2. Today:
• Assisted Decision Making Capacity legislation
• Advance Care Planning
• Advance Healthcare Directives
• Challenges with advance care planning
• Quick Update
3. Assisted Decision Making (Capacity) Bill
2013
• Replaces the Lunacy Regulation (Ireland) Act 1871
• Published by Department of Justice 15th July 2013
• Introduced in the Dáil in December 2013 (2nd Stage)
• Referred to Select Committee on Justice in December
2013
• Committee suggests amendments including Advance
Healthcare Directives
• Amendments published and Committee Stage of Bill
taken in June 2015
• Bill as amended agreed in the Dáil
• Bill now with Seanad and Committee Stage due 17th Nov
4. Assisted Decision Making (Capacity) Bill
2013
• Includes provision for Advance Healthcare Directives
which were previously legal under common law but had
no legislative underpinning.
• Will require Codes of Practice/Guidelines for its full
implementation
• Hope it will be enacted before end 2015
• May not be commenced
• Minister for Justice will commence most of the Act
• Minister for Health will commence the AHD section
5. Assisted Decision Making (Capacity) Bill
2013
Codes of Practice
It’s anticipated that the bill will be enacted in the Dáil in December 2015. The likely next steps will be:
• The Director of the Decision Support Service will be established and responsible for publishing all codes of
practice related to assisted decision making.
• The Minister for Health will appoint a multi-disciplinary Working Group to formulate an overarching code of
practice for healthcare professionals.
• The remit of the Working Group will be to ‘interpret’ and expand in detail the legislation i.e. develop an
overarching code of practice for healthcare professionals.
• There will be a need for more detailed profession-specific codes of practice. Such codes will most likely
focus on day to day practice.
• While the Director of the Decision Support Service will be the person responsible for publishing all codes of
practice it is likely that professional bodies will need to develop profession-specific codes of practice
• .
6. Assisted Decision Making Capacity
legislation
• Presumption of Capacity
• Understand
• Retain
• Weigh
• Communicate
7. Assisted Decision Making Capacity
legislation
• Functional Capacity Assessment
• Time and issue specific
• Levels of Assisted Decision Making:
• Decision Making Assistant
• Co-decision Maker
• Decision Making representative
• Power of Attorney
• Advance Healthcare Directives
8. Assisted Decision Making Capacity
legislation
• Guiding Principles
• Will & Preferences
• Least restrictive
• Proportionate
• Limited in duration
• Take into account beliefs and values
9. Advance Care Planning
• … refers to ‘a process of discussion and reflection about
goals, values and preferences for future treatment in the
context of an anticipated deterioration in the patient’s
condition with loss of capacity to make decisions and
communicate these to others (RCPI, 2014).
• This process may lead to the formulation of an advance
healthcare directive, an advance decision to refuse
treatment or to the appointment of a decision making
assistant to help interpret a person’s advance preferences
(McCarthy et al, 2011).
10. Advance Healthcare Directives:
• … is a document that describes one’s future preferences
for medical treatment in anticipation of a time when one
is unable to express these preferences because of illness
or injury (Roth, 2014).
• It is a decision made by a person while he or she has
decision-making capacity regarding the medical treatment
he or she would wish to receive (and more frequently not
to receive) if he or she subsequently loses capacity
(McCarthy et al 2011).
• Advance healthcare directives can be revoked orally at
any time once capacity is present and only become active
when capacity is lost.
11. Challenges With Advance Care Planning:
• What Challenges do you experience with advance care
planning in your practice?
12. Challenges With Advance Care Planning:
• Time
• Competing tasks
• Training and Education
• Timing of initiation of discussions
• Uncertainty about the value of advance care planning
• Unclear about legal responsibilities
• Wanting to maintain hope
13. Worth remembering…
• Advance care planning can:
• Contribute to an improved quality of life at the end of life.
• Ensure future wishes can be carried out
PEOPLE WANT TO HAVE CONVERSATIONS, ARE
WILLING TO RECORD PREFERENCES & FEEL
RELIEVED WHEN ISSUES HAVE BEEN DISCUSSED
(Dempsey, 2013, O’Shea et al, 2013, Moorman, 2011 & Sharp et al 2013)
15. Resources:
• Guidance document: Facilitating discussions on future
and end of life care with person with dementia &
Factsheet
• Think Ahead
• HSE National Consent Policy
• NMBI Code of Professional Conduct and Ethics for
Registered Nurses and Registered Midwives
• Guide to Professional Conduct and Ethics for Medical
Practitioners
• Guiding Principles of Assisted Decision Making (Capacity)
Bill (2013). Pages 17 & 18
16. For more information:
Angela Edghill, Advocacy Coordinator
angela.edghill@hospicefoundation.ie
Deirdre Shanagher, Development Officer
deirdre.shanagher@hospicefoundation.ie
Editor's Notes
Flips the current situation on it’s head – HCWs have to presume capacity – all practicable efforts must be taken to assist the person if one ingredient missing – eg knowing a good time of day to discuss issues with a person.
A person may require different levels of assistance with different decisions (explained later) -
People have the right to make unwise decisions
May need varying levels of assistance depending on decision being made.
Can have more than one assistant for each area – eg financial, day to day and healthcare
A decision making assistant assists with making decisions.
The Bill allows an appointer to appoint one or more decision-making assistants.
Decision-making authority remains with the appointer who will be actively assisted in accessing information, in understanding information, in making and expressing decisions on matters specified in the agreement.
The assistant must ascertain the will and preferences of the appointer and endeavour to ensure that the appointers decisions are implemented
A co-decision maker will make decisions jointly with the person whose capacity is in question or will soon be in question
the Bill sets out provisions for the appointment of suitable people to make joint decisions in relation to a person’s personal welfare and/or property and financial affairs.
This person or people will be appointed by the person whose capacity is in question or soon will be in question
This person must explain relevant information concerning the decision and assist the person to communicate their preferences when making a decision
A decision making representative applies where the court is unable to make a co-decision making order or has made a declaration that a person lacks capacity even with the assistance of a co-decision maker
The attorney is given authority by the maker of the enduring power of attorney to act in relation to all or specific parts of personal welfare (5). With regard to health care decisions the attorney is limited to making decisions only in circumstances where a person lacks capacity
Best interests principle will not apply though used in the UK
Guiding principles used instead
The principles apply to all HCWs and decision making assistants, co-decision makers, representatives and attorneys.
ACP & AHD are separate but don’t appear that way in the literature.
HSE National Consent Policy
Medical Council Ethical Guidance.
Re legislation:
Presume capacity
If ingredient missing and no enduring power of attorney
levels of decision making assistance
Assistant
Co Decision maker
Representative
Advance healthcare directive
The final product is a full document and a 2 page factsheet that was designed to be accessible by healthcare staff so it can be hung on clinic room walls as a prompt.