DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Independent Mental Capacity Advocacy

For Health Care professionals

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Content

• Types of decision where an IMCA may be involved

• What constitutes Serious Medical Treatment ?

• Documenting the decision and the capacity assessment

• Who is the assessor/decision maker?

• Who is appropriate to consult for SMT decisions?

• Case Law

• Making an IMCA Referral

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Mental Capacity Act 2005

What you need to know about involving an Independent Mental Capacity Advocate (IMCA) in

Best Interest decision making

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Types of decision when an IMCA may be involved;When a person is assessed as lacking mental capacity, and there is no one else appropriate to consult with, there is a legal duty to instruct an IMCA for the following decisions;

1) Serious Medical Treatment

2) Change of Accommodation

And IMCA may be instructed for the following decisions;

1) Adult safeguarding

2) Care Review

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Serious Medical Treatment decisions

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

MCA 10.45 - SMT is defined as treatment which involves giving new treatment, stopping treatment or withholding treatment that could be offered where … what is proposed is likely to have serious consequences for P.

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

The Mental Capacity Act code of practice defines an SMT decision as the following; Serious medical treatment is defined as treatment which involves;

• giving new treatment, stopping treatment that has already started or withholding treatment that could be offered in circumstances where:

• if a single treatment is proposed there is a fine balance between the likely benefits and the burdens to the patient and the risks involved

• a decision between a choice of treatments is finely balanced, or

• what is proposed is likely to have serious consequences for the patient.

‘Serious consequences’ are those which could have a serious impact on the patient, either from the effects of the treatment itself or its wider implications. This may include treatments which:

• cause serious and prolonged pain, distress or side effects

• have potentially major consequences for the patient (for example, stopping life-sustaining treatment or having major surgery such as heart surgery), or

• have a serious impact on the patient’s future life choices (for example, interventions for ovarian cancer).

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Examples of SMT decisions;

• chemotherapy and surgery for cancer • electro-convulsive therapy • therapeutic sterilisation • major surgery (such as open-heart surgery or brain/neuro-surgery) • major amputations (for example, loss of an arm or leg) • treatments which will result in permanent loss of hearing or sight • withholding or stopping artificial nutrition and hydration, and• termination of pregnancy.• DNACPR and end of life planning• treatment involving General Anaesthetic• the proposed treatment could have serious consequences for the

client

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Documenting the Best Interest Decision

• Is there an impairment of or disturbance in the functioning of the person’s mind or brain?

• Is the impairment or disturbance sufficient that the person lacks the capacity to make that particular decision?

The functional testThe person is unable to make a decision if they cannot:

1. Understand information about the decision to be made2. Retain that information in their mind3. Use or weigh-up the information as part of the decision process4. Communicate their decision

Document the capacity assessment

The 2 stage test

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Document the Best Interest Decision

• How was the Best Interests decision reached?

• What factors were taken into account?

• What other treatment options were considered in reaching the decision?

• Who was consulted?

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

The assessor/decision maker

• The GP/Doctor is the decision maker when considering an SMT / DNACPR

• The GP/Doctor needs to assess the person’s capacity to be involved in this decision (Mental Capacity Act Codes of Practice S.4.40 / S4.42):

“If a doctor or healthcare professional proposes treatment or an examination, they must assess the person’s capacity to consent…..ultimately it is up to the professional responsible for the person’s treatment to make sure that capacity has been assessed.”

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

10.42 MCA code of practice .– Where SMT is being considered for a person who lacks capacity to consent and there is no-one appropriate to consult NHS bodies must instruct an IMCA (S.37MCA)

Consultation

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

When there is a duty to instruct an IMCA

• When a person has been assessed as lacking capacity regarding the proposed serious medical treatment decision. If there is no one else appropriate to consult with regarding the best interest decision, the decision maker has a legal duty to instruct an IMCA.

• A disagreement between professionals and the appropriate person is not reason to deem them not appropriate to consult with.

• However, an IMCA can be instructed if there are concerns that the family/friend may not be acting in the person’s best interest.

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

If a person lacks capacity to consent –who is appropriate to consult?

• Are there appropriate friends, family or unpaid carers to discuss the SMT/DNACPR decision with ?

• An appropriate person must be someone not acting in a paid capacity; it cannot be another paid professional. An appropriate person could be a friend or family member of the client. (S.10 – Code of Practice 2005)

• Is there an LPA for health and welfare decisions? If yes the person/s with LPA must be consulted

• If there is no LPA – friends and family can still be consulted if they are appropriate

• No appropriate person to consult? An IMCA must be consulted (S.10.8 MCA)

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

When an IMCA is not required;

• The client has mental capacity regarding the SMT decision

• There is someone who is appropriate to be consulted for the decision

• An urgent decision is required to provide life sustaining treatment

• The medical treatment would not be considered ‘serious medical treatment’ as described in the Mental Capacity Act code of practice.

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Urgent Decisions

Urgent decisions will have to be made and immediate action taken in someone’s best interests in these situations. It may not be practical or appropriate to delay treatment or to consult the person or known attorney’s, IMCAs (S 3.6 MCA Code of Practice)

Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing …. “If a CPR decision is needed when an IMCA is not available, the decision should be made, the reasons for it should be documented in the health record and an IMCA should be consulted at the first available opportunity.”

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

• To meet with the person and represent their views and wishes throughout the decision making process.

• The ensure that the Mental Capacity Act principles are complied with, and raise concerns where necessary.

• To consult with the decision maker about the treatment options and ask questions, raise issues and offer information on the person’s behalf

• To ask for a second medical opinion if required- this could be regarding mental capacity or treatment options.

• To consult with all relevant people to gather information relevant to the decision. This could include persons past views or wishes, spiritual or cultural beliefs and what course of action the client may have wanted when they had mental capacity.

• To attend best interest meetings as required.

• To produce a written report which is shared with the decision maker.

• To recommend an application to the Court Of Protection for complex decisions which are so finely balanced that a decision cannot be reached, or if there is dispute.

What is the Role of the IMCA?

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020 • “Is to support an represent the person who lacks capacity…..IMCA’s have the

right to see relevant health care and social care records.”

• This would include the right to see the mental capacity assessment.

• “Any information or reports provided by the IMCA must be taken into account as part of the process of working out whether a proposed decision is in the person’s best interests.” (Mental Capacity Act of Codes of Practice – Chapter 10)

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Case Law relating to consultation for

DNACPR decisions

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Tracey v Cambridge University Hospitals NHS Foundation Trust & Ors [2014] EWCA Civ 82

The court held that the clinician has a duty to consult the patient inrelation to DNACPR (the person had capacity)

"unless he or she thinks that the patient will be distressed by being consulted and that that distress might cause the patient physical or psychological harm".

It must be emphasised that the court is insisting only that doctors consult before making this decision.

Explicitly, the court leaves the decision whether the DNACPR decision should be made to the doctor.

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Winspear v City Hospitals Sunderland NHS Trust (2015)

“where a patient lacks the requisite capacity, section 4(7) MCA encompasses the procedural obligations to consult. The obligation can only be waived in situations where it is truly impracticable or inappropriate to hold such a discussion”

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

Guidance from the British Medical Association, the Resuscitation Council (UK), and the Royal College of Nursing (previously known as the "Joint Statement")

“emphasises the importance of involving people (or their representatives if they are unable to make decisions for themselves) in the decision-making process; this often involves a person making a shared decision with their healthcare professionals, but where CPR has no realistic chance of success it may involve informing people of the decision and explaining the basis for it;” (Cardiopulmonary Resuscitation (3rd edition - 1st revision)

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

St Catherine’s Hospice Care Homes Team

• Agreed local procedure “When to instruct an IMCA if a DNACPR decision is being considered for a resident in a Care Home”

Please see handout sheet which details:

• Care home responsibilities

• GP responsibilities

• Referral and eligibility for IMCA

• Review of DNACPR form

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

How to refer

The IMCA service is provided by Total Advocacy in North Yorkshire

• Online referral forms can be completed at the Cloverleaf Advocacy website

Website: www.cloverleaf-advocacy.co.uk

• Email cst.referrals@cloverleaf-advocacy.co.uk

• Telephone: 01609 765355 to complete a telephone referral

DNACPR INFORMATION

- for Health Care Professionals

DATE: 25/02/2020

ANY QUESTIONS?