 Yes  No

1. Framework for all care decisions Use this if you wish to make a care decision with, or on behalf of, an individual aged 18yr or over  Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision Emergency Statement If this an emergency requiring immediate treatment treat if this is likely to succeed and benefit the patient  Child / young person lacking capacityUse this for any child or young person who does have not have capacity for that care decision  Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision  Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision  Framework for CPR decisionsUse this for making CPR decisions. Adapted from 2007 BMA/RC/RCN Joint Statement on CPR and 2014 Deciding right  InformationDecision tree Help Glossary Links and acknowledgements     

2. Initial framework for all care decisions  Use this if you wish to make a care decision with, or on behalf of, an individual aged 18yr or over A1 Is a care decision needed or requested by the individual?  Yes No

3. Initial framework for all care decisions Use this if you wish to make a care decision with, or on behalf of, an individual aged 18yr or over • Continue to elicit the needs and concerns of the individual and carers, at their pace and communicating in a way they understand. • If you are uncertain or lack knowledge of the individual's clinical condition and treatment possibilities, or their reaction to their illness, ask a colleague who does have this knowledge to lead the discussion. • To discuss future care decisions use the principles of advance care planning (see www.nhs.uk/Planners/end-of-life-care/Documents/Planning-for-your-future-care.pdf ) • To explain risks of care consider using use Shared Decision Making (see www.rightcare.nhs.uk/index.php/shared-decision-making/sdm-project-latest/ )

4. Initial framework for all care decisions  Use this if you wish to make a care decision with, or on behalf of, an individual aged 18yr or over A2 Do you suspect the individual may have an impairment or disturbance of mind or brain?  Yes No

5. Initial framework for all care decisions Use this if you wish to make a care decision with, or on behalf of, an individual aged 18yr or over • Ensure that you have provided all the information needed for their decision in a way they can understand. • The 2005 MCA requires you to assume the individual has capacity. • This applies even if you think their decision is unwise or illogical. • NEXT

6. Initial framework for all care decisions Use this if you wish to make a care decision with, or on behalf of, an individual aged 18yr or over Test the capacity for this specific care decision (capacity can be different for different decisions) Can the individual understand the information you have provided? retain this information long enough to weigh it up? weigh up the pros and cons of the care option? communicate their decision? If the individual cannot manage any one of these, they do not have capacity for this decision Note that 1) and 2) are your responsibility. You must ensure the information is understandable and every means of communication has been explored. To guide you and document the capacity test you may wish to use MCA form available on Deciding rightwww.cnne.org.uk/end-of-life-care---the-clinical-network/Decidingright/plusresources NEXT

7. Initial framework for all care decisions  Use this if you wish to make a care decision with, or on behalf of, an individual aged 18yr or over A3 Does this individual have capacity for this decision? • Yes •  No If this is an adult go here If this is a child or young person go here

8. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision B1 Does the individual need to make a care decision?  Yes No

9. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision • Continue to elicit the needs and concerns of the individual and carers, at their pace and communicating in a way they understand. • When they are ready to make a decision go to section on Framework for all care decisions

10. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision B2 Is the decision about care in the future in the event that the individual loses capacity for that decision?  Yes No

11. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision Go though established procedures for informed consent by a person with capacity for that decision.

12. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision B3 Does the individual want to refuse a specific treatment in the future in the event of losing capacity for that decision?  Yes No

13. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision • If the individual wishes, they can make an advance statement about their wishes and preferences, beliefs and values. This advance statement does not have to be written and can be verbal. • The individual can choose to refuse CPR in some or any circumstances, in which case a DNACPR should be completed stating that the individual with capacity is refusing CPR. • If the individual wants their decision to be legally binding the individual must complete an ADRT form. • The individual may want to consider discussing with carers an EHCP form to document what they would want to happen in an anticipated emergency. • For examples of forms concordant with the MCA seewww.cnne.org.uk/end-of-life-care---the-clinical-network/Decidingright/plusregionalforms • For further information, see the section on checking the validity of advance decisions • NEXT

14. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision B4 If the individual loses capacity in the future, do they want to appoint someone to make the decision on their behalf?  Yes No

15. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision • Any individual 18yrs or over can choose to complete an ADRT which, if valid (correctly completed) and applicable to the circumstances is legally binding on carers. The ADRT only become active once the individual loses capacity for those decisions. • If the ADRT refuses CPR, a DNACPR form should also be completed. • An EHCP can also be completed to document what the individual would want to happen in an anticipated emergency. • For examples of forms concordant with the MCA seewww.cnne.org.uk/end-of-life-care---the-clinical-network/Decidingright/plusregionalforms • For further information, see the section on checking the validity of advance decisions

16. Individual with capacity Use this if you wish to make a care decision with an individual who has been shown, or can be assumed to have, capacity for that care decision • The individual over 18yrs can set up a LPA. This can be done online (see www.gov.uk/power-of-attorney/overview) and there is a fee. Solicitors can help and may charge an additional fee. • There are two types: Property and Affairs and Personal Welfare (Health and Welfare). Only the second type is valid for making health and social care decisions. • When the individual loses capacity the LPA (like all carers) is bound by the MCA Best interestsprocess (see Glossary)

17. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision Best interests is not simply what the clinician believes is best but is a checklist from the Mental Capacity Act to estimate the best decision or the one the individual would have made if they still had capacity. The MCA applies in full to anyone aged 18yrs and over. The MCA also applies to those aged 16 to 17yrs with these exceptions: a) only people aged 18 and over can make a Lasting Power of Attorney (LPA) or an advance decision to refuse medical treatment (ADRT) and b) the Court of Protection may only make a statutory will for a person aged 18 and over. For all those aged 15yrs and below the MCA does not protect their decisions with two exceptions: a) the Court of Protection can make decisions about a child’s property or finances (or appoint a deputy to make these decisions) and b) offences of ill treatment or wilful neglect of a person who lacks capacity can also apply to victims younger than 16. There are three key differences between those 18yrs and older, and those 17yrs and younger: 1) Assumption of capacity: anyone aged 18yrs and over must be assumed to have capacity. For those aged 17yrs or below, assumption of capacity applies for most care decisions (eg. anaesthesia) but it does not apply to rarer types of procedure such as organ donation. 2) Authority of those with parental responsibility: at age 18yrs parents can no longer have responsibility for making decisions. At 17yrs and below parents can still make decisions, but if the individual is shown to have capacity for the decision being made, this will take precedence. 3) Deciding best interests: At age 16yrs and above there is a specific process required by the MCA. At age 15yrs and below, this process is not a legal requirement, but it remains an excellent decision framework. NEXT

18. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C1 Is there anyone who can speak for the individual?  Yes No

19. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision If there is time, you must consider instructing an Independent Mental Capacity Advocate (IMCA) and receive a report from an IMCA. Every locality in England and Wales has an IMCA service. NEXT

20. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C2 Have you avoided making assumptions solely on the basis of the individual’s age, appearance, condition or behaviour?  Yes No

21. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision Would you have made a different decision in another similar individual? If so, why did you make the decision? If your decision was based solely on age, appearance, condition or behaviour, you need to review your decision. NEXT

22. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C3 Have you considered all issues when making a decision for the individual?  Yes No

23. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision • Have all the options been considered, including other specialist opinions and disciplines? • Have their previous wishes and preferences, beliefs and values been taken into account? • NEXT

24. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C4 Is the loss of capacity irreversible?  Yes No

25. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C4a Is there is time to wait until capacity returns?  Yes No

26. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision Wait for capacity to return and ask the individual

27. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C5 Has the individual been involved in making the decision?  Yes No

28. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision • You must permit and encourage the individual to take part in the process. Their opinion is not binding, but it must be taken into account. • NEXT

29. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C6 Have you avoided being motivated by a desire to bring about the individual's death?  Yes No

30. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision Where the decision relates to life sustaining treatment in an individual lacking capacity, death may be the consequence of the decision. However, death must not be the motivating reason for the decision by the carer or clinician NEXT

31. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C7 Have you considered the least restrictive option?  Yes No

32. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision Taking into account all the factors, what decisions would be least restrictive in terms of physical, psychological and social function? NEXT

33. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision C8 Have you considered other factors?  Yes No

34. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision Have you considered factors such as emotional bonds, family obligations that the individual would be likely to consider if they were making the decision? NEXT

35. Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision • C9 • What is in the individual's best interests? • Gather all the information elicited from questions C1 to C8 (note these are the minimum required by the Mental Capacity Act). • Estimate the decision the individual would have made if they had capacity or, if they never had capacity, the best decision for that individual. • In the event of disagreement offer a second opinion or refer to the local ethics advisory group. • As a last resort, refer to the Court of Protection.

36. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision Start the MCA best interests process. This is not simply what the clinician believes is best but is a checklist to estimate the best decision or the one the individual would have made if they still had capacity You can use the MCA form on Deciding right to guide you and document this process. It is available on www.cnne.org.uk/end-of-life-care---the-clinical-network/Decidingright/plusresources For key care decisions this process is best done at a meeting that includes key people who know the individual, including those involved in the care. NEXT

37. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision D1 Is there anyone who can speak for the individual?  Yes No

38. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision If there is time, you must consider instructing an Independent Mental Capacity Advocate (IMCA) and receive a report from an IMCA. Every locality in England and Wales has an IMCA service. NEXT

39. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision D2 Have you avoided making assumptions solely on the basis of the individual’s age, appearance, condition or behaviour?  Yes No

40. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision Would you have made a different decision in another individual? If so, why did you make the decision? If your decision was based solely on age, appearance, condition or behaviour, you need to review your decision. NEXT

41. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision D3 Have you considered everything the individual would have taken into account?  Yes No

42. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision Have all the options been considered, including other specialist opinions and disciplines? Have any advance decisions been considered? NEXT

43. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision D4 Is the loss of capacity irreversible?  Yes No

44. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision D4a Is there is time to wait until capacity returns?  Yes No

45. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision Wait for capacity to return and ask the individual

46. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision D5 Has the individual been involved in making the decision?  Yes No

47. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision You must permit and encourage the individual to take part in the process. Their opinion is not binding, but it must be taken into account. NEXT

48. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision D6 Have you avoided being motivated by a desire to bring about the individual's death?  Yes No

49. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision Where the decision relates to life sustaining treatment in an individual lacking capacity, death may be the consequence of the decision. However, death must not be the motivating reason for the decision by the carer or clinician. NEXT

50. Adult lacking capacityUse this if you wish to make a care decision on behalf of an individual aged 18 yrs or over who has been shown not to have capacity for that care decision D7 Have you considered the least restrictive option?  Yes No