Adults with incapacity: code of practice for medical practitioners

ANNEX 5 TREATMENT PLAN FOR PATIENTS

NOTES ON COMPLETION OF TREATMENT PLAN

This plan is intended to guide healthcare professionals who are caring for patients who have multiple and complex needs. It should be attached to a certificate of incapacity and retained in the patient's multidisciplinary case record.

A. Under the Act, you can only intervene if it will benefit the patient. Your intervention must be the least restrictive in relation to the patient's freedom in order to achieve the required benefit. You must take the patient's views into account and you must consult other relevant people, where reasonable and practical.

Include all present or foreseeable disorders and/or interventions for physical and mental disorders not included in "Fundamental Healthcare Procedures" (see note B). You should consider the patient's capacity to consent to each intervention. Under the Act, the patient is incapable if he/she is incapable of acting, or making decisions, or communicating decisions, or understanding decisions, or retaining the memory of decisions. Exclude all interventions that would ordinarily need the signed consent of the patient. Interventions of this sort need a separate certificate of incapacity . For example, if you write "coronary heart disease and hypertension" on the plan, this authorises you to prevent disease with aspirin, or treat disease with anti-hypertensive drugs, but not operate to bypass blocked arteries.

You may not include on this form any treatment regulated under section 48 of the Act. Please consult the regulations and separate guidance issued on these treatments.

B. Fundamental healthcare procedures include all measures to promote or safeguard the following: nutrition, hydration, hygiene, skin care and integrity, elimination, relief of pain and discomfort, mobility, communication, eyesight, hearing and simple oral hygiene.

C. The Act requires you to take the views of others into account when deciding on an intervention. You should discuss this plan with professional carers and relatives of the patient. Any person with an interest in the welfare of the patient may appeal a treatment decision to the Sheriff. If the patient has a Welfare Attorney or Guardian with the authority to consent to treatment, you must consult this person where reasonable and practical. You can find out if your patient has a Welfare Attorney or Guardian by contacting the Public Guardian on 01324 678300. If this person disagrees with any element of your plan, you must obtain a second opinion from a Nominated Practitioner appointed by the Mental Welfare Commission for Scotland, tel. 0131 222 6111.

You may find that you need to treat a condition that is not specified in your treatment plan. If this is a short lived condition, a separate certificate in relation to it might suffice. If it is a condition that is likely to need ongoing intervention, you should consider rewriting the treatment plan.

This treatment plan is only valid for the period specified in the certificate of incapacity.

ADULTS WITH INCAPACITY (SCOTLAND) ACT 2000

ADULTS WITH INCAPACITY (SCOTLAND) ACT 2000

Notes on worked examples

Example A: Mrs Smith is an elderly lady in hospital continuing care. She has been suffering from stroke disease, dementia and has other medical conditions. She now has an advanced degree of dementia and her physical condition is very poor. She can be aggressive and uncooperative with simple interventions, including bathing and hygiene. She is incontinent and her mobility is declining. She has suffered from recurrent chest infections and should have annual influenza vaccination.

The Consultant reviews the treatment plan as part of an annual review and discusses the future with the ward manager and the patient's daughter. The plan allows for all fundamental healthcare to be given despite her resistance as she is agreed to be incapable in relation to many of these interventions. It would not be reasonable or practical to decide on capacity in relation to each individual aspect of fundamental care. The other aspects of the treatment plan reflect present and predicted interventions. Discussion reveals that she is allergic to penicillin and has reacted badly to certain classes of medication for behaviour disturbance in the past. The daughter insists that these are listed as exceptions in the treatment plan. This is recorded on the treatment plan and on separate documentation in accordance with NHS Board policy.

Example B: Mr Green suffers from learning disability and epilepsy. He lives with his parents and receives input from the Community Learning Disability team. He has some problems with behaviour and has been treated for episodes of bipolar mood disorder. He has no need for interventions listed under "Fundamental Healthcare procedures" except for speech therapy. He is judged to be capable in relation to this procedure. A case review is held to discuss the rest of the treatment plan. All agree that he needs a psychological approach to his behaviour problems but that he lacks the capacity to fully understand what this procedure involves. He also does not appreciate that he has epilepsy and sometimes refuses his medication. The treatment plan gives his carers more authority to try to get him to take medication when he is reluctant. However, he knows that his mood can be unstable and agrees that he needs treatment for this. He was treated with lithium once and had severe side effects. All agree that he is capable of deciding that this treatment should be excluded and this is recorded on the treatment plan. If he resists other treatment for mental disorder, treatment under the Mental Health (Care and Treatment) (Scotland) Act 2003 should be considered.

These examples illustrate the importance of following the general principles of the Act. They also show how the Act can help to reinforce good medical practice in making decisions in consultation with other relevant parties.