Mental

Capacity Act (MCA)

A report of the 3rd reserch visit of Fact finding mission to investigate medical and welfare
situation in the UK

2009

NHS

Mental Capacity Act (MCA):

Mental Capacity Act 2005 (MCA) 2005

http://www.legislation.gov.uk/ukpga/2005/9/contents
Human Right Act1998

1.


4
a.
b.
c.

d.
2.


Mental Health Act 1983 MCA
3.


(http://www.scie.org.uk/publications/mca/bestinterests.asp)
4. http://www.scie.org.uk/mca/imca
http://www.nhs.uk/Conditions/social-care-and-support-guide/Pages/lasting-power-of-att
orney.aspx: Lasting Power of Attorney
5. 2014
DoLS (Deprivation of Liberty Safeguard)
http://www.scie.org.uk/publications/mca/deprivation-of-liberty
Unwise decision

DN(A)R

ReSPECT - (Recommended Summary Plan for Emergency Care and Treatment)

MCA
DN(A)R (Do not attempt rescicitate)
ReSPECT
- Recommended Summary Plan for Emergency Care and Treatment
http://www.respectprocess.org.uk/healthprofessionals.php)

ReSPECT(1)(2)

(3)
(4)

URL
(1) ReSPECT (http://www.respectprocess.org.uk/healthprofessionals.php)
(2)
http://www.respectprocess.org.uk/_pdfs/ReSPECT-Clinicians-Guide.pdf)
(3) ReSPECT
(http://www.respectprocess.org.uk/_pdfs/ReSPECT-Act-and-Adopt.pdf)
(4) (http://www.respectprocess.org.uk/_pdfs/ReSPECT-Implementation-Roadmap.pdf)

ReSPECTRoyal London NHS HospitalCQCInadequet

Special Measure
ReSPECT

 - PDSA (Plan - Do - Study - Act)

(https://www.england.nhs.uk/ourwork/qual-clin-lead/clinaudit/)
NHSInstitute for Healthcare Improvement
(http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx)

NHSThe NHS 5 year forward view

(https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf)

Associates in Process Improvement

SMARTSpecific
MeasurableAchievableRealistic
Time-specific




PDSA

PDSA

P


D
S

APDSA

P

NHS forward plan (https://www.england.nhs.uk/five-year-forward-view/)

STP (Sustainability and transformation partnerships https://www.england.nhs.uk/stps/)
Vanguard (https://www.england.nhs.uk/2017/06/what-on-earth-is-a-vanguard/)

2005NHS (National Health Service) National Institute

for Mental Health in England (NIMHE) NHS

2008Centre for Mental HealthMaking Recovery a Reality

(http://www.ispraisrael.org.il/Items/00606/Making_recovery_a_reality_policy_paper.pdf

(1)

(a)
(b) -

(2)
()

(3)

(Peer Support)
(Lived Experience)

(4)
Social Inclusion

(a)


(b)


(Shared Meanings)(Instillation of Hope)


Richard @ Energetic NLP Psychotherapy in East London

(https://psychicplumbing.com/2016/01/11/the-recovery-model/) Website

2008
(1) Care Services Improvement Partnership (CSIP) (2) Royal College of
Psychiatrists (RCPsych) (3) Social Care Institute for Excellence (SCIE) 3
A common purpose: Recovery in future mental
health services(http://www.scie.org.uk/publications/positionpapers/pp08.pdf)

2008

A Vision for a Recovery Model in Irish Mental Health

Services(http://www.mhcirl.ie/File/discpapvforarecmod.pdf)


Care Act 2014
http://www.scie.org.uk/care-act-2014/2014

(Bio-Psycho-Social model)
(Formulation) (a clearer
guide to aetiology, prognosis and treatment
)

1. Presenting problem
2. Predisposing factors

3. Precipitating factors

4. Perpetuating factors

5. Protective factors

PDSA

Is diagnosis enough to guide interventions in mental health?

Using case formulation in clinical practice BMC Med.2012;10:111.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3523045/) Clinical formulation: where it
came from, what it is and why it matters BJPsych Adv 2017,23(2):95-103
P
Multidesciplinary team

(1)
MCA (2) ReSPECTCPRDN(A)R
(3)
PDSA(4)
()

Websites
Royal College of General Practitioners http://www.rcgp.org.uk/
Royal Pharmaceutical Society (RPS) https://www.rpharms.com/
British Medical Association (BMA): http://www.bma.org.uk/
Local Care Direct http://www.localcaredirect.org/
Alzheimers Society https://www.alzheimers.org.uk/
St Johns Hospice http://www.stjohnshospice.org.uk/
Nuffield Trust (Ms N Curry & Ms H. Holder) http://www.nuffieldtrust.org.uk/

 How to complete a ReSPECT form: Quick guide for clinicians

The numbers relate to the section numbers on the ReSPECT form. Version 1.0
1. Personal details Preferred name
Insert clearly the persons full name, date of birth Ask the person (or if they cannot answer ask their
and address. Insert the date on which the form is family or other carers) the name by which they
completed. Whenever possible, include their NHS/ would like to be addressed.
CHI health and care number.

2. Summary of relevant information for this plan

Whenever possible complete this in discussion with the person and with reference to available health
records. If they do not have capacity to participate in decisions, whenever possible complete this in
discussion with their family or other representatives.
A. Insert a brief summary of the background to the recommendations in section 4 (e.g. diagnosis,
previous and present condition, prognosis, communication difficulties and how to overcome them);
B. Record specific detail and the location of documents such as advance statements,
Advance Decisions to Refuse Treatment, advance care plans, organ donor cards.

3. Personal preferences to guide this plan (when the person has capacity)
Ask the person to describe their priorities for their care. The scale can be used to help them to
understand how, for some, the emphasis may change from focusing on all possible interventions to try
to sustain life to focusing primarily or mainly on care and treatment to control symptoms. The scale
can be used to aid discussion only, or a mark can be made on it if they wish. Remember to explain that
this plan is for use in an emergency when the person is not able to make decisions about their care and
treatment. If they are able to make decisions, they can make choices at the time.
Prioritise sustaining life Prioritising life-sustaining treatments does not mean that the person would
not receive treatment to control symptoms, but they may want to be considered for some life-sustaining
treatments that involve a degree of discomfort. There may be clear limits to the types of care and
treatment the person would or would not want to be considered for, and on the circumstances in
which they would or would not want those.
Prioritise comfort Prioritising comfort indicates that the person wants primarily those types of care
and treatment whose purpose is to control symptoms and provide comfort. This does not mean that
the person would not be offered (for example) antibiotic treatment for an infection, especially as that
treatment may relieve the symptoms caused by the infection. However the person would not want more
invasive types of treatment that involve some discomfort and some risk and whose primary purpose is to
sustain life rather than relieve discomfort. The second box is to allow individuals to have recorded the
aspect of their life that is most important to them. For some this may be maintaining cognitive function,
for others maintaining independence or mobility. Some may want all treatments for some time, but
would not want to be on life support for a prolonged period.

4. Clinical recommendations for emergency care and treatment

These are the recommendations to guide decision-making in a future emergency. If the person does not
have capacity to participate in deciding these recommendations, their family or other representatives
should be involved in discussions whenever possible. Start by signing the goal of care as either focusing
on life-sustaining treatment or focusing on symptom control.
Clinical guidance Record clear detail of those types of care or treatment that the person would or
would not want to be considered for and that would or would not work in their individual situation.
Include whether or not the person would want to be taken to hospital and in what circumstances.
Include other level-of-care decisions, for example whether they should be considered for intensive
care admission, or whether ( for example) only non-invasive ventilation would be recommended. It is
important to complete this box clearly as it is these recommendations that will be used to
guide decision-making in an emergency. Remember that the ReSPECT form is not a substitute for
recording a detailed clinical assessment and plan of treatment in the persons health record.
CPR decision... Sign ONE of these boxes ONLY. Remember that there must be a presumption in favour
of involvement of the person (and/or their family or other representatives) in the decision-making
process unless that would cause the person harm. If CPR would not work and is not being offered,
that should be explained in the context of the persons priorities and goals of care.
5. Capacity and representation at time of completion
Does the person have sufficient capacity to participate in making the recommendations on
this plan?
Consider and answer this question for all adults. If there is any reason to suspect impaired capacity
perform a formal assessment of capacity and document it fully in the persons health records.

Do they have a legal proxy (e.g. welfare attorney, person with parental responsibility)
who can participate on their behalf in making the recommendations?
Consider and answer this question for adults and children. When the answer is yes insert details in
section 8.

6. Involvement in making this plan

The clinician signing this plan...
You must circle at least one of the statements A, B, C, D. Then record the date (or dates) of
conversations about the recommendations and the names and roles of those involved. Make sure that
detail of what was discussed and agreed is documented in the health record. On the ReSPECT form
record where that further detail has been documented.

If this plan is being completed without involving the patient

If there has been no shared decision-making with the person themselves (or no involvement of family
or other representatives of a person who does not have capacity to be involved) use the red-bordered
box to summarise the reasons for this. Make sure that the reasons are detailed fully in the clinical
record, together with a clearly defined plan to involve the person or their representatives as soon as
this is possible or appropriate.

7. Clinicians signatures
Clinicians signatures
This section must be signed (inserting also the date and time of signing) by the professional who
completes the ReSPECT form. If that is not the senior responsible clinician, they should be informed of
the plans completion, and at the earliest practicable opportunity they should review and endorse the
recommendations by adding their signature (or, if appropriate, consider further discussion and possible
revision of the plan). The senior responsible clinician will usually be the persons GP or consultant. In
some situations (e.g. nurse-led units) a senior nurse may have this role.

8. Emergency contacts
Use this section to record contact details of people who should be considered for immediate contact
in the event of major deterioration, imminent death, or any change in the persons condition that may
warrant reconsideration of the previously recorded recommendations.

9. Confirmation of validity (e.g. for change of condition)

This section should be left blank at the time of initial completion of the plan. Remember to document
in the health records whether and when review of the recommendations on this ReSPECT form should
be considered. The recommendations on the ReSPECT form do not have a defined expiry date, as
the need for review must be considered carefully for each person at each stage of their clinical progress.
Review may be prompted by a request from the person or their representative, by a change in the
persons condition or by their transfer from one care setting to another. In any of these situations, it is
good practice for the responsible clinician to review the content of the ReSPECT form. If they confirm
that the recommendations are still correct and appropriate, they should sign and date the review
box to indicate that review has occurred. If the recommendations may no longer be correct, another
conversation should be had with the patient and, where appropriate, a new ReSPECT form created.
 Recommended Summary Plan
for Emergency Care and Treatment
ACT & ADOPT Dissemination and implementation checklist (version 1.0)

Regional Actions

A
Acknowledgement
Secure organisational sponsorship in the geographical area and ensure it understands
the need for ReSPECT and is willing to promote its dissemination and implementation in
that area.
Acknowledge that a national communication strategy exists for ReSPECT but that each
health and care community needs to consider how and when to implement ReSPECT.

C
Communication
Establish an implementation group (this needs to span the implementation and
continue beyond in a monitoring role).
Appoint implementation lead(s) and champions from local health and care
communities (e.g. NHS Trust CEOs, ambulance service, resuscitation officers, critical care,
paediatricians, main medical and surgical specialties, social care, palliative care, learning
disability, patient advisory groups, nursing homes, ethical and legal representatives,
Clinical Commissioning Groups, GPs, clinical information systems).

T
Tactics
Develop and agree an implementation plan, including roles and responsibilities, time
scales, resources, risks, interdependencies and funding.
Secure project management and support for audit and service improvement.
Ensure that information and resources link to the ReSPECT website.
Consider the impact of implementing ReSPECT on partner agencies in local health and
care communities.

Organisational Adoption*

A
Adoption
Formal adoption of ReSPECT by a lead group (e.g. Trust board).
Consider making ReSPECT an organisational goal with associated metrics.

D
Dissemination
Presentations to all clinical and organisation groups (see overleaf for more details).
Develop a communication strategy appropriate to the organisation that takes
advantage of the nationally developed ReSPECT communication materials.

O
Organisational
Identify how ReSPECT will impact on supplies for new forms, print strategy (e.g. ability
to print in colour) and electronic records.

issues

P
Policy revision
Identify which policies can be modified or replaced (e.g. resuscitation, advance care
planning, policies relating to capacity legislation).

T
Training
Identify the existing training gaps and overlap and concentrate on filling the practice
gap rather than setting up additional layers of training.
Consider using ReSPECT as a descriptor for all training relating to MCA, advance care
planning and advance CPR decisions.

*Detailed organisational checklist overleaf

Act & Adopt model adapted with permission from Deciding right http://www.nescn.nhs.uk/common-themes/deciding-right/
Content from Implementation Roadmap adapted with permission from NIHR CLAHRC Wessex October 2016
 Organisational Checklist

Adoption
Sponsorship group (e.g. Trust board) has formally agreed to adopt ReSPECT having understood the principles embodied
in ReSPECT, including the terms of use.

Dissemination
Large organisation dissemination checklist (e.g. NHS Trust): clinical policy group; lead nurse groups; resuscitation
committee; all relevant departments (e.g. all medical specialties, all surgical specialties, chaplaincy, critical care,
emergency department, gynaecology, maternity, mental health, ophthalmology, musculoskeletal, paediatrics,
psychology, social work,); patient advisory group; legal lead; capacity/safeguarding lead; learning disability liaison
lead; discharge lead; education and training teams; IT teams; quality assurance and audit teams; reception and clinical
secretarial leads.
Small to medium size organisation dissemination list (e.g. hospice, nursing home, GP practice): clinical management
committee or group; policy group; documentation group; education/training group; medical and nursing staff;
social worker, psychologist, chaplain; rehabilitation team (physiotherapists, occupational therapists); volunteer lead;
receptionists; clinical secretaries.
Promotion: Use national ReSPECT communication materials to develop organisational materials (e.g. patient and
professional leaflets, letters, posters, presentation materials for PowerPoint, intranet and website)
Liaise with IT about promoting ReSPECT on the organisations intranet and with communication teams about internal
promotion

Organisational issues
Identify systems and documents impacted by ReSPECT
Review and identify how various processes and systems might be impacted by ReSPECT (e.g. other care plans, discharge
letters).
Consider and agree on plan to incorporate ReSPECT into paper and electronic patient health records and other relevant
information systems. Agree print and digital strategy.
Transitioning from DNACPR to ReSPECT
Ensure that the resuscitation committee/group has agreed to implement ReSPECT.
Develop a plan to introduce ReSPECT and phase out DNACPR policy and documents.
Inform and work with regional ambulance services to enable recognition and use of ReSPECT.
Inform and work with all linked health and care communities to enable recognition and use of ReSPECT.
Set a date for full transition to ReSPECT.

Policy revision
Identify which policies are impacted by ReSPECT and can be modified or replaced.
In particular address the unification policy on DNACPR, advance care planning, policies relating to capacity legislation.
Embed ReSPECT in these policies.

Teaching and training

Consider auditing any practice gaps in compliance with capacity legislation, shared decision-making, communication,
advance care planning and consent.
Consider using ReSPECT badge to re-launch training to fill any practice gaps identified. Adapt mandatory training to
include ReSPECT, rather than adding more mandatory training.
Draw up a training plan that reflects the needs and roles of different groups and takes advantage of the knowledge of
what works well in the organisation.

Implementation
Agree plan for implementation. This may be a phased implementation or pilot period.
Testing out the process first before full implementation is an option at this stage.
Ensure the communication plan is in place, drawing on the national ReSPECT resources.

Monitoring and review

ReSPECT is a change in policy and culture that may disrupt existing practice and ways of working.
Adapt existing data tools to access and monitor relevant data for analysis and reporting, including audit. Agree these
before ReSPECT is embedded.
The ReSPECT team wants to receive feedback from those involved in implementing ReSPECT.
Please visit www.ReSPECTprocess.org.uk to get information about how to submit your feedback.
 Recommended Summary Plan Implementation Roadmap
for Emergency Care and Treatment Version 1.0
Organisation
decides to implement
ReSPECT Continues throughout implementation

Adoption Dissemination Organisational Policy Training Implementation Monitoring and

issues revision review

Formal adoption Present to all clinical Identify and review Identify which Identify training Agree Review feedback
by lead group, e.g. and organisational processes and policies need needs implementation from staff and
Trust board groups systems impacted by modification/ approach (full, stakeholders
ReSPECT replacement phased, pilot)

Sign up to ReSPECT Develop appropriate Electronic records Embed ReSPECT in Audit gaps in Pilot testing if Feedback progress
terms of use communications and systems (e.g. existing policies existing training preferred approach locally
strategy building on discharge summary) to supplement/
ReSPECT materials compliment

Understanding of Partner organisation Resuscitation Transition from Use ReSPECT badge Detailed Feedback progress
ReSPECT principles engagement Committee/ Lead DNACPR to ReSPECT to launch training implementation to ReSPECT
and impact agrees to ReSPECT (no longer separate plans
DNACPR)

Outline plan, risks, Public and patient Impact on supplies Advance Care Adapt mandatory Transition from Audit compliance/
dependencies, engagement for forms Planning training to include DNACPR to ReSPECT review measures
resources, time ReSPECT
scales, roles

ReSPECT as DNACPR to Print and digital Capacity legislation Develop training Implementation Incorporate
organisational goal ReSPECT Transition strategy (e.g. colour plan communications feedback going
with associated engagement printing) (draw on ReSPECT forward
metrics resources)

Implementation Roadmap adapted with permission from NIHR CLAHRC Wessex October 2016
Act & Adopt model content adapted with permission from Deciding right http://www.nescn.nhs.uk/common-themes/deciding-right/