End of Life Care. Best Interests Decisions for. End of Life Care. Emergency services please go to page 11

Transcription

1 Emergency services please go to page 11 Best Interests Decisions for End of Life Care End of Life Care Developed to support people with Advanced Dementia 1

2 Further Information Gloucestershire County Council Mental Capacity Act website: Gloucestershire Hospitals Patient Advice & Liaison Service (PALS) Tel: Web: Patient-Advice-and-Liaison-Service-PALS/ PALS Patient advice and support for Gloucestershire Tel: or This booklet is based on the form called MCA2 (Mental Capacity Act) used across Gloucestershire s health and social care community to document where significant decisions are being considered. The MCA2 form is an appendix to the Gloucestershire multi-agency MCA policy, procedures and guidance. Advance Care Planning The Mental Capacity Act 2005 protects people who are unable to make decisions (This is known as to lack capacity ). It also allows the opportunity for people to express wishes and preferences about how they would like to be treated should they lose the ability to make decisions. This may include refusing certain treatments, although does not allow the refusal of basic care, such as being offered food and drink by mouth. It gives legal protection to vulnerable adults on a range of issues, giving clarity on who can make decisions, in what circumstances, and the process that must be followed. Reference: Treatment and Care towards the end of life, good practice in decision making. General Medical Council (GMC) May The Gloucestershire leaflet Why the Mental Capacity Act Matters gives more information about the Act and where to find other information; If translation is required for relatives or others please refer to your organisations translation services. To discuss receiving this information in other formats please contact: FREEPOST RRYY-KSGT-AGBR, PALS, Gloucestershire Clinical Commissioning Group, Sanger House, 5220 Valiant Court, Gloucester Business Park, Brockworth, Gloucester GL3 4FE PALS focuses on improving NHS services to patients. 2 2

3 Introduction: Where a person is unable to make decisions for themselves about end of life care and/or treatment, professionals are legally required to make decisions for the person in their best interests. When making best interests decisions, everything possible should be done to consider the person s wishes and feelings both past and present, and to involve the person as much as possible. The professional must also take into consideration the views of family and others who are significant to the person as part of the best interests process. As this document relates to medical decisions and the assessment of capacity the decision maker will be the GP. The following booklet has been devised to be used where there are concerns about a person s ability to make decisions about end of life care and/or treatment. The booklet can be used to demonstrate the assessment of the person s capacity in this area of decision making, and where a person does not have capacity there is an opportunity to record the decisions that all agree are in the person s best interests. Legal Position Both euthanasia and assisted suicide are illegal under English law. Euthanasia is the act of deliberately ending a person s life to relieve suffering. Best Interests Decisions in relation to End of Life Care supports individual s treatment and care who lack capacity. This Booklet focuses on whether it is the best interests to give treatment, rather than on whether it his/hers best interests to withhold or withdraw it (MCA Code of Practice 5.31). The purpose of this document guards against Euthanasia and the motivation to bring about a person s death The booklet is divided into 6 sections and there is a glossary overleaf to explain terms used. Part One: Section 1: Section 2: Section 3: Section 4: Section 5: Section 6: Part Two: Best Interests Medical Treatment Decisions Personal Details Capacity Assessment Best Interests checklist Consultation of Best Interests discussion regarding treatment Best Interests discussion/consultation regarding treatments Summary of Best Interests discussion General end of life care planning 3

4 Glossary of terms /Meaning of terms used: Advance decision to refuse treatment a decision to refuse specified treatment made in advance by a person who has the capacity to do so. This decision will apply at a future time when the person lacks capacity to consent to or refuse the specified treatment. Specific rules apply to advance decisions to refuse life sustaining treatment. Attorney/Donee Person appointed under Lasting power of Attorney (LPA) or Enduring Power of Attorney (EPA) who has legal right to make decisions within the scope of their authority on behalf of the person (the donor) who made the Power of Attorney. Best Interests any decision made or anything done for a person who lacks capacity must be done in their best interests. Capacity the ability to make a decision about a particular matter at the time the decision needs to be made. Carer someone who provides (unpaid) care. Consent agreement to a care plan or treatment regime. For consent to be legally valid, the person giving it must have the capacity to take the decision, have been given sufficient information to make the decision and not have been under any duress or inappropriate pressure. CPD Court of Protection Deputy. DNAR/AND Do Not Attempt Resuscitation/Allow a Natural Death. Decision Maker a person making a decision in the best interests of a person lacking capacity to make the decision. For the purpose of this document which relates to medical decisions, the assessment of capacity and thereby decision maker will be the GP with responsibility of care at that time. Deputy person appointed by the Court of Protection with authority prescribed by the Court to make decisions on behalf of a person lacking capacity to make particular decisions. Donor a person who makes a Lasting or Enduring Power of Attorney. EPA Enduring Power of Attorney. IMCA Independent Mental Capacity Advocate. Person who provides support and representation for a person who lacks capacity to make specific decisions where the person is unbefriended (has no friends or family to represent them/unable to represent them). Lasting Power of Attorney a power created under the Mental Capacity Act appointing an attorney (or attorneys) to make decisions about the donor s personal welfare (including healthcare) and/or property and affairs. Life sustaining treatment treatment that, in the view of the person providing healthcare, is necessary to keep the person alive. Mental capacity assessment assessment to establish whether a person lacks capacity in relation to a specific area of decision making. Personal welfare decisions about a person s healthcare, where they live, what clothes they wear, what they eat and anything needed for their general care and well-being. Many acts of care are to do with personal welfare. Property and affairs any possessions owned by a person (e.g. a house or flat, jewellery or other possessions), money from income, savings or investments and any expenditure. 4

5 Section 1: Personal Details: NHS number: Name of person: Date of Birth: Place where the person is currently living: Please enter details of anyone who is the closest person, other key people and Enduring Power of Attorney (EPA) for property and affairs, Lasting Power of Attorney (LPA) for personal welfare (including healthcare) and/or property and affairs, Court of Protection Deputy: Key Roles: Name/Contact details Comment Closest Person: Consideration must be given to whether they can contribute to the assessment of capacity made by the GP. For example explaining the information that needs to be understood in a form the person can understand. Other Key People define role: As above LPA or Deputy (health and welfare): If the person has a LPA or Deputy with personal welfare authority they are the decision maker in relation to end of life care. Seek advice and reference Gloucestershire MCA multi agency policy section 15. NB: Advance Decisions: If the person has a valid and applicable Advance Decision an assessment of their capacity should be undertaken. If the person lacks capacity to the specified treatments within the Advance Decision then this will have authority over any consideration of Best Interests. Further guidance; Gloucestershire multi agency policy and procedures, section 12, Appendix MCA5 Advance Decision Guidance and Appendix MCA6 Advance Decisions Checklist. This document will be kept with the person s health record within the care home. A copy of page 11 (Summary of Best Interests Decisions Made) must be sent and kept with the GP records as well as the South West Ambulance Service. 5

6 Section 2 Capacity Assessment MUST be completed by the GP prior to starting the Best Interests process. Can the person make decisions about: zcardiopulmonary resuscitation (CPR) zacute admissions to hospital. zmedical interventions zartificial food and hydration The Mental Capacity Act (MCA) would class these as separate medical decisions. The GP/Doctor before assessing capacity should be clear about the information the person would need to understand to give consent to or refuse these decisions. For example in relation to CPR what would be done, why and what the foreseeable consequences would be to having/not having CPR performed. The GP/Doctor can complete just one assessment for this. Inability to make decisions The Mental Capacity Act 2005 sets out a two stage capacity assessment to check whether a person is able or unable to make a decision for him/herself. First Stage Does the person have an impairment of, or a disturbance in the functioning of their mind or brain? e.g. dementia, significant learning disabilities or brain damage. If NO the person will not lack capacity under the Act (Ref: MCA Code of Practice 4.11) If YES then Second stage Does the impairment or disturbance mean that the person is unable to make a decision when they need to? To be able to make a decision a person needs to be able to demonstrate that they are able to do the following 4 things: Understand the information relevant to the decision required. Retain that information hold onto the information long enough to make the decision. Weigh up the pros and the cons of the options as part of the process of making the decision. Communicate the person must be able to communicate their decision. 6

7 Name: Capacity Assessment: First stage: Does the person have an impairment or disturbance of the mind or brain? Yes No Diagnosis: NHS Number: Second stage: Is the person able to understand information related to the decision? Yes No Record /summarise details of communication with the person: Is the person able to retain information related to the decision? Yes No Record /summarise details of communication with the person: Is the person able to use or weigh the information whilst considering the decision? Yes No Record /summarise details of communication with the person: Is the person able to communicate their decision by any means? Yes No N/A NB: Ref Code of Practice: 4.15 The first three points (understand, retain, weigh up the information) should be applied together. If a person cannot do any of these three things, they will be treated as unable to make the decision. The fourth only applies in situations where people cannot communicate their decision in any way. A No answer in any of the 4 domains above constitutes incapacity. All reasonable steps were taken to enable the person to make the decision. These were: Name: Signature: Date: 7

8 Name: NHS Number: Section 3: Best Interests Checklist regarding end of life decisions a) What is most important to the person regarding general end of life wishes and preferences, both past and present, regarding the four medical decisions outlined in Section 2? (this will include religious beliefs, cultural beliefs and lifestyle). NB: If an Advance Care Planning (ACP) document has been completed, either the Gloucestershire ACP document or other formats of ACP by the person, consider the contents for anything that relates to end of life care and outline the person s described wishes and preferences; b) What are the relevant circumstances (clinical presentation leading to judgment): c) Will the person regain capacity in the future: Yes / No d) I have not made a decision based solely on age, appearance, behaviour or condition: e) As far as possible I encouraged the person to participate in the decision: f) I confirm I have not been motivated by a desire to bring about the person s death: 8

9 Name: NHS Number: Section 4: Consultation of Best Interests discussion regarding treatments Views of interested others (e.g. family, friends, formal and informal carers, advocate). What they believe is in the Best Interests of the person in relation to the treatment options AND what, if the person had capacity their wishes would have been. If there are no other appropriate people to consult then referral should be made to an IMCA. Details: In consultation and with reference to the Best Interests Checklist we have considered the pros and cons (benefits and disbenefits) in relation to: zmedical Not just the outcome, but what will be the burden and benefit of the care/ treatment. zwelfare How will this impact (for better or worse) on the way the person ends their life? zsocial Impact on the person s relationships etc? zemotional How will the person feel, react? Names of people spoken to and views they gave: Describe any possible conflicts/disagreements: NB: in the situation where a person moves care home this plan will be transferred to the new care home team. 9

10 Name: Section 5: Best Interests discussion/consultation regarding treatments: In considering best interest for the person, explore the advantages and disadvantages of each of the following medical decisions taking. Regarding CPR (cardiopulmonary resuscitation): Not to attempt to restart the person s heart if their heart or lungs were to stop working: Yes/No (delete as necessary) Detail of discussion: NHS Number: Regarding non acute admissions to hospital: (identified as at the end of life and needing comfort measures only): Yes/No (delete as necessary) Detail of discussion: Regarding medical interventions including intra-venous antibiotics: Yes/No (delete as necessary) Detail of discussion: Regarding being artificially fed or hydrated, this may be the use of through the nose to the stomach (naso-gastric feeding) or the use of tubes directly into the stomach (peg feeding): Yes/No (delete as necessary) Detail of discussion: 10

11 Name: Section 6: Summary of Best Interests decisions made (refer to sections 4 and 5 for details: z CPR (cardiopulmonary resuscitation): To attempt CPR DNaR/AND Yellow sticker can be found in Detail (if needed): NHS Number: Not to attempt CPR z Admission to hospital: To admit to hospital Detail (if needed) z Medical interventions: Provide treatment Detail (if needed) z Artificial food and hydration: To artificially feed and hydrate Detail (if needed) Not to admit to hospital Not to provide treatment Not to artificially feed and hydrate Detail below any other decisions z z z Name and signature of GP/Doctor completing this summary: Date: A copy of this section needs to be posted or faxed to the Clinical Alerts Team, South Western Ambulance Service NHS Foundation Trust, North Division Emergency Operations Centre, Acuma House, Axis 4/5, Woodlands, Almondsbury, Bristol, BS32 4J T: Review Date: Who to be involved: Review Date: Who to be involved: This form relates to a full Best Interests assessment for a person lacking capacity to end of life care treatment decisions. The full form can be found within care home records. 11

12 Name: Part Two: NHS Number: General end of life planning What is most important to the person regarding general end of life wishes and preferences, both past and present? NB: If an Advance Care Planning (ACP) document has been completed either the Gloucestershire ACP document or other formats of ACP by the person, consider the contents for anything that relates to end of life care and outline the person s described wishes and preferences; For example music/fragrance/important people to be there/not there: Organ/tissue donation: Preferred place of death: A) pain management/specifics relating to comfort/dignity; (If needed attach any further information to this document). B) Views of interested others (e.g. family, friends, carers, advocate). What involvement would they like at what stage? What involvement in the review process? (If needed attach any further information to this booklet). Completed by: Designation: Signed by: 12

13 Funeral Planning Name: NHS Number: Details Person I wish to be responsible for making my funeral arrangements My preferred funeral director is My pre-paid funeral plan is with I wish to be buried/cremated/ other (e.g. donation for medical science specific documents will need to be signed) I wish my funeral service to be in accordance with my faith. Please state (if any) I would like the venue to be I would like the following music, hymns or readings included I would like the following person(s) to conduct the service if possible Other details and information you would like to record e.g. donations to named charity, flowers, people to be informed Completed by: Designation: Signed by: 13

14 14 Notes

15 Notes 15

16 Gloucestershire Care Services NHS Trust 16 Review date: October 2014