Best interests

Any treatment or decision must be made in the patient's best interests. In determining best interests, you should consider all the relevant circumstances, including:

the patient's past and present wishes and feelings, in particular any relevant written statement made when they had capacity
the beliefs and values likely to influence a decision if the patient had capacity
other factors they would be likely to consider if they were able to do so.

Keep in mind that the concept of best interests extends beyond clinical issues. It also encompasses the patient's values and preferences when competent, their psychological health, wellbeing, quality of life, relationship with family or other carers, spiritual and religious welfare and their financial interests.

If possible, take into account the views of those named by the patient as someone to be consulted about their best interests (see below for more information).
If no one has been named, these matters should be considered with the patient's close relative and/or their friend or carer.
A patient's best interests should not be determined based on their age, appearance, condition or behaviour.
Always keep a record in the patient's clinical record of how their best interests were established.
Before a treatment starts, or a decision is made, you should consider whether the purpose of the decision or treatment can be achieved just as effectively in a way that is less restrictive of the patient's rights and freedom of action.

Advance decisions and LPAs in England and Wales

A patient who currently lacks capacity may have made an advance decision when they did have capacity to refuse or limit treatment. If you're aware of such a decision and can establish it is valid and applies to the treatment proposed, you must follow it.

In England and Wales, patients can appoint an attorney under a lasting power of attorney (LPA) for health and welfare who may authorise dental decisions on their behalf. An LPA must be registered with the Office of the Public Guardian (OPG).

You can request an access code from the attorney named on the LPA, which enables you to view a summary of the LPA, check whether an LPA is valid and check who the attorneys are on an LPA.

View a lasting power of attorney - gov.uk

LPAs can't give attorneys the power to demand specific forms of dental treatment if dental professionals don't believe they are necessary or appropriate to the patient's condition.

The Independent Mental Capacity Advocate Services (IMCA), England and Wales

The IMCA is an advocacy service commissioned by local authorities in England and Local heath boards in Wales.

Where the patient has no one close to represent them, you might need to seek the views of an Independent Mental Capacity Advocate (IMCA) in deciding the patient's best interests in certain circumstances (likely to be rare) where 'serious medical treatment' is proposed. These circumstances include situations where there is a fine balance between the likely benefits and burdens/risks of treatment.

Welfare attorneys in Scotland

In Scotland, under the Adults with Incapacity (Scotland) Act 2000, a competent adult can appoint someone as a welfare attorney to act/make medical decisions on their behalf should they lose the capacity to make those decisions by themselves.

After a power of attorney is registered with the Office of the Public Guardian (OPC) Scotland, a certificate of registration is provided. Certification can be verified using an online service at the OPC's website.

In Scotland, the law also provides for a general power to provide non-emergency treatment for an adult patient who is unable to give consent and does not have a welfare attorney. The dental professional primarily responsible for treatment must have completed a certificate of incapacity before any treatment is undertaken, other than in an emergency.

Northern Ireland

The Mental Capacity Act (NI) 2016 is only partially in force at the time of writing (for example, in relation to deprivation of liberty safeguards) but when fully implemented it will bring NI legislation in line with the rest of the UK.

Until the 2016 Act is fully in force, common law principles apply and a patient who lacks capacity can only be treated where it is both necessary and in their best interests.

DDU advice

When deciding what constitutes a patient's best interests, take into account factors other than just their dental condition. Consider consulting with others, including getting a second opinion from a colleague, before proceeding with treatment.
Make a record in the patient's notes of the process by which you worked out the patient's capacity or lack of capacity, and their best interests. Include how the decisions were reached, the reasons, who was consulted and the factors considered.
Consider alternative treatments that may be more appropriate for the patient. The treatment you provide should be the least restrictive of the patient's rights and freedoms.

Making decisions on behalf of adults lacking capacity

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