Documenting best interests decisions

A best interests decision is a decision made for a patient who lacks capacity. The notes should show how the decision was reached, so that others can see it.

Capacity has to be assessed for the specific decision. It also has to be recorded as lacking, for the particular decision, before a best interests decision can be made. A diagnosis such as dementia does not itself establish incapacity (lacking capacity) for a particular decision, so the capacity assessment for the specific decision should be recorded.

Record who was involved in the discussion. Note who took part and the views each person expressed, including the patient's known wishes, feelings and values. Family members should be consulted and their views written down, but they have no automatic authority to consent on a patient's behalf. Their views inform the decision.

Then record the decision itself and the reasons for it, and say when it will be reviewed, since circumstances change. Document at the time of the decision, not later, so that everyone caring for the patient knows what has been decided and why.

Check too for an advance decision, a refusal of named treatment made with capacity. Record that it exists and that it was checked to be valid and to apply to the situation. Where it is valid and applies to the situation, it is binding and takes precedence over best interests decisions, so a best interests decision covers what the advance decision does not. A family member cannot create a patient's advance decision after capacity has been lost.