Deciding right Regional Forms

These forms and associated guidance are for use by professionals working with patients who are making advance care decisions. They are recognised by organisations across the region and should be used in all instances of advance care planning locally.  The North East Ambulance Service (NEAS) will only accept the Deciding right forms. This page has the most recent forms. Older versions of the DNACPR form will no longer be acceptable after 31st December 2018, please use the most recent versions on this page for all new cases. Forms can be printed and completed manually or there is an electronic version that can be completed on screen.

Do Not Attempt Cardio Pulmonary Resuscitation: DNACPR

This documents the decision not to offer cardiopulmonary resuscitation in the event of a cardiac or respiratory arrest.  It also documents the reason for the decision and other details and is concordant with the Mental Capacity Act.  This regional form applies across all care settings and in all ages.  Please make sure that the patient held form is printed in colour. Download the DNACPR NHS Print form v17a 2018 Download DNACPR COPY form v17a 2018 Download the DNACPR-NHS-Fillable-form-v17

Examples of completed DNACPR Forms

Heart Failure

DNACPRv17 Document

ADRT Document

EHCP Document

Muscular Dystrophy

DNACPRv17 Document

ADRT Document

EHCP Document

Ordering of DNACPR forms

DNACPR Ordering information Dec 2018

Advance Decision to Refuse Treatment (ADRT)

This documents an adult patient’s decision to refuse a specific treatment.  It complies with requirements when refusing life-sustaining treatment and applies in all settings for people aged 18 years and over. Download the ADRT PRINT form Download the ADRT ON-SCREEN fillable Download the Advance Decisions Checklist

Mental Capacity Act Assessment Forms

For individuals who lack capacity to engage independently in the completion of an Advance Statement or Advance Decision to Refuse Treatment (ADRT) conversations are necessary regarding any known preferences and wishes and estimating what the person would want should be discussed between their relatives, carers and health professionals.  This should be done via the best decision making process in line with MCA 2005.  The agreed information should then be documented in a clear format and supported by MCA best interest decision making documentation.

The MCA1 part of this form allows a capacity assessment to be documented.  If the individual does not have capacity for a specific care decision, the MCA2 part of the form follows the requirements of the Mental Capacity Act best interests process. Download the MCA-1and2-generic-v15 (updated link) – a Word document: printable and e-fillable on screen.  Use this document to record additional information to support the Mental Capacity Assessment and the Best Interest Decision Making process.  Individual organisation logos can be added.

Emergency Health Care Plan (EHCP)

This documents the care needed during and after an anticipated emergency.  These decisions will have been made with the individual if they have capacity If they do not have capacity by the best interest process, the person with parental responsibility or a court order.  It does not include a CPR decision.  It applies in all settings and all ages.

Download the EHCP NHS Fillable form

Download the EHCP NHS Print form

Download the EHCP Instructional Template

Download the EHCP Advice sheet Nov 2018

Download the EHCP Useful Phrases

Advance Statement (March 2019)

The Northern England Clinical Networks Advance Statement (March 2019)

The Department of Health is encouraging people, especially those with a life limiting condition, to have the opportunity to discuss their personal preferences and choices around their future care.  These discussions will take place with professionals who can support them and this may also include family and carers.  These discussions can then be recorded in an Advance Statement.  This can enable services to be aware of the individual’s wishes if unable to communicate themselves.  The document can be printed from the link below and completed with a patient or completed from the link below as a fillable document and then printed out and left with the patient.

Network Advance Statement printable FINAL

Network Advance Statement fillable FINAL

Advance Statement Information for patients, relatives and carers

An example of an Advance Statement Completed Document can be found here

There may be occasions when the above Advance Statement documents may not be appropriate to meet the person’s needs.  The following links will take you to some alternatives for which the Northern England Clinical Networks have sought permission from the relevant organisations.

Northumberland Tyne & Wear NHS Foundation Trust have produced an easy read patient information leaflet entitled Advance Decisions and Advance Statements: Making choices about your care and treatment, a copy of which can be found here

Sunderland Learning Disability Services have worked closely with colleagues in palliative care to make sure they share the knowledge and experience…developing information that is easy to understand about becoming poorly and maybe reaching the end of your life.  They have also developed what they call My End of Life Booklet.  Its a good idea to fill this in when you are well so that in the future people who love and care for you will know what you wanted when you are no longer there.  Please follow this link for their information on reaching the end of life.  This is excellent information for people with learning disabilities, their families and all carers.  There are three further leaflets available and also a word bank that aims to explain complicated words

North East Ambulance Service (NEAS) Special Patient Note (SPN) Form Version 2 (August 2018)

NEAS can apply a flag to the patients address to advise call handlers of any decisions identified on the SPN form.  The information on the SPN form will support the decision making by NEAS and help the clinicians to prioriitise if an ambulance is required.  If an ambulance crew attends the address, they will be notified of the SPN whilst on route to the address.

As from August 2018 please use the SPN form version 2 which must be completed electronically and sent via email to special.patient.notes@nhs.net 

If you require a word version of this form it can be downloaded from the NEAS website using this link

The form MUST have valid to and from dates as well as referrer details for NEAS to action the form and input the SPN onto the 999 and 111 system.