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MENTAL CAPACITY ACT PROFORMA

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					       MENTAL
     CAPACITY ACT
      PROFORMA
The aim of this document is to ensure that any significant and specific
decisions made on behalf of a patient who lacks capacity comply with the
Mental Capacity Act 2005

The Proforma has been designed to be used for people with advanced and
progressive conditions who have palliative care needs and for patients who
are near the end of life. The capacity of these patients can be compromised
by disease progression (eg brain metastases), potentially reversible causes
(eg hypercalcaemia) and the use of drugs such as opioids intended for
symptom control



             Is there a significant decision to be made? 

             Is capacity impaired?                          

             Colour-code on front of notes                  




                     Hospice of the Good Shepherd Chester
                        MENTAL CAPACITY ACT PROFORMA

Patient Details

Name
Date of Birth
Address



Diagnosis

Assessment of Capacity
Assume the patient has capacity unless determined otherwise. Testing for capacity does
not need to be global but should be applied to each care decision as it arises. Follow the
Flowchart and record the assessment for each decision on FORM 1

Advance Decision or Statement
If the patient has made an Advance Decision or Advance Statement TICK HERE 
Complete FORM 2

Lasting Power of Attorney
If the patient has made a Lasting Power of Attorney -                TICK HERE 
Complete FORM 3

Family Discussion
Record any discussions regarding care decisions with family and carers on FORM 4

Multi-Disciplinary Team (MDT) Discussion
Record any MDT discussions regarding care decisions on FORM 5

Independent Mental Capacity Advocate (IMCA)
If the patient does not have any family members, informal carers or friends and lacks
capacity for care decisions an IMCA must be appointed.             TICK HERE 
Complete FORM 6

Court Appointed Deputy (CAD)
If it is not possible to reach a consensus decision with family and carers an application
may be made for a CAD.                                                TICK HERE 
Complete FORM 7

Best Interests
If the patient lacks capacity and in the absence of an Advance Decision or Donee of
Lasting Power of Attorney, care decisions should be made in best interests of the patient
following discussions with family/carers, MDT and IMCA/CAD if appointed.
Record decision on FORM 8


                          Hospice of the Good Shepherd Chester
            ASSESSMENT OF CAPACITY FLOWCHART

         Does the patient have an impairment of,
no       or a disturbance in the functioning of, the               Reassess
            mind or brain? eg brain metastases,
            dementia, delirium, severe distress

                         yes

         Is the patient able to understand the           no
     information relevant to this specific decision
                       decision?
                        yes

                Is the patient able to retain that       no
                          information?

                         yes

              Is the patient able to weigh that          no
           information as part of the process of
               making this specific decision?

                         yes

        Is the patient able to communicate this          no
      specific decision (whether by talking, using
          sign language or any other means)?

          yes

Patient has capacity               Patient lacks capacity


                                                               Provide support to
                                                               enhance capacity

                             If there is potential for
                            recovery of capacity or             Treat reversible
                              if capacity fluctuating               causes




                        Hospice of the Good Shepherd Chester
              FORM 1 - ASSESSMENT OF CAPACITY FOR PATIENTS IN A PALLIATIVE CARE SETTING
                      (To be used for major decisions only e.g. not for ordinary decisions of daily activity)

       For each care decision follow Flowchart to determine the patient’s capacity
       Record outcome on chart below
       If patient has capacity record patient’s own decision
       If patient lacks capacity record method of decision-making according to Mental Capacity Act eg Advance Decision (AD),
        Donee of Lasting Power of Attorney (LPA), Best Interests (BI)
       If decision taken in Best Interests this must be demonstrated in the MDT discussion

Patient’s Name ……………………

Date/      Care         Is patient     If yes - record    If no – record     Reason for lack   Decision Taken       Signature
Time      Decision       able to       patient’s own        method of          of capacity                            Name
                          make            decision       decision-making                                           Designation
                        decision?                          according to
                           Y/N                                 MCA
                                                         AD     
                                                         LPA 
                                                         BI     
                                                         AD     
                                                         LPA 
                                                         BI     
                                                         AD     
                                                         LPA 
                                                         BI     
                                                         AD     
                                                         LPA 
                                                         BI     
                                                         AD     
                                                         LPA 
                                                         BI     


                                               Hospice of the Good Shepherd Chester
                   FORM 2 - ADVANCE CARE PLANNING
        Advance Decision, Advance Statement, Preferred Priorities for Care
                    (See form 3 for lasting power of attorney)

An Advance Decision refusing consent for treatment which is made by the patient which
is valid, applicable and specific is legally binding (see code of practice for clarification)
Relevant professional and witness (preferably family member) sign below to confirm this

If the patient has made an Advance Decision tick here 
File a copy of the Advance Decision in the patient’s medical records 

An Advance Statement made by the patient requesting treatment or giving details of the
patient’s wishes and preferences regarding care in a Preferred Priorities for Care
Document are not legally binding but must be taken into account when making care
decisions

If the patient has made an Advance Statement tick here 
        File a copy of the Advance Statement in the patient’s medical records 
If the patient has completed a Preferred Priorities for Care Document tick here 
        File a copy of PPC in the patient’s medical records 

Record any specific refusals or requests below together with any decisions made on the
basis of these refusals or requests

Patient’s Name ……………………

Refusals (Summary – see medical records for full copy of original Advance Decision)




Completed by ………..….          Signature ……..……         Designation ……….        Date ……….

Witnessed by ………..….          Signature ……..……         Designation ……….        Date ……….

Requests




                          Hospice of the Good Shepherd Chester
                 FORM 2 - ADVANCE CARE PLANNING (continued)

        Decisions made on the basis of Advance Decision or Advance Statement or
                        Preferred Priorities for Care Document

Patient’s Name ……………………

Date/                                                              Signature/Name/
Time                                                               Designation




                         Hospice of the Good Shepherd Chester
                   FORM 3 - LASTING POWER OF ATTORNEY


A Donee of Lasting Power of Attorney (LPA) is enabled to give or refuse consent for
medical treatment and must be consulted when treatment decisions are to be considered.
Treatment refusals are legally binding; requests for treatment are not legally binding but
must be taken into account.
(NB. LPA is only valid if in a prescribed form and registered with the Public Guardian)
File a copy of the prescribed form in the patient’s medical records 

Patient’s Name ……………………

Details of Donee of Lasting Power of Attorney
Name

Address



Telephone

Mobile

To be contacted at night?                         YES / NO


Give details of any discussions and decisions made below
Use a separate sheet for each Donee (if more than one) and for each decision
To be signed by relevant health care professional and Donee of LPA
Date/              Discussions                      Decisions           Signature/Name/
Time                                                                    Designation




                            Hospice of the Good Shepherd Chester
            FORM 3 - LASTING POWER OF ATTORNEY (continued)


Patient’s Name ……………………

Give details of any discussions and decisions made below
Use a separate sheet for each Donee (if more than one) and for each decision
To be signed by Consultant and Donee of LPA
Date/              Discussions                     Decisions            Signature/Name/
Time                                                                    Designation




Give details of any discussions and decisions made below
Use a separate sheet for each Donee (if more than one) and for each decision
To be signed by Consultant and Donee of LPA
Date/              Discussions                     Decisions            Signature/Name/
Time                                                                    Designation




                        Hospice of the Good Shepherd Chester
                  FORM 4 - FAMILY AND CARER DISCUSSIONS

If the patient lacks capacity, specific treatment decisions must be discussed with close
family members and informal carers. The views of family and carers are not legally
binding but must be taken into account, and must be in the patient’s best interests.

Patient’s Name ……………………

Give details of any discussions below
Date/                                                                     Signature/Name/
Time                                                                      Designation




                          Hospice of the Good Shepherd Chester
                           FORM 5 - MDT DISCUSSIONS


The team should include all relevant professionals
Document any actions taken to enhance capacity

Patient’s Name ……………………

Give details of attendance (with names) and details of discussions below
Date/                                                                   Signature/Name/
Time                                                                    Designation




                         Hospice of the Good Shepherd Chester
            FORM 6 – Independent Mental Capacity Advocate (IMCA)

An IMCA must be appointed to represent and support a patient who lacks capacity in
relation to provision of
      Serious medical treatment
      Accommodation by NHS body
      Accommodation by local authority
if there is no other person whom it would be appropriate to consult

Exceptions - if there is:
    A person nominated by the pt to be consulted
    A donee of Lasting Power of Attorney
    A deputy appointed by the court
    A donee of Enduring Power of Attorney
    An obligation under the Mental Health Act
    A need to provide treatment urgently

Procedure
    Contact the appropriate authority to request appointment of an IMCA
      Contact details -
    Record contact details for the IMCA below
    Record any discussions with the IMCA and decisions made as a result overleaf

Details of Independent Mental Capacity Advocate

Patient’s Name ……………………

Name

Address



Telephone

Mobile

To be contacted at night?                        YES / NO




                            Hospice of the Good Shepherd Chester
           FORM 6 – Independent Mental Capacity Advocate (continued)

Patient’s Name ……………………

Give details of any discussions and decisions below

Date/                                                           Signature/Name/
Time                                                            Designation




                         Hospice of the Good Shepherd Chester
                     FORM 7 – Court Appointed Deputy (CAD)

If a court has appointed a CAD, this person must be consulted with regard to care
decisions on behalf of the patient providing the patient does not have capacity
A CAD is also subject to the best interests provisions.
File copy of court order in the patient’s medical records 
Record contact details for the CAD below
Record any discussions with the CAD and decisions made below

Patient’s Name ……………………

Details of Court Appointed Deputy
Name

Address



Telephone

Mobile

To be contacted at night?                        YES / NO


Give details of any discussions below
Date/                                                                   Signature/Name/
Time                                                                    Designation




                            Hospice of the Good Shepherd Chester
               FORM 7 – Court Appointed Deputy (CAD)(continued)


Patient’s Name ……………………

Give details of any discussions below
Date/                                                           Signature/Name/
Time                                                            Designation




                         Hospice of the Good Shepherd Chester
                               FORM 8 - Best Interests

This form to be used if the patient lacks capacity and in the absence of an Advance
Decision or Donee of Lasting Power of Attorney. Decisions should be made in best
interests of the patient following discussions with family/carers, MDT and IMCA/CAD if
appointed.

The following factors should be considered:
    Whether it is likely that the person will at some time have capacity
    As far as reasonably practicable, permit and encourage the person to participate,
       or to improve his ability to participate
    The person's past and present wishes and feelings and, in particular, any relevant
       written statement made by him when he had capacity eg. PPC or other
       documentation which would have influence
    The beliefs and values that would be likely to influence his decision if he had
       capacity
    The other factors that he would be likely to consider if he were able to do so

Patient’s Name ……………………

Record discussions and decisions below if not recorded elsewhere
Date/                                               Who consulted      Signature/Name/
Time                                                eg Carer/MDT/      Designation
                                                    IMCA/CAD




                         Hospice of the Good Shepherd Chester
                           FORM 8 - Best Interests (continued)


Patient’s Name ……………………

Record discussions and decisions below if not recorded elsewhere
Date/                                               Who consulted       Signature/Name/
Time                                                eg Carer/MDT/       Designation
                                                    IMCA/CAD




References
Mental Capacity Act 2005 - www.opsi.gov.uk/acts/acts2005/20050009.htm
Code of Practice February 2007 - www.dca.gov.uk/menincap/legis.htm



                           Hospice of the Good Shepherd Chester

				
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