Consent Form for Adults Unable to Consent

ClinicalGenetics

7thFloor,BoroughWing

Guy’sHospital

GreatMazePond Tel: 02071881364

LondonSE19RT

Consent Form for Adults Unable to Consent

To be completed byhealth professional proposingtest.

Please see guidance on health professionaloverleaf for details of situationswhere court appeals must first be sought.

Patient’sname: PatientPRUnumber: : Date ofbirth: Male Female

Responsiblehealthprofessional: Specialrequirements(e.g. other language or communication method):

A Detailsofproposedtest

blood sample to be analysed for:

tissue sample to be analysed for:

other sample (please specify):

B Assessmentofpatient’scapacity

I confirm that the patient lacks capacity to give or withhold consentto this test because:

the patient is unable to comprehend and retain information material to the decision

the patient is unable to use and weigh thisinformation in the decision-making process

the patient is unconscious

Details about howthis decision wasreached (exclude if patient unconscious):

...... ………………………………..……..

...... ………………………………..………

C Assessmentofpatient’sbestinterests

To the best of my knowledge the patient has not refused this test previously orin a valid advance directive.Where possible and appropriate, I have consulted with colleagues and those close to the patient. I believe the procedure to be in the patient’sbest interests because:

...... ………………………………..……..

Testcannotwaituntilcapacityrecovered(ifincapacityis likely to be temporary)because:

...... ………………………………..……..

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D Statementofhealthprofessionalproposingtest

Inmyclinicaljudgement,theproposedtestisinthebestinterestsofthispatient,wholacks capacitytoconsentforhimselforherself. Wherepossibleandappropriate,Ihavediscussedthe patient’sconditionwiththoseclosetohimorherandtakentheirknowledgeofthepatient’sviews and beliefs into account in determining his or her best interests.

Signature………….………………………..………….… Date ..……...... …………………………………………………..

Name (PRINT)…………………...... ……… Job title……..….……………...….……………………………..

 A second opinion has been sought(pleaseask colleagueto complete section below)

Comment:…………………………………….……………………………………………………………

...... ………………………..

Signature………….………………………..………….… Date ..……...... …………………………………………………..

Name (PRINT)…………………...... ……… Job title……..….……………...….……………………………..

E Involvementofthepatient’sfamilyorothersclosetothepatient

Thefinalresponsibilityfordeterminingwhetheratestisinanincapacitatedpatient’sbestinterests lieswiththehealthprofessionalperformingthetest.However,itisgoodpracticetoconsultwith thoseclosetothepatient(e.g.spouse/partner,familyandfriends,carer,supporteroradvocate) unless you have good reason to believe that the patient would not have wished particular individualstobeconsulted,orunlesstheurgencyoftheirsituationpreventsthis.“Bestinterests” gofarwiderthan“bestmedicalinterests”,andincludefactorssuchasthepatient’swishesand beliefswhencompetent,theircurrentwishes,theirgeneralwellbeingandtheirspiritualand religious welfare.

Ifapersonclosetothepatientwasnotavailableinperson,hasthismatterbeendiscussed in anyother way(e.g. over thetelephone)? Yes No

Details:......

......

Voluntarystatementofrelative(s)orothersclosetothepatient

I / We have been involved in a discussion with therelevant health professionals over the testing of………………………………………………….…(patient’s name) and understand that he / she is unable to give his / her own consent, based on the criteria set out in this form. I / We also understand that testing canlawfully be provided if it is in his / her best interests to receive it.

Comments about this decision:

...... ………...... …...

...... …………. Signature: ………….…………………………… Date: ..……...... ………………………………….. Name (PRINT): ……………………………….... Relationship to patient:…………………………. Address (if not same as patient):...... ……………………………………………….

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Guidancetohealthprofessionals(tobereadinconjunctionwithconsentpolicy)

Thisformshouldonlybeusedwhereitwouldbeusualtoseekwrittenconsentbutanadultpatient(18or over)lackscapacitytogiveorwithholdconsenttotreatment.Ifanadulthascapacitytoacceptorrefuse treatment,youshouldusethestandardconsentformandrespectanyrefusal.Wheretreatmentisvery urgent(forexampleifthepatientiscriticallyill),itmaynotbefeasibletofillinaformatthetime,butyou shoulddocumentyourclinicaldecisionsappropriatelyafterwards.Iftreatmentisbeingprovidedunderthe authorityofPartIVoftheMentalHealthAct1983,differentlegalprovisionsapplyandyouarerequiredtofillinmore specialisedforms (althoughinsome circumstancesyoumayfindithelpfultousethisformaswell).If theadultnowlackscapacity,buthasclearlyrefusedparticulartreatmentinadvanceoftheirlossof capacity(forexampleinanadvancedirectiveor‘livingwill’),thenyoumustabidebythatrefusalifitwas validlymadeandisapplicabletothecircumstances.Forfurtherinformationonthelawonconsent,seethe DepartmentofHealthReferenceguidetoconsentforexaminationortreatment(

Whentreatmentcanbegiventoapatientwhoisunabletoconsent

Fortreatmenttobegiventoapatientwhoisunabletoconsent,thefollowingmustapply:

• thepatientmustlackthecapacity(‘competence’)togiveorwithholdconsenttothisprocedureAND

• theproceduremustbeinthepatient’sbestinterests.

Capacity

Apatientwilllackcapacitytoconsenttoaparticularinterventionifheorsheis:

• unabletocomprehendandretaininformationmaterialtothedecision,especiallyastotheconsequences ofhaving,ornothaving,theinterventioninquestion;and/or

• unabletouseandweighthisinformationinthedecision-makingprocess.

Beforemakingajudgementthata patientlackscapacityyoumusttakeallstepsreasonableinthe circumstancestoassistthepatientintakingtheirowndecisions(thiswillclearlynotapplyifthepatientis unconscious).Thismayinvolveexplainingwhatisinvolvedinverysimplelanguage,usingpicturesand communicationanddecision-aidsasappropriate.Peoplecloseto thepatient(spouse/partner,family, friendsandcarers)mayoftenbeabletohelp,asmayspecialistcolleaguessuchasspeechandlanguage therapistsorlearningdisabilityteams,andindependentadvocatesorsupporters.Capacityis‘decision- specific’:apatientmaylackcapacitytotakeaparticularcomplexdecision,butbequiteabletotakeother morestraightforwarddecisionsorpartsofdecisions.

Bestinterests

Apatient’sbestinterestsarenotlimitedtotheirbestmedicalinterests.Otherfactorsthatformpartofthe bestinterestsdecisioninclude:

• thewishesandbeliefsofthepatientwhencompetent

• theircurrentwishes

• theirgeneralwell-being

• theirspiritualandreligiouswelfare

Two incapacitated patients, whose physical condition is identical, may therefore have different best interests.

Unlessthepatienthasclearlyindicatedthatparticularindividualsshouldnotbeinvolvedintheircare,or unlesstheurgencyoftheirsituationpreventsit,youshouldattempttoinvolvepeopleclosetothepatient (spouse/partner, familyandfriends,carer,supporteroradvocate)inthedecision-makingprocess.Those closetothe patientcannotrequireyou toprovideparticulartreatmentthat you donotbelievetobeclinically appropriate.Howeverthey willknowthepatientmuchbetterthan you do,and thereforearelikelytobeable to providevaluableinformationaboutthepatient’swishesandvalues.

Secondopinionsandcourtinvolvement

Wheretreatmentis complexand/orpeoplecloseto the patientexpressdoubtsaboutthe proposed treatment,asecondopinionshouldbesought,unlesstheurgencyofthepatient’sconditionpreventsthis.

Donation of regenerative tissue such as bone marrow, sterilisation for contraceptive purposes and withdrawalofartificialnutritionorhydrationfromapatientinPVSmustneverbeundertakenwithoutprior HighCourtapproval.HighCourtapprovalcanalsobesoughtwheretherearedoubtsaboutthepatient’s

capacityorbestinterests.