Care Plan, scanned images, Mental Capacity Folder.

10.9 With the agreement of the individual, a copy of the Advance Statement should be

circulated to all members of the care team including the General Practitioner. With the support of their Care Coordinator, the individual must ensure that anyone referred to in the Advance Statement that is not a member of the care team, is given their own copy. If permission is not given, the individual needs to be aware of the possible consequences i.e. that person may not be able to take the Advance Statement into account.

10.10 Whether the patient or the professional records the patient’s views, steps should be

taken, unless the patient objects, to ensure that the information:

is drawn to the attention of other professionals who ought to know about it, and,

It is included in care plans and other documentation which will help ensure that the patient’s views are remembered and considered in situations where they are relevant in future.

10.11 The process of identifying the existence of an Advance Statement through the Care Coordination/CPA/MDT care planning process will facilitate the alerting of health and social care professionals who may not have current involvement with the service users care e.g. Initial Response Service via the electronic patient record.

10.12 An Advance Statement should be reviewed with the individual and the care team

every 6 months through the process of a Lead Professional/Care Coordination review (unless another process is agreed). However an individual can review the Advance Statement at any time.

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10.13 If the review results in changes to the Advance Statement the updated document must be circulated (as indicated in points 3.8 and 3.9). It is the responsibility of each holder of the Advance Statement to make the old copy inactive. This may be with the help of the Care Co-ordinator/ Lead Professional.

10.14 It is the responsibility of each member of the care team to ensure that the Advance

Statement is held appropriately within clinical records and informs their intervention and decision-making.

10.15 If any concerns arise as to the legal effect of the Advance Statement to refuse

treatment initial advice should be sought from the Mental Health Legislation Team. 11 INPATIENT ADMISSION 11.1 If the Individual is being admitted in Normal Working Hours:

The referring person (initial response team clinician, crisis team clinician, medical staff or community team clinician) will be expected to supply the admitting nurse on the ward with a copy of an individual’s Advance Statement.

11.2 If the Individual is being admitted Out of Normal Working Hours:

The initial response team clinician, crisis team clinician, medical staff or community team clinician will take reasonable steps to determine whether an Advance Statement, is in place, (checking the patients’ medical record, asking the individual and their Family/Carer) obtain a copy, record the individuals wishes, views, beliefs and feelings and take account of them

The ward will follow this up in normal working hours through contact with the Care Coordinator or consultant or checking on the electronic patient record and where an Advance Statement is in place this will be provided to the ward in addition to the Lead Professional/Care Coordination current assessment and risk profile as part of the admission documentation

12 YOUNG CARERS

12.1 The Trust Advance Statement proforma provides the opportunity to identify someone who can be consulted with a view to clarifying their contents. If a young carer (i.e. someone under the age of 18 years) is identified this would not be a bar to consulting them. The young person’s potential immaturity may need to be taken into account on a case by case basis when deciding how much credence to give to their contribution.

12.2 If staff are involved in supporting a service user draw up an Advance Statement where a young carer is named they must take reasonable steps to ensure that they are not subject to duress. If the process raises concerns about a child’s welfare advice can be sought from the Safeguarding Team.

13 COMPLAINTS 13.1 Individuals who feel that their Advance Decision to refuse treatment or Advance

Statement has not been taken account of, or it has been overridden without

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explanation, may take up their concerns with individual health or social care professionals.

13.2 Should this fail to provide an acceptable explanation; the Trust have an agreed complaints procedure, CNTW(O)07 Comments, Compliments and Complaints Policy.

14 TRAINING 14.1 A rolling programme of training covering Advance Decisions to refuse treatment and

Advance Statements is incorporated into CNTW MHA/MCA/DoLS training. 15 ASSOCIATED DOCUMENTS

CNTW(C)01 – Resuscitation Policy

CNTW(C)05 – Consent to Treatment

CNTW(C)20 – Care Coordination/CPA Policy

CNTW(C)34 – Mental Capacity Act Policy

CNTW(O)07 – Comments, Compliments and Complaints

CNTW(O)16 - Accessing Legal Advice

CNTW(O)55 - Mental Health Act Policy 16 REFERENCES

The Mental Capacity Act 2005

Mental Capacity Act, Code of Practice 2005

General Medical Council – ‘Seeking Patient Consent; The Ethical Considerations’

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