Record of Decision to Withdraw Implantable Cardioverter Defibrillator (ICD) Therapy in an Adult Patient Name: Patient’s Section 9 continued Is it the consensus view that it is in the for ICD therapy to be withdrawn? patient’s “best interests” Yes No If yes, proceed to section 10 If no and consensus cannot be reached about and particularly if the patient/those “best interests” close to them or the IMCA disagree with the clinical view, seek legal advice about how to proceed. Section 10 I am the doctor currently in charge of the care of Delete as necessary I am satisfied that I have obtained the patient's valid informed consent to withdraw ICD therapy. I have obtained the consent of the attorney, (who I am satisfied is appointed under patient’s an LPA to give consent in these circumstances) to withdrawal of the ICD therapy. I am satisfied that an advance refusal of ICD therapy exists, which is valid and applicable to the current circumstances. I am satisfied that the patient lacks capacity to consent to withdrawal of treatment and confirm that I believe it is in the best interests that ICD therapy should be patient’s withdrawn. I have attempted to complete the necessary steps to ascertain any relevant views/wishes of the patient prior to becoming incapacitated and have taken account of the views offered by those close to the patient (where available), the IMCA, where applicable, and the views of the multidisciplinary team. I am satisfied that the patient lacks capacity to consent to withdrawal of treatment and confirm that I believe it is in the best interests that ICD therapy should be withdrawn. patient’s Name Position Signature Date 18
Record of Decision to Withdraw Implantable Cardioverter Defibrillator (ICD) Therapy in an Adult Patient Patient’s Name: Section 9 continued Is it the consensus view that it is in the patient’s “best interests” for ICD therapy to be withdrawn? Yes No If yes, proceed to section 10 If no and consensus cannot be reached about “best interests” and particularly if the patient/those close to them or the IMCA disagree with the clinical view, seek legal advice about how to proceed. Section 10 I am the doctor currently in charge of the care of Delete as necessary I am satisfied that I have obtained the patient's valid informed consent to withdraw ICD therapy. I have obtained the consent of the patient’s attorney, (who I am satisfied is appointed under an LPA to give consent in these circumstances) to withdrawal of the ICD therapy. I am satisfied that an advance refusal of ICD therapy exists, which is valid and applicable to the current circumstances. I am satisfied that the patient lacks capacity to consent to withdrawal of treatment and confirm that I believe it is in the patient’s best interests that ICD therapy should be withdrawn. I have attempted to complete the necessary steps to ascertain any relevant views/wishes of the patient prior to becoming incapacitated and have taken account of the views offered by those close to the patient (where available), the IMCA, where applicable, and the views of the multidisciplinary team. I am satisfied that the patient lacks capacity to consent to withdrawal of treatment and confirm that I believe it is in the patient’s best interests that ICD therapy should be withdrawn. Name Position Signature Date 18