The dialogue leading to a decision continued
Supporting patients' decision making
Patients need relevant information (see paragraph 10) to be shared in a way they can understand and retain, so they can use it to make a decision. To help patients understand and retain relevant information you should:
- share it in a place and at a time when they are most likely to understand and retain it
- anticipate whether they are likely to find any of it distressing and, if so, be considerate when sharing it
- accommodate a patient’s wishes if they would like to record the discussion*
- accommodate a patient’s wishes if they would like anyone else – a relative, partner, friend, carer or advocate – to be involved in discussions and/or help them make decisions
- use an interpreter or translation1 service if they have difficulty understanding spoken English
- share it in a format they prefer - written, audio, translated, pictures or other media or methods
- give them time and opportunity to consider it before and after making a decision.
If a patient is a Welsh language speaker, this may be a legal requirement.
You should be alert to signs that patients may need support to understand and retain the relevant information, use it to make a decision, or communicate that decision to you.
You should make sure that reasonable adjustments2 are made so that patients with additional needs have enough time and support to understand relevant information and make a decision. In all cases, you must treat patients fairly and not discriminate against them.
Good medical practice paragraph 33 states; 'You must consider and respond to the needs of patients with impairments or disabilities. Not all impairments and disabilities are easy to identify so you should ask patients what support they need, and offer reasonable adjustments that are proportionate to the circumstances.’ ‘Reasonable adjustments’ does not only mean changes to the physical environment. It can include, for example, being flexible about appointment time or length, and making arrangements for those with communication difficulties, such as impaired hearing. For more information, see the Equality and Human Rights Commission’s website.
You must check whether patients have understood the information they have been given, and if they would like more information before making a decision.
The scope of decisions
You must be clear about the scope of decisions so that patients understand exactly what they are consenting to. You must not exceed the scope of a patient’s consent, except in an emergency.*
Agreeing the scope of a patient’s consent with them in advance is particularly important if:
- treatment or care will be provided in stages with opportunities to review and adjust in between
- different healthcare professionals will provide different parts of the treatment or care
- there may be opportunity, once an intervention is underway and the patient’s decision-making ability is compromised, to carry out another intervention
- there is significant risk of a specific harm occurring during an intervention, which would present more than one way to proceed.*
Looking ahead to future decisions
For some patients, there are foreseeable circumstances when they will have a choice of options at a time when they might find it more difficult to make decisions – for example because:
- they may be in pain, confused or afraid
- their capacity or insight may be impaired by their condition or the effects of an intervention
- a decision may need to be made quickly so there will be less time for dialogue.
You should anticipate such circumstances and discuss them with patients in advance if practical, so that when a decision needs to be made patients have already had time and opportunity to consider the relevant information (see paragraph 10). Discussing a risk of serious harm will be easier to do in advance than in a time-pressured situation when the patient might be in pain, confused or afraid, and the mention of potential serious harm for the first time could be distressing.
Discussing options in advance doesn’t remove the need to have a further dialogue immediately before providing treatment, and at regular intervals as treatment or care progresses. Even if there’s a care plan in place, or the patient’s made an advance decision, you should still talk to them about the options available in case the options have changed or the patient has changed their mind.
If a patient has a condition that is likely to impair their capacity as it progresses, you should sensitively encourage them to think about what they might want to happen if they become unable to make healthcare decisions. You should bear in mind that some patients may not be ready to talk about these issues. Such discussions might include:
- the patient’s wishes and fears, their preferences about future options for care, and the values and priorities that influence their decision making
- any treatment or care the patient might want to refuse, and in what circumstances
- any interventions that might become necessary in an emergency, such as cardiopulmonary resuscitation (CPR)3
- whether the patient would like anyone else – relatives, friends, carers or representatives – to be involved in decisions about their care.
A patient may want to nominate someone to make decisions on their behalf if they lose capacity or they may want to make an advance statement about refusing or requesting a particular treatment. In these circumstances, you should let patients know that there are ways to formalise their wishes and suggest that they seek support and independent advice about this.*
You must record a summary of your discussion with the patient about their future care and any decisions they make, including as much detail as practical about the patient’s wishes and fears, their preferences about future options for care, and the values and priorities that influence their decision making. If possible, you should make this record while the patient has capacity to review and understand it.
You should make sure the record of this discussion is flagged and made available to the patient and others involved in their care, so everyone is clear about what has been agreed. Any decision or preference should be easy to access and regularly reviewed.
If you are giving treatment or care to a patient who is nearing the end of their life, you must follow the guidance in Treatment and care towards the end of life: decision making.