Professor of Neurological Rehabilitation, OxINMAHR, and Movement Science Group, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK.
Honorary Professor and Co-Director of the Coma and Disorders of Consciousness Research Centre, School of Law and Politics, Cardiff University, Cardiff, UK.
Clin Rehabil. 2019 Oct;33(10):1571-1585. doi: 10.1177/0269215519852987. Epub 2019 Jun 6.
To clarify the concept of best interests, setting out how they should be ascertained and used to make healthcare decisions for patients who lack the mental capacity to make decisions.
The legal framework is the Mental Capacity Act (MCA) 2005, which applies to England and Wales.
Unless there is a valid and applicable Advance Decision, an appointed decision-maker needs to decide for those without capacity. This may be someone appointed by the patient through a Lasting Power of Attorney, or a Deputy appointed by the court. Otherwise the decision-maker is usually the responsible clinician. Different approaches exist to surrogate decision-making cross-nationally. In England and Wales, decision-making is governed by the MCA 2005, which uses a person-centred, flexible best interests (substituted interests) approach.
The MCA is often not followed in healthcare settings, despite widespread mandatory training. The possible reasons include its focus on single decisions, when multiple decisions are made daily, the potential time involved and lack of clarity about who is the responsible decision-maker.
One solution is to decide a strategic policy to cover more significant (usually health-related) decisions and to separate these from day-to-day relational decisions covering care and activities. Once persistent lack of capacity is confirmed, an early meeting should be arranged with family and friends, to start a process of sharing information about the patient's medical condition and their values, wishes, feelings and beliefs with a view to making timely treatment decisions in the patient's best interests.
阐明最佳利益的概念，阐述如何确定和使用这些概念，以便为没有能力做出决策的患者做出医疗保健决策。
法律框架是 2005 年《精神能力法》（MCA），适用于英格兰和威尔士。
除非有有效的和适用的预先决定，否则需要为那些没有能力的人指定一个决策者。这可以是患者通过持久授权书指定的人，也可以是法院指定的代理人。否则，决策者通常是负责的临床医生。跨国界存在不同的替代决策方法。在英格兰和威尔士，决策受 2005 年《精神能力法》的管辖，该法采用以人为主、灵活的最佳利益（替代利益）方法。
尽管进行了广泛的强制性培训，但医疗保健环境中仍经常不遵守《精神能力法》。可能的原因包括其侧重于单一决策，而日常需要做出多项决策，潜在的时间投入以及关于谁是负责决策者的不明确性。
一种解决方案是决定一项战略政策，涵盖更重要的（通常与健康相关）决策，并将这些决策与日常关系决策（涵盖护理和活动）分开。一旦确认持续缺乏能力，应安排与家人和朋友举行早期会议，开始一个过程，分享有关患者病情及其价值观、愿望、感受和信仰的信息，以便在患者的最佳利益下及时做出治疗决策。
