Best Interests Decisions in Dementia Care: A Practical Meeting and Documentation Standard

January 23, 2026

In dementia services, “best interests” can become shorthand for “we decided”, which creates risk: families challenge decisions, commissioners question defensibility, and inspectors find gaps between policy and practice. A robust best-interests pathway is not legal jargon—it is a practical meeting and documentation standard that shows how the person’s rights, wishes, wellbeing and safety were balanced, and how least restrictive options were tested over time. This article sits within the wider Safeguarding, capacity, consent and human rights suite and reflects expectations embedded in core dementia service models used by commissioners to judge whether decisions are consistent, person-centred and properly governed.

When a best-interests decision is required (and when it is not)

Best interests applies only when a person lacks capacity for a specific decision at a specific time, even after you have taken all practical steps to maximise capacity. In operational terms, best-interests is required when the decision:

Has significant impact on liberty, safety, health, contact, finances or living arrangements.
Creates or maintains restrictions (e.g., locked doors, observation, contact limitations, routine PRN use).
Is disputed by family, professionals or the person (where capacity is fluctuating).
Has repeated consequences (e.g., ongoing refusal of care leading to harm).

It is not required for every daily choice. Overuse creates “meeting fatigue” and weakens quality. Underuse creates risk and challenge. A defensible threshold is to convene when the decision changes the person’s rights, routines or risks in a sustained way.

A defensible best-interests pathway: what “good” looks like in practice

Services get into difficulty when best-interests becomes a template exercise without evidence of thinking or outcomes. A defensible pathway includes:

Define the decision in one sentence (e.g., “Should we restrict unaccompanied outdoor access between 4pm–7pm?”).
Maximise capacity (timing, environment, communication aids, familiar staff, simplified choices).
Evidence the person’s wishes (current statements, observed preferences, life history, known values).
Consult relevant people (family, advocate where appropriate, staff who know the person, clinical input).
Identify options including least restrictive alternatives, with pros/cons and risk mitigations.
Decide, document and review with an explicit review date and exit criteria.

Most importantly, the record must show how you weighed rights and wellbeing—not just what you chose.

Running a best-interests meeting that is useful (not performative)

A practical meeting structure helps avoid drift and conflict. A useful agenda looks like this:

1) Purpose and scope: what decision is being made today, and what is out of scope.
2) Capacity summary: what steps were taken to maximise capacity and the outcome.
3) The person’s voice: what they have said, shown, or consistently preferred; what matters to them.
4) Risks and impacts: safety, distress, relationships, dignity, health outcomes, restrictive impact.
5) Options: least restrictive alternatives and mitigations; what will be trialled.
6) Decision and rationale: why this option best balances rights and wellbeing.
7) Review plan: evidence metrics, timescales, and who is responsible for monitoring.

Keep minutes factual and focused. Avoid loaded language (“non-compliant”, “difficult”) and focus on observable outcomes and reasons.

Operational Example 1: Refusal of personal care with escalating skin integrity risk

Context: A person with dementia increasingly refuses bathing and continence care. Staff are worried about skin breakdown and infection risk. The family insists the person “would never refuse if approached properly”.

Support approach: The service defines the decision: “What personal care interventions are necessary, and how can we deliver them in the least restrictive, least distressing way?” Capacity is assessed for this specific decision, including steps to maximise capacity (timing, privacy, familiar staff, simplified choices). The team consults family about preferences and past routines and considers advocacy if the person’s voice is being overshadowed.

Day-to-day delivery detail: The care plan includes a refusal protocol: offer choices (wash at sink vs shower, male/female staff, music, preferred products), document what worked, and set escalation triggers (redness, pain indicators, strong odour, repeated soiling). Staff record the approach attempted before any more intrusive intervention. Clinical input is sought early to reduce crisis escalation. The meeting decision sets clear limits: when it is safe to delay and when it is not, with dignity safeguards (privacy, consent checks at each step, stopping rules if distress escalates).

How effectiveness or change is evidenced: Evidence includes skin integrity monitoring, reduced distress markers during care, improved acceptance rates, and documented learning in supervision. Review notes show whether the plan can be further relaxed as trust rebuilds.

Operational Example 2: Managing unaccompanied outdoor access and community walking

Context: A person routinely tries to leave to “go to the shops”. They have previously become lost and were found distressed. Staff propose restricting outdoor access unless accompanied; the person becomes angry when blocked and tries to push past.

Support approach: The service frames the decision as a balance of liberty and safety, not “stop them leaving”. The meeting considers options: accompanied walks at set times, a safe garden route, community walking groups, signage that supports orientation, and activity planning that reduces exit-seeking triggers. Restrictions are considered only alongside active enablement measures.

Day-to-day delivery detail: Staff implement a predictable “walk and purpose” routine: a short outdoor walk after lunch, a second walk during the typical exit-seeking period, and meaningful tasks in between. Records capture triggers, de-escalation methods, and whether alternatives reduced distress. If restriction is used (e.g., locked door), the plan defines time windows, staff responsibilities, and review data (frequency of attempts, distress duration, outcomes after walks). The service uses incident trend reviews to ensure staffing patterns and environment design are part of the solution.

How effectiveness or change is evidenced: Reduced exit-seeking frequency, fewer incidents, improved mood, and increased engagement show that least restrictive practice is active, not theoretical. Review minutes demonstrate consideration of stepping down restriction as risk reduces.

Operational Example 3: Contact arrangements where visits trigger distress

Context: A family member’s visits repeatedly lead to distress, shouting and agitation. Another relative asks the service to restrict contact. Staff worry about rights to family life and fear complaints.

Support approach: The meeting defines the decision: “What contact arrangement best supports the person’s wellbeing while respecting family life?” The service assesses capacity for contact preferences and maximises it by discussing at calm times with familiar staff, using simple options. An advocate is considered to support the person’s voice if conflict is high.

Day-to-day delivery detail: The service introduces a structured visiting plan: shorter visits, agreed topics/behaviours, a staff presence if needed, and a calm exit strategy if distress rises. Staff record objective indicators: the person’s mood pre/during/post visit, sleep and appetite impact, and any distress cues. If a restriction on contact is necessary, it is time-limited, proportionate, documented with rationale, and reviewed with clear criteria for relaxation.

How effectiveness or change is evidenced: Evidence includes reduced distress around visits, improved emotional stability, fewer incidents, and transparent review documentation showing the restriction is actively minimised.

Expectations to evidence

Commissioner expectation

Commissioners expect best-interests decisions to be auditable and outcome-driven: clear thresholds for convening, consistent documentation across the service, evidence of least restrictive options being trialled, and a review cycle that shows decisions are not “set and forget”. They will look for how decisions translate into day-to-day delivery and measurable impact.

Regulator / Inspector expectation (CQC)

CQC will look for person-centred, rights-based decision-making: the person’s voice and preferences evidenced, capacity maximised, consultation documented, and restrictions justified and reviewed. Inspectors will test whether staff can explain the decision in plain language and show how it improved outcomes or reduced distress, not just that a meeting occurred.

Quality controls that make best-interests defensible at scale

High-performing services build simple controls that prevent inconsistent practice:

Decision log: significant decisions, review dates, and whether restrictions increased or decreased over time.
Sampling audit: monthly check of a small number of decisions for capacity evidence, options analysis and review outcomes.
Supervision prompts: staff coached on recording quality, de-escalation, and maintaining the person’s voice in conflict.
Learning loop: themes feed into environment changes, staffing design, training priorities and activity planning.

The goal is a best-interests process that is consistent, rights-first and operationally real—clear enough to use on shift and strong enough to stand up to scrutiny.