What Happens in a Best Interests Meeting?

You arrive at handover and hear, “There’s a best interests meeting this afternoon.”

It sounds formal, but the purpose should be straightforward: to make a particular decision for a person who cannot make it themselves, while keeping that person’s rights, wishes and values at the centre.

This article concerns England and Wales, where best-interests decision-making comes from the Mental Capacity Act 2005.

Is a Meeting Always Required?

No.

Many ordinary care decisions are made without a formal meeting. A meeting is more likely when the decision is serious, complex, disputed or involves several services.

Examples may include:

• major treatment with significant risks
• long-term accommodation or discharge arrangements
• clinically assisted nutrition and hydration
• care restrictions that may affect the person’s liberty
• a serious disagreement between professionals or family members

The process should match the importance and urgency of the decision. An emergency cannot always wait for a scheduled meeting, but the law still applies.

Start With the Exact Decision

A useful meeting begins with one clearly framed question.

“What is best for this patient?” is too wide.

“Should the patient be discharged to the proposed nursing placement now, or should another option be pursued?” is specific enough for people to consider the evidence and alternatives.

The team should also confirm that the person lacks capacity for this particular decision at this time. A diagnosis or an old assessment is not enough.

Who Is the Decision-Maker?

The person responsible for making the decision depends on what is being decided.

For medical treatment, it is usually the healthcare professional responsible for that treatment. For social care or accommodation, it may be the professional responsible for arranging that part of the person’s care.

A properly appointed health and welfare attorney or a court-appointed deputy may hold relevant authority, but the legal document must be checked.

A chairperson can organise the discussion without becoming the legal decision-maker. The record should make clear who holds responsibility for the final decision.

Who Might Attend?

The group should include people who can contribute relevant information, not everyone who happens to be available.

Depending on the decision, this may include:

• the patient, with appropriate support
• the decision-maker
• nursing and medical staff
• allied health professionals
• social work or discharge staff
• family, friends or carers
• a health and welfare attorney or deputy
• an Independent Mental Capacity Advocate
• an independent advocate or communication specialist

Relatives provide important evidence about the person. Unless they have legal authority, they do not receive a deciding vote.

The Patient Still Belongs in the Process

The person should be involved as fully as possible.

That may mean attending all or part of the meeting, receiving information in an accessible format, using an advocate, sharing views beforehand or having their known wishes presented clearly.

A decision that the meeting would cause the person distress should not become an easy reason to exclude them. The team should consider how participation can be adapted.

What Must Be Considered?

Section 4 of the Mental Capacity Act sets out the best-interests checklist.

The decision-maker should consider:

• all relevant circumstances
• whether the person may regain capacity and whether the decision can wait
• how to encourage and improve the person’s participation
• the person’s past and present wishes and feelings
• their beliefs and values
• other factors they would probably consider
• the views of people it is appropriate to consult
• whether a less restrictive option could achieve the purpose

The decision must not be based merely on the person’s age, appearance, condition or behaviour.

Best Interests Is Not a Vote

A meeting may end with several different views.

Three relatives supporting one option and two clinicians supporting another does not settle the decision by majority.

The decision-maker must weigh the evidence, apply the law and explain why the chosen option is in the person’s best interests.

Clinical benefit is important, but it is not the only consideration. The person’s own values may change how benefits and burdens are understood.

What If Nobody Agrees?

National Institute for Health and Care Excellence guidance recommends trying to resolve disputes before the decision is implemented where possible.

This may include:

• clarifying misunderstandings
• sharing missing information
• obtaining a second clinical opinion
• using mediation
• holding an ethics discussion
• seeking senior legal advice

Serious unresolved disputes may need to be referred to the Court of Protection. Cases involving life-sustaining treatment, major restrictions or significant disagreement should be escalated early.

What Should the Record Show?

The written record should include:

• the specific decision
• the capacity assessment and its outcome
• who the decision-maker was
• who attended or was consulted
• how the person participated
• their wishes, feelings, beliefs and values
• the options and less restrictive alternatives considered
• the benefits and burdens of each option
• areas of agreement and disagreement
• the final decision and reasons
• the plan for review

A list of attendees followed by “agreed in best interests” is not enough for a complex decision.

A Student Nurse in the Meeting

A student may know details that are easy to miss.

You may have heard the patient explain what matters to them during personal care, noticed when they communicate most clearly or seen how different options affect their distress and comfort.

Share factual observations, not assumptions.

You could say:

“Yesterday morning, when the ward was quieter, she repeatedly said that being near her sister was important and used the same words on three occasions.”

That is more useful than saying, “I think she would want this.”

Ask your practice supervisor what your role is, maintain confidentiality and document only within your responsibility.

A Note for Scottish Students

Scotland does not use the Mental Capacity Act best-interests framework.

Decisions under the Adults with Incapacity (Scotland) Act 2000 must follow the Scottish principles of benefit, least restriction, taking account of the adult’s wishes, consulting relevant others and encouraging the adult’s skills.

A meeting in Scotland may look similar in practice, but the legal language and test must be correct for Scotland.

The Bleepbook Takeaway

A best interests meeting is not a room full of people deciding what is easiest.

It is a structured way to make one decision, involve the person, weigh the available options and show why the outcome is lawful and genuinely centred on them.

References

GOV.UK. Mental Capacity Act Code of Practice.

Legislation.gov.uk. Mental Capacity Act 2005, section 4.

National Institute for Health and Care Excellence. Decision-making and mental capacity (NG108).

National Institute for Health and Care Excellence. Best interests decision-making quality statement.