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Northern England Strategic Clinical Networks   Home (c) NESCN October 2014. Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design:

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Presentation on theme: "Northern England Strategic Clinical Networks   Home (c) NESCN October 2014. Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design:"— Presentation transcript:

1 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Emergency Statement  If this is an emergency requiring immediate treatment, treat if this is likely to succeed and benefit the patient 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 Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision Adult lacking capacity Use 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 decisions Use this for making CPR decisions. Adapted from 2007 BMA/RC/RCN Joint Statement on CPR and 2014 Deciding right       Information Decision tree Help Glossa Links, acknowledgements and terms of use   

2 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Yes No A1 Is a care decision needed or requested by the individual?

3 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Yes No A2 Do you suspect the individual may have an impairment or disturbance of mind or brain?

5 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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). Ensure that you accurately document the results of the test Can the individual 1.understand the information you have provided? 2.retain this information long enough to weigh it up? 3.weigh up the pros and cons of the care option? 4.communicate their decision? If the individual cannot manage any one of these, they do not have capacity for this decision Note that tests 1) and 4) are your responsibility. You must ensure that the information is understandable and that 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 right NEXT

7 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Yes NoIf this is an adult click herehere If this is a child or young person click herehere A3 Does this individual have capacity for this decision?

8 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No B1 Does the individual need to make a care decision? 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

9 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 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

10 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No B2 Is the decision about care in the future in the event that the individual loses capacity for that decision? 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

11 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Go through established procedures for informed consent by a person with capacity for that decision. 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

12 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No B3 Does the individual want to refuse a specific treatment in the future in the event of losing capacity for that decision? 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

13 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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. Ensure that all discussions and decisions are accurately recorded For examples of forms concordant with the MCA see For further information, see the section on checking the validity of advance decisions NEXT 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

14 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No B4 If the individual loses capacity in the future, do they want to appoint someone to make the decision on their behalf? 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

15 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 see For further information, see the section on checking the validity of advance decisions 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

16 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid The individual over 18yrs can set up a LPA. This can be done online (see of-attorney/overview) and there is a fee. Solicitors can help and may charge an additional fee.www.gov.uk/power- of-attorney/overview 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 interests process (see Glossary) 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

17 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

18 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C1 Is there anyone who can speak for the individual? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

19 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

20 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C2 Have you avoided making assumptions solely on the basis of the individual’s age, appearance, condition or behaviour? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

21 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

22 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C3 Have you considered all issues when making a decision for the individual? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

23 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

24 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C4 Is the loss of capacity irreversible? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

25 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C4a Is there is time to wait until capacity returns? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

26 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Wait for capacity to return and ask the individual Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

27 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C5 Has the individual been involved in making the decision? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

28 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

29 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C6 Have you avoided being motivated by a desire to bring about the individual's death? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

30 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

31 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C7 Have you considered the least restrictive option? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

32 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Taking into account all the factors, what decisions would be least restrictive in terms of physical, psychological and social function? NEXT Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

33 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No C8 Have you considered other factors? Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

34 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

35 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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. Ensure that all discussions and decisions are accurately documented Child / young person lacking capacity Use this for any child or young person who does have not have capacity for that care decision

36 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 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. Ensure that all discussions and decisions are accurately documented NEXT Adult lacking capacity Use 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

37 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D1 Is there anyone who can speak for the individual? Adult lacking capacity Use 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

38 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid You must instruct an Independent Mental Capacity Advocate (IMCA) if - a decision is needed to provide, withhold or withdraw serious medical treatment, or for decisions relating to long-term residence-change (ie. more than 28 days in hospital or more than 8 weeks in the community) - there is time to do so An IMCA will still be needed if - only paid staff can speak for the individual - the individual’s friends or relatives are available but are in strong disagreement about the options IMCAs are independent of the care and treatment decision being made. They do not make a best interests decision but will enable the process and provide a report. Every locality in England and Wales has an IMCA service. NEXT Adult lacking capacity Use 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

39 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D2 Have you avoided making assumptions solely on the basis of the individual’s age, appearance, condition or behaviour? Adult lacking capacity Use 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

40 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Adult lacking capacity Use 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

41 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D3 Have you considered everything the individual would have taken into account? Adult lacking capacity Use 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

42 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Have all the options been considered, including other specialist opinions and disciplines? Have any advance decisions been considered? NEXT Adult lacking capacity Use 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

43 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D4 Is the loss of capacity irreversible? Adult lacking capacity Use 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

44 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D4a Is there is time to wait until capacity returns? Adult lacking capacity Use 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

45 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Wait for capacity to return and ask the individual Adult lacking capacity Use 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

46 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D5 Has the individual been involved in making the decision? Adult lacking capacity Use 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

47 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Adult lacking capacity Use 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

48 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D6 Have you avoided being motivated by a desire to bring about the individual's death? Adult lacking capacity Use 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

49 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Adult lacking capacity Use 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

50 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D7 Have you considered the least restrictive option? Adult lacking capacity Use 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

51 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Taking into account all the factors, what decisions would be least restrictive in terms of physical, psychological and social function? NEXT Adult lacking capacity Use 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

52 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No D8 Have you considered other factors? Adult lacking capacity Use 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

53 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 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 Adult lacking capacity Use 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

54 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid D9 What is in the individual's best interests? Gather all the information elicited from questions D1 to D8 (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. Adult lacking capacity Use 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

55 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No E1 Does the individual have capacity for this decision now or could have it in the future? Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

56 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid The decision of the individual with capacity takes precedence over any other decision. If time allows, await the individual's decision and go to section on Framework for all care decisions Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

57 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No E2 Are any previous advance decisions missing or lost? Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

58 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Validity and applicability cannot be confirmed. Verbal reports of previous advance decisions are not binding, but verbal decisions are valid and there is a legal requirement to take them into account when going through the MCA best interests process, ie. it cannot be ignored A verbal ADRT that refuses life-sustaining treatment is not legally binding, but must be taken into account in deciding a person’s best interests. NEXT Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

59 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No E3 Has there been a more recent advance decision applicable to the current care decision? Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

60 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Check the latest advance decision. The most recent advance decision usually takes precedence. NEXT Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

61 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No E4 Is this a 'living will' or 'advance directive'? Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

62 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid These predate the 2005 MCA and are no longer in use. Most 'living wills' are advance statements (see Glossary) Most 'advance directives' are refusals of treatment but must comply with the requirements of an ADRT to be legally binding (see Glossary) NEXT Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

63 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No E5 Is this an advance statement? Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

64 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid This is any verbal or written statement of preferences and wishes, beliefs and values. An advance statement is not legally binding on carers but there is a legal requirement to take it into account when going through the MCA best interests process, ie. it cannot be ignored NEXT Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

65 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No E6 Is this an Advance Decision to Refuse Treatment (ADRT) ? Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

66 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid To be valid and applicable this ADRT must - have been completed when the individual was aged 18yrs or more and had capacity for this decision - apply to the current circumstances - be the latest decision the individual made - for refusal of life sustaining treatment, be written, signed, witnessed and state that the decision is to apply even if the patient’s life is at risk. If an ADRT is valid and applicable it is legally binding, ie. it has the same authority as a patient with capacity refusing treatment. NEXT Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

67 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No E7 Is this an LPA order ? Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

68 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid To be valid and applicable this LPA must - have been completed when the individual was aged 18 yrs or more and had capacity for this decision - apply to the current circumstances - for care decisions this must be a personal welfare (health and welfare) LPA - be registered with the Office of the Public Guardian - be the latest decision the individual made - involve consultation with any jointly appointed Attorney with responsibility for the relevant decision - specifically authorise decisions around life-sustaining treatment if that is the decision that is needed. Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

69 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid The advance decision may not be covered by the Mental Capacity Act. Ask the individual to clarify their intentions regarding their advance decision Checking advance decisions Use this if you wish to check the validity and applicability of an advance decision

70 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No F1 Is a cardiac or respiratory arrest a clear possibility in the circumstances of the individual? Framework for CPR decisions Use this for making CPR decisions. Adapted from 2007 BMA/RC/RCN Joint Statement on CPR and 2014 Deciding right

71 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid It is often appropriate to consider CPR in assessing a patient but, if there is no reason to anticipate an arrest, a clinician cannot make a CPR decision in advance. A patient with capacity retains the right to refuse CPR in any circumstances. Consequences: The young person or adult with capacity must be given opportunities to receive information or an explanation about any aspect of their treatment. If the individual wishes, this may include information about CPR treatment and its likely success in different circumstances. Continue to communicate progress to the individual (and to the partner/family if the individual agrees). Continue to elicit the concerns of the individual, partner or family and review regularly to check if circumstances have changed. Ensure that all discussions and decisions and accurately recorded In the event of an unexpected arrest: carry out CPR treatment if there is a reasonable possibility of success (if in doubt, start CPR and call for help from colleagues, arrest team or paramedics). Framework for CPR decisions Use this for making CPR decisions. Adapted from 2007 BMA/RC/RCN Joint Statement on CPR and 2014 Deciding right

72 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Yes No F2 Is there a realistic chance that CPR could be successful? Framework for CPR decisions Use this for making CPR decisions. Adapted from 2007 BMA/RC/RCN Joint Statement on CPR and 2014 Deciding right

73 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid It is likely that the individual is going to die naturally because of an irreversible condition. Consent is not possible since CPR is not an available option, but communication about end of life issues should continue. Consequences: Document the reason why there is no realistic chance that CPR could be successful, eg. “Deterioration caused by advanced cancer.” Continue to communicate progress to the patient (and to the partner/family if the patient agrees or if the patient lacks capacity). This explanation may include information as to why CPR treatment is not an option. Continue to elicit the concerns of the individual, partner, family or parents. Review regularly to check if circumstances have changed To allow a comfortable and natural death effective supportive care should be in place, with access if necessary to specialist palliative care, and with support for the partner, family or parents. If a second opinion is requested, this request should be respected, whenever possible. In the event of the expected death, AND (Allow Natural Dying) with effective supportive care in place, including specialist palliative care if needed. Framework for CPR decisions Use this for making CPR decisions. Adapted from 2007 BMA/RC/RCN Joint Statement on CPR and 2014 Deciding right

74 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid If the individual has capacity for this decision: they must be consented since their decision is paramount. They may choose to refuse CPR and this must be honoured, even if the clinicians believe this to be unwise or illogical. A few patients with capacity will not wish to discuss CPR and, since CPR could be successful, they cannot have a DNACPR put in place without their permission. If the individual lacks capacity: if this is an arrest requiring immediate treatment the decision rests with those present using the information they have available. For any decision in advance this cannot be made by any one individual. It must be made using the MCA best interests process described in this App. See the sections for adult or child/young person lacking capacity for the steps needed to make care decisions in people who lack capacity for those decisions. Ensure that all discussions and decisions are accurately documented Framework for CPR decisions Use this for making CPR decisions. Adapted from 2007 BMA/RC/RCN Joint Statement on CPR and 2014 Deciding right

75 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Emergency Treat if possible Person-centred Dialogue (Shared Decision Making) If capacity has been l If capacity has been lost Emergency anticipated EHCP +/- DNACPR Best Interests process  Advance Statement  ADRT  Personal Welfare LPA  Advance Statement  ADRT  Personal Welfare LPA If capacity is present but a loss is anticipated Click to see decisions The decision of the individual with capacity usually takes precedence over any other decision

76 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid This app is a decision aid to help you through the process of making care decisions in advance for people who will or may lose capacity in the future, or who have already lose capacity for those decisions. The app will not provide you with the answer, but will ensure that the way an individual's care decisions are made is compliant with the Mental Capacity Act (MCA) and national guidance on CPR decisions and advance care planning. Even for care decisions that seem obvious it is essential to ensure they follow the requirements of the MCA. This is not optional since the MCA became law in 2005 and was fully implemented in However, most care professionals find that the MCA provides an excellent decision framework that ensures that the individual is kept at the centre of the decision process. This empowers the individual but also empowers to partner, family, parents and professionals to realise they have made the decision the individual would have wanted and which is that individual's best interests. There will be occasions when a decision is difficult because the risks and benefits are finely balanced of because there is a profound difference of opinion. In such cases second opinions and local Clinical Ethics Advisory Groups can be invaluable, but on a few occasions it will be necessary to ask the Courts to decide. If any aspects of the app are unclear, confusing or incorrect, please contact the development team through Claud Regnard on Information Help

77 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid ADRT = Advance Decision to Refuse Treatment; DNACPR = a form that documents a 'Do Not Attempt Cardio-Pulmonary Resuscitation' decision; EHCP = Emergency Health Care Plan; Individual = a person of any age who is receiving care; LPA = Lasting Power of Attorney; MCA = the 2005 Mental Capacity Act. Information Glossary Advance care planning (ACP) This is a voluntary process of discussion and review to help an individual who has capacity to anticipate how their condition may affect them in the future. If they wish, they can set on record choices or decisions about their care and treatment so that these can then be referred to by those responsible for their care or treatment (whether professional staff or family carers) in the event that they lose capacity to decide once their illness progresses. ACP has three possible outcomes: - a verbal or written advance statement of wishes and feelings, beliefs and values - a verbal or written advance decision to refuse treatment (ADRT) (must be written with specific requirements if refusing life-sustaining treatment- see below) - a lasting power of attorney (see opposite). Advance decision In the Mental Capacity Act this applies specifically to an advance decisions to refuse treatment (ADRT)- see below. Advance decision to refuse treatment (ADRT) A verbal or written legally binding refusal of specified future treatment by an adult aged 18 or over with capacity regarding their future care should they lose capacity for this decision. There is no requirement to involve any professional, but advice from a clinician can help ensure the refusal is understandable and clear to clinicians who will read it in the future, while legal advice can ensure a written document fulfils the legal requirements. An ADRT must be made by a person with capacity for these decisions, and only becomes active when the individual loses capacity for these decisions. To be legally binding it must be valid (made by an individual with capacity and following specific requirements if refusing life-sustaining treatment) and applicable to the circumstances. ADRTs that refuse life-sustaining treatment must follow specific requirements including being written, signed, witnessed, state clearly the treatment being refused and the circumstances under which the refusal must take place, and contain a phrase such as, “I refuse this treatment even if my life is at risk.” If valid and applicable, an ADRT has the same effect as if the individual still had capacity. Because of the time needed to assess the validity and applicability of an ADRT, they are not helpful in acute emergencies that require immediate treatment, but must be acknowledged when time allows. Advance statementA verbal or written statement by an individual with capacity describing their wishes and feelings, beliefs and values about their future care. There is no requirement to involve anyone else, but individuals can find professionals, and relatives or carers helpful. An advance statement cannot be made on behalf of an individual who lacks capacity to make these decisions. It only becomes active when the individual loses capacity for these decisions. It is not legally binding, but carers are bound to take it into account when deciding the best interests of a person who has lost capacity. Advance directive A term in use prior to the Mental Capacity Act. Now replaced by ADRTs and advance statements. Best interests Best interests has three requirements: 1. The suggestion of a care option made by a health or social care professional based on their expertise and experience, and on their understanding of circumstances of the child, young person or adult patient. 2. The understanding and opinion of that care option by the individual with capacity, based on their wishes and feelings, beliefs and values. For individuals without capacity for a specific care decision the best Interests process under the MCA must be followed. 3. A willingness to engage in a dialogue to negotiate the option that is in the individual’s best interest. For individuals who lack capacity the Mental Capacity Act requires that a minimum of a nine-point checklist is completed (see MCA1&2 form in the resources section of the Deciding right website)

78 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Information Glossary Capacity The ability of an individual to understand the issues of a decision, retain that information, weigh up the facts and communicate their decision. Capacity must be assumed in all individuals unless there is a suspicion of an impairment or disturbance of mind or brain. In this situation, capacity for that decision must be tested (see MCA1&2 form in the resources section of the Deciding right website). A person with capacity can make any decision they wish, even if others view that decision as illogical or unwise. Capacity is specific to the decision being made- therefore an individual can have capacity for one decision, but not another. If an individual lacks capacity for a specific decision carers must make the decision following the best interests requirements of the Mental Capacity Act (see MCA1&2 form in the resources section of the Deciding right website). Cardiopulmonary resuscitation (CPR) Emergency treatment that supports the circulation of blood and/or air in the event of a respiratory and/or cardiac arrest. CPR decisionA decision for or against cardiopulmonary resuscitation. Such decisions only apply to restoring circulation or breathing. They do not decide the suitability of any other type of treatment, and never prevent the administration of basic comfort and healthcare needs. Do not attempt cardiopulmonary resuscitation (DNACPR) A decision to withhold CPR in the event of a future arrest. Communication is a key part of making such a decision. Consent to refuse CPR is required if -the individual has capacity for that decision and an arrest is anticipated and CPR could be successful. A DNACPR form is completed by a clinician with responsibility for the child, young person or adult. A DNACPR decision can be made for an individual who does not have capacity, but must follow the best interests requirements of the Mental Capacity Act. Emergency health care plan (EHCP) Care plan covering the management of an anticipated emergency. Can be written in discussion with the individual who has capacity for those decisions, with the parents of a child, or made in an adult who lacks capacity following the best interests requirements of the Mental Capacity Act. General care planning Embraces the care of people with and without capacity to make their own decisions, and is consequently applicable to all children, young people and adults for all types of care. A person centred dialogue is the key to establishing the individual’s goals of care based on their current needs. However, a general care plan can be written on behalf of an individual without capacity for those care decisions, as long as it is completed following the best interests (see opposite) of that individual. Lasting power of attorney (LPA) There are two different types of LPA: A property and affairs LPA: this covers finances replaces the previous Enduring Power of Attorney. It does not have power to make health decisions. A personal welfare LPA (also called a health & welfare LPA by the Office of the Public Guardian): this must be made while the individual has capacity, but only becomes active when the individual lacks capacity to make the required decision. The LPA must act according to the principles of best interests (see previous page). Can be extended to life- sustaining treatment decisions but this must be expressly contained in the original application. A personal welfare LPA only supersedes an ADRT if this LPA was appointed after the ADRT was made, and if the conditions of the LPA cover the same issues as in the ADRT Living willA term in use prior to the Mental Capacity Act. Now replaced by ADRTs and advance statements. Shared decision making A process of dialogue between two experts: the clinician and the child, young person or adult patient. Although clinicians are the experts about treatment options, the individual is the expert about their own circumstances. Shared decision making pools their individual expertise by working together as partners. Best interests can only be achieved through shared decision making. See Best Interests.

79 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Links If you want general information about make care decisions See MCA Code of Practice on https://www.justice.gov.uk/protecting-the-vulnerable/mental-capacity-act See GMC advice on good practice: See Deciding right: See NHS Right Care: https://www.justice.gov.uk/protecting-the-vulnerable/mental-capacity-actwww.gmc-uk.org/guidance/index.aspwww.nescn.nhs.uk/deciding-rightwww.rightcare.nhs.uk The text and logic algorithm was written by Claud Regnard, St. Oswald's Hospice, Newcastle upon Tyne. This app would not have been possible without Elizabeth Kendrick (chair of north east end of life care group) who donated a NHS innovations award to fund its development and the essential help of Louise Wilson, Adrienne Moffett and Lynda Dearden from NHS England Northern Clinical Networks and Senate. We are grateful to the many clinicians who tested the app and the continued support from the Deciding right implementation group and the north east end of life care group. Licence: Created for NHS England Deciding right initiative by Claud Regnard, St. Oswald's Hospice. App created for Apple and android smartphones and tablets by Craig Hamilton at Indigo, Newcastle See next for Terms of Use Information Links Acknowledgements

80 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid 1. By using this Deciding Right application, you agree to these terms of use which form an agreement between You and Us. You should read these terms carefully. If you do not agree with any of these terms, you should not use this Deciding Right application in any way. The Mental Capacity Act 2005 supersedes any advice or information offered in this application. 2. If you have any questions or concerns about this Deciding Right application, you may the author 3. In these terms ”We”, ”Us” and ”Our” refer to the application developers, owners and controllers, as applicable, being NHS England Northern Clinical Network and Senate, which is hosted by the National Health Service Commissioning Board established pursuant to the National Health Service Act 2006 and its successors, partners, affiliates, subsidiaries and assigns. The terms ”You”, ”User” and ”End-User” refer to you as a user of this application. 4. These terms may be amended at any time by Us and the terms viewable here are the latest version of Our terms. However, the terms as they apply to You on the day on which You first use this Deciding Right application shall apply between Us and You. 5. This application is also subject to the terms and conditions of the relevant application store provider from which you have downloaded the application. 6. This application is restricted for use on Android and IOS devices. Your limited rights to use this Deciding Right application 7. By downloading this application, We grant You a limited, non-exclusive, non-transferable licence to use the Deciding Right application for personal use only and for the purpose of assisting a discussion between You and/or Your doctor (or other professional healthcare provider) in reaching a decision in accordance with the Mental Capacity Act 2005 (the “Purpose”). 8. You must not share or transfer to anyone else any passwords given to You to obtain information in connection with Your use of this application. 9. Except as expressly set out in these terms and conditions or as permitted by law, You agree: a) not to copy the application or related documents except where such copying is incidental to normal use of the application, or where it is necessary for the purpose of back-up or operational security; b) not to rent, lease, sub-license, loan, translate, merge, adapt, vary or modify the application or documents; c) not to make alterations to, or modifications of, the whole or any part of the application, or permit the application or any part of it to be combined with, or become incorporated in, any other programs; Next Terms of Use of this Deciding right application

81 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid d) not to disassemble, decompile, reverse-engineer or create derivative works based on the whole or any part of the application or attempt to do any such thing except to the extent that (by virtue of section 296A of the Copyright, Designs and Patents Act 1988) such actions cannot be prohibited because they are essential for the purpose of achieving inter-operability of the application with another software program, and provided that the information obtained by You during such activities: i. is used only for the purpose of achieving inter-operability of the application with another software program; ii. is not unnecessarily disclosed or communicated without our prior written consent to any third party; and iii. is not used to create any software that is substantially similar to the application; e) to keep all copies of the application secure and to maintain accurate and up-to-date records of the number and locations of all copies of the application; f) to include Our copyright notice on all entire and partial copies You make of the application on any medium; g) not to provide or otherwise make available the application in whole or in part (including object and source code), in any form to any person without prior written consent from Us; and h) to comply with all technology control or export laws and regulations that apply to the technology used or supported by the application or any service. Use of this Application by minors (individuals under the age of 18 years) 10. This application is designed for use by adults in England and Wales relating to adult care settings and decisions. If You have agreed to allow Your minor child, or a child for whom You are legal guardian (a “Minor”), to use this application, You agree that You shall be solely responsible for: (a) the conduct of such Minor; (b) monitoring such Minor’s access to and use of the application; and (c) the consequences of any use of the application by such Minor (subject to paragraph 23 below). NEXT Terms of Use of this Deciding right application (cont)

82 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Intellectual property 11. All rights, title and interest in and to this Deciding Right application (including but not limited to all copyrights, database rights, designs, trade marks, service marks, trade names and all derivative works relating thereto) are owned or controlled by and shall remain at all time vested in Us. 12. You must not use any NHS names or logos without prior permission. 13. The copying, redistribution or publication by You of the whole or any part of this application is strictly prohibited. Neither should you purport to transfer or licence the whole or any part of this application to anyone else. Further, a modification of the whole or any part of this application by You for any purpose shall constitute a violation of Our copyright and other proprietary rights in the application. Data ownership 14. The Deciding Right application offers a series of scenarios and decision points. The application does not ask for, collect or retain data on the host device or anywhere else. Accuracy / information and content in screenshots subject to change 15. Every effort is made to provide information and content on the screenshots that is accurate and up to date at the time that You view it. However, changes made to the master charts by Us may not be immediately reflected in the downloadable application. We do not warrant or make any representation regarding the correctness, accuracy, reliability or otherwise of the information and content on the screenshots. No warranties 16. This Deciding Right application is provided on an "as is," "as available" basis without warranties of any kind, express or implied, including, but not limited to, those of title, merchantability, fitness for a particular purpose or non-infringement of third party intellectual property, or any other warranty arising from a course of dealing, usage, or trade practice. No oral advice or written information provided on the screenshots shall create a warranty, representation or guarantee; nor shall You rely on any such information or advice. NEXT Terms of Use of this Deciding right application (cont)

83 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Professional assistance 17. You must not rely on the information and content on the screenshots in this Deciding Right application as an alternative to consulting the Mental Capacity Act 2005 original documentation or other medical or legal advice. If You have any specific questions about any medical/clinical or legal matter You should consult your doctor or other professional healthcare provider or legal adviser. If You think you may be suffering from any medical/clinical condition You should seek immediate medical attention. You should never delay seeking medical/clinical advice, disregard medical/clinical advice, or discontinue medical/clinical treatment because of information in this application. 18. We do not answer specific medical or legal questions arising from Your use of this application and We recommend that you use this application in partnership with Your own doctor or other professional healthcare provider or legal adviser. Our disclaimer of liability for Your use of this application 19. The Deciding Right application is for personal use only and is restricted to the sole purpose of assisting discussions between You and/or Your doctor (or other professional healthcare provider) in reaching a decision in accordance with the Mental Capacity Act It is not intended to replace a consultation with a qualified medical professional or meet Your health or medical needs. 20. We assume no responsibility for any claims, losses to damages howsoever caused (whether direct or indirect) resulting from Your use of, and decision to use or contents of, this Deciding Right application for the Purpose permitted in these terms except to the extent that liability cannot be excluded by law. 21. This application contains links to websites. We do not monitor the content on third-party websites. We do not accept any responsibility for the content of any third party website and a link to another site in no way constitutes our endorsement of the contents therein. 22. We accept no responsibility for mistakes, omissions, interruptions, deletion of files, viruses, worms or other malicious software contained within the application, errors, defects, or any failure of performance, communications failure, theft, destruction or unauthorized access to the application or any other software. 23. These terms of use do not seek to exclude or limit in any way Our liability to You for personal injury or death cause as a result of Our negligence or seek to exclude or limit Our liability for fraud or fraudulent misrepresentation by Us. NEXT Terms of Use of this Deciding right application (cont)

84 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Professional assistance 17. You must not rely on the information and content on the screenshots in this Deciding Right application as an alternative to consulting the Mental Capacity Act 2005 original documentation or other medical or legal advice. If You have any specific questions about any medical/clinical or legal matter You should consult your doctor or other professional healthcare provider or legal adviser. If You think you may be suffering from any medical/clinical condition You should seek immediate medical attention. You should never delay seeking medical/clinical advice, disregard medical/clinical advice, or discontinue medical/clinical treatment because of information in this application. 18. We do not answer specific medical or legal questions arising from Your use of this application and We recommend that you use this application in partnership with Your own doctor or other professional healthcare provider or legal adviser. Our disclaimer of liability for Your use of this application 19. The Deciding Right application is for personal use only and is restricted to the sole purpose of assisting discussions between You and/or Your doctor (or other professional healthcare provider) in reaching a decision in accordance with the Mental Capacity Act It is not intended to replace a consultation with a qualified medical professional or meet Your health or medical needs. 20. We assume no responsibility for any claims, losses to damages howsoever caused (whether direct or indirect) resulting from Your use of, and decision to use or contents of, this Deciding Right application for the Purpose permitted in these terms except to the extent that liability cannot be excluded by law. 21. This application contains links to websites. We do not monitor the content on third-party websites. We do not accept any responsibility for the content of any third party website and a link to another site in no way constitutes our endorsement of the contents therein. 22. We accept no responsibility for mistakes, omissions, interruptions, deletion of files, viruses, worms or other malicious software contained within the application, errors, defects, or any failure of performance, communications failure, theft, destruction or unauthorized access to the application or any other software. 23. These terms of use do not seek to exclude or limit in any way Our liability to You for personal injury or death cause as a result of Our negligence or seek to exclude or limit Our liability for fraud or fraudulent misrepresentation by Us. NEXT Terms of Use of this Deciding right application (cont)

85 Northern England Strategic Clinical Networks   Home (c) NESCN October Logic algorithm and text: Claud Regnard (St. Oswald’s Hospice). App design: Craig Hamilton (Indigo). Newcastle-upon-Tyne Deciding right decision aid Severance 24. If any of these terms or part of these terms are determined to be illegal, invalid or otherwise unenforceable then the remaining terms shall remain in full force and effect. Jurisdiction 25. These terms of use shall be governed by and interpreted in accordance with the laws of England and Wales and You agree to submit to the jurisdiction of the courts of England and Wales in respect of any disputes which may arise in relation to this app. © National Health Service Commissioning Board for North England Strategic Clinical Network Written by Claud Regnard. Terms of Use of this Deciding right application (cont)


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