An Advance Decision:
An Advance Decision refusing electro-convulsive therapy cannot be overridden even if the person is detained under the Mental Health Act. The person can only be given such treatment in an emergency, to save their life. (MHA section 58a) (Part 31: The Mental Capacity Act and the Mental Health Act)
An Advance Decision can be made to indicate someone’s wish not to receive life sustaining treatment, such as resuscitation or mechanical ventilation.
If the Advance Decision relates to life sustaining treatment then the Decision must be in writing, signed and witnessed.
It is wise to make sure that such a Decision is copied into all medical or care notes and that the person carries a copy of it with them. Everyone who may be asked about such a Decision should be fully aware of it, what it says and where it is. It is wise to discuss it with all practitioners.
These orders relate to a decision made in advance as to whether someone should be resuscitated in the event of a cardiac arrest.
If someone has capacity to make this decision they should make it for themselves and their wishes must be respected. If there may be doubts about their capacity it may be wise to record that they have capacity to make this decision. (Part 6: How to assess capacity) (Part 10: How to record decisions)
If someone doesn’t have capacity to make a DNAR a best interests decision can be made. This is serious medical treatment and a full assessment is needed before decisions are made. There needs to be an assessment of the person’s capacity to make the decision and a record of how the best interests decision has been reached. This will include speaking to the person’s family, but the family do not make the decision. If the person is unbefriended there will need to be a referral for Independent Mental Capacity Advocate representation and an evidence-based report before the decision is made. The decision-maker will be the doctor providing medical care. (Part 15: Independent Mental Capacity Advocates) (Part 6: How to assess capacity) (Part 7: Being a decision-maker) (Part 8: Best interests decisions)
If someone is in hospital the consultant will be the decision-maker and will lead the process. If someone is in the community the decision-maker will be their GP or the Palliative Care Team. Family members are never the decision-makers for this decision and should never be asked to make this decision.
It is important that any DNAR includes clear direction for any carers as to what to do in the event of someone collapsing. It is helpful to include directions for paramedic crews.
All decisions about such emergency care will need to be regularly reviewed.
If someone has previously been able to make their own decision but has now lost capacity their views should be taken into account. However a best interests decision will need to be made and this may not be the same as the person’s previous decision.
An Advance Statement can be made about any aspect of care or accommodation or lifestyle.
These statements would be considered as evidence of the person’s wishes when a best interests decision is being made, however an Advance Statement is not legally binding. For instance; it would be possible for someone to make an Advance Statement saying that they don’t want to go into residential care; if they later lose capacity and admission to care becomes an option, the Advance Statement would be taken into consideration but the refusal would not be legally binding. A best interests decision would be made after consideration of all the current relevant circumstances.
It is possible to use an Advance Statement to indicate what care or treatment someone would like to receive. People who have a relapsing problem with their mental health may know when they are well that a particular form of treatment is helpful, but may lose capacity to make that decision when they are unwell. It is possible to make an Advance Statement indicating choices about treatment; however, the decision about treatment would be made by the decision-maker at that time, who would pay due regard to any Advance Statements. (Part 8: Best interests decisions)
This page was last modified: 3rd Jan 2014