Adults who lack the capacity to consent to investigation or treatment

Adults who lack the capacity to consent to investigation or treatment

(Consent Form 4)
Patient No:*
Name of proposed procedure or course of treatment
Assessment of patient’s capacity (in accordance with the Mental Capacity Act)

I confirm that the patient lacks capacity to give or withhold consent to this procedure or course of treatment because of an impairment of the mind or brain or disturbance affecting the way their mind or brain works (for example, a disability, condition or trauma, or the effect of drugs or alcohol) and they cannot do one or more of the following:
• understand information about the procedure or course of treatment
• retain that information in their mind
• use or weigh that information as part of the decision-making process, or
• communicate their decision (by talking, using sign language or any other means)
Further details of this assessment can be noted here: (for example how above judgements reached, which colleagues consulted, what attempts were made to assist the patient to make his or her own decision and why these were notsuccessful):
Advance decision to refuse medical treatment

This patient has not made an advanced decision to refuse medical treatment.
To the best of your knowledge, the patient has not refused this procedure in a valid Advance Decision.
Where an advance decision to refuse medical treatment has been made, please document the details of the treatment to be refused here:
Assessment of patient’s best interests

As far as is reasonably possible, I have considered the person’s past and present wishes and feelings (in particular if they have been written down) and any beliefs and values that would likely influence the decision in question.

As far as possible, I have consulted other people (those involved in caring for the patient, interested in their welfare or the patient has said should be consulted) as appropriate. I have considered the patient’s best interests in accordance with the requirements of the Mental Capacity Act and believe the procedure to be in their best interests

Involvement of the patient’s family and others close to the patient.

The final responsibility for determining whether a procedure is in an incapacitated patient’s best interests lies with the health professional performing the procedure. However, it is good practice to consult with those close to the patient (eg spouse/partner, family and friends, carer, supporter or advocate) unless you have good reason to believe that the patient would not have wished for particular individuals to be consulted, or unless the urgency of their situation prevents this.

“Best interests” go far wider than “best medical interests”, and include factors such as the patient’s wishes and beliefs when competent, their current wishes, their general well-being and their spiritual and religious welfare.
Where the lack of capacity is likely to be temporary, for example if patient is unconscious, or where patient has fluctuating capacity, complete the following section:The treatment cannot wait until the patient recovers capacity because:
Independent Mental Capacity Advocate (IMCA). For decisions about serious medical treatment, where there is no one appropriate to consult other than paid staff, has an Independent Mental Capacity Advocate (IMCA) been instructed?
Name of IMCA

First NameLast Name
Signature

Powered by Jotform SignClear
Lasting Power of Attorney/ Court Appointed Deputy
If the patient has authorised an attorney to make decisions about the procedure in question under a Lasting Power of Attorney or a Court Appointed Deputy has been authorised to make decisions about the procedure in question, they have authority to make decisions in the patient’s best interests.

I have been authorised to make decisions about the procedure in question under a Lasting Power of Attorney/ as a Court Appointed Deputy. I have considered the relevant circumstances relating to the decision under the heading ‘Assessment of patient’s best interests’ and believe the procedure to be in the patient’s best interests.
Name

First NameLast Name
Signature

Powered by Jotform SignClear
Name

First NameLast Name
Relationship to patient
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Signature of health professional proposing treatment
The above procedure is, in my clinical judgement, in the best interests of the patient, who lacks capacity to consent for himself or herself. Where possible and appropriate I have discussed the patient’s condition with those close to him or her, and taken their knowledge of the patient’s views and beliefs into account in determining his or her best interests.
Consultant/Medical Officer*

First NameLast Name
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty: