Assessment Of Decision-making Capacity Research Articles

188 How Emergency Physicians Approach Refusal of Observation After Naloxone Resuscitation

Patients who are resuscitated with naloxone frequently refuse a period of observation, even though they may be suffering a variety of medical and psychiatric comorbidities. This confronts emergency physicians (EPs) with the challenge of how best to serve patients’ interests while respecting autonomy. We sought to characterize how EPs think about this kind of dilemma and the strategies they use to resolve them. We conducted qualitative semistructured interviews with a convenience sample of 59 emergency physicians attending ACEP Scientific Assembly in October 2018. Three case vignettes designed to bring out different clinical and ethical features were used as prompts. Interviews were transcribed and analyzed by three reviewers using a constant comparative method consistent with modified grounded theory, an iterative coding process to identify patterns of responses and derive key themes. Discrepancies in coding were reviewed and resolved by consensus among all reviewers. Across the three vignettes, EPs showed a diversity of approaches. Some EPs showed a readiness to refuse to comply with a patient’s wishes even when they determined a patient demonstrated decisionmaking capacity (ranging from 17% on the most straightforward case to 46% on the most complex case). Conversely, some EPs were willing to allow patients to leave the ED without assessing capacity or despite determining the patient lacked capacity (from 14% for a patient with frequent visits to 5% on a patient on multiple long-acting agents). Common reasons for complying with patient demands were concerns about patients’ rights (44%) and concerns for the safety of ED staff (17%). EPs demonstrated wide variability in their approach to assessing decisionmaking capacity in such patients. Some equated capacity with the ability to walk and talk (29%), some analyzed it solely in terms of understanding the risks and benefits of complying with or refusing observation (39%) and others included the ability of the patient to relate the decision to their own values or goals (22%). Emergency physicians approach this kind of ethical dilemma in widely divergent ways. Consensus about strategies for navigating patients’ wishes relative to clinical concerns are needed to help EPs manage these challenging cases.

27 Decision-Making Capacity Assessment: Occupational Therapy’s Contribution within a Multidisciplinary Approach

Abstract Background Increasing age and life expectancy, alongside the growing incidence of chronic conditions and dementia-related diseases, indicate more older individuals are likely to experience challenges regarding decision-making capacity. In Ireland, the Assisted Decision Making (Capacity) Act 2015 provides a statuary framework for adults who are experiencing difficulties with decision-making. This legislation has significant implications for all who work in health and social care, especially those working with older adults. An online survey was conducted to explore occupational therapy practices regarding decision-making capacity assessment and factors impacting on engagement in this area. Methods Occupational therapists in Ireland were invited to participate in a cross-sectional online questionnaire. Results One hundred and seventy-two occupational therapists responded. Most occupational therapists (65.77%, n=98) reported involvement in decision-making capacity assessments, particularly those working with older adults. Occupational therapists were more frequently requested to contribute to assessments of capacity regarding independent living (79.19%, n=118), driving (45.89%, n=67), and financial management (44.44%, n=64). Occupational therapists reported using a combination of approaches to inform decision-making capacity assessment, including interviews, observations and assessments of cognition and functional performance, and emphasised a strength-based approach. Many participants reported decision-making capacity assessment is more difficult than other aspects of practice and that they are not satisfied with decision-making capacity assessment procedures in their workplace. A large majority (91.86%, n=113) reported occupational therapists would benefit from additional training and practice resources for decision-making capacity assessment. Conclusion The study confirms that occupational therapists have a role to play in assessment of decision-making capacity assessment, particularly regarding independent living. However, the recommended approach to assessment should include all appropriate multidisciplinary team members. There is need for further education, resources and guidelines for occupational therapists and other healthcare professionals to better guide decision-making capacity assessment.

Approaches for assessing decision-making capacity in older adults

Objective This review will identify and map existing evidence on current approaches to determining decision-making capacity in older adults. It will provide a summary of available evidence and policies and identify gaps in research. Introduction Assessment of decision-making capacity is emerging as an important issue in society and healthcare. It is considered an ethically challenging area of clinical practice, and issues with implementation have been identified internationally. With the aging population increasing globally, approaches to assess and support decision-making are becoming more pertinent. Inclusion criteria This scoping review will consider studies on assessment approaches and procedures that are used to evaluate the decision-making capacity of older adults, aged 60 years and over. It will include those with age-related cognitive impairment, dementia, and neurodegenerative conditions. Quantitative, qualitative, and mixed-methods studies along with gray literature, including expert opinions, policies reports, and practice guides, will be included. Methods The JBI scoping review methodological framework will be used. The review will also be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist for scoping reviews. The following major healthcare databases will be searched: MEDLINE, PsycINFO, Embase, CINAHL, Cochrane Databases, Web of Science, and Scopus. The search will cover studies published in English from January 2000 to the present date. Titles and abstracts will be screened against inclusion criteria. Data will be extracted using a form developed for this review. A stakeholder consultation meeting will be held to provide feedback on the findings.

Characteristics of patients referred for assessment of decision-making capacity in the acute medical setting of an outer-metropolitan hospital-A retrospective case series.

To identify characteristics of older people referred for assessment of decision-making capacity in the acute hospital setting. A retrospective chart audit was undertaken for 98 consecutive medical inpatients referred for capacity assessments between February 2015 and August 2017 in an outer-metropolitan hospital. The data were analysed using descriptive and univariate analysis. In this case series, 56% of patients had a diagnosis of dementia. Social isolation was common; 70% were not presently married, and 63% had no community services. For 90% of patients, the referral was to determine the person's capacity to make their own accommodation decisions-usually to return home on discharge. Of those with impaired capacity, 54% were discharged to residential aged care, whilst most who retained capacity were discharged home (73%). Those with impaired capacity were more likely to have a diagnosis of dementia and a prolonged length of stay (both P<0.001).

Informed consent for early-phase clinical trials: therapeutic misestimation, unrealistic optimism and appreciation

Unrealistic therapeutic beliefs are very common—the majority of patient-subjects (up to 94%) enrol in phase 1 trials seeking and expecting significant medical benefit, even though the likelihood of such benefit...

Interest of Functional Neuroimaging in Assessing Decision-making Capacity of Older People With Neurocognitive Disorders

Interest of Functional Neuroimaging in Assessing Decision-making Capacity of Older People With Neurocognitive Disorders

Criteria, Procedures, and Future Prospects of Involuntary Treatment in Psychiatry Around the World: A Narrative Review.

The use of involuntary treatments in psychiatry comes with some benefits and many disadvantages for the patient’s experience and the therapeutic outcome. This review proposes to compare the procedures and criteria for involuntary psychiatric treatment and to outline the current situation concerning the relevant legislation and practices around the world. Various historical and present-day criteria and procedures are described and compared, showing a certain degree of heterogeneity to this day. Studies relating to patient experiences of coercive measures and their effects on the therapeutic relationship and continued adherence are examined. The breach of the principle of self-determination appears as a central element of the critique; underlined both in clinical reality and in jurisprudence. Moreover, assessment of the patient's decision-making capacity regarding their own care, the use of advance treatment directives, and the reduction of the mental patient's stigma in favour of greater social and therapeutic support appear important. We highlight the similarities and differences between legislation and practice in various parts of Europe, North America, Asia, and some areas of Latin America, Africa and the South Pacific. Other aspects that we explored include the patient’s experience of coercion; the repercussions on the therapeutic relationship and adherence to treatment following coercion; the role it plays in the prevention of suicide; ethical problems; and possible alternatives to reduce the use of coercive measures.

Cumulative Prognostic Score Predicting Mortality in Patients Older Than 80 Years Admitted to the ICU.

OBJECTIVESTo develop a scoring system model that predicts mortality within 30 days of admission of patients older than 80 years admitted to intensive care units (ICUs).DESIGNProspective cohort study.SETTINGA total of 306 ICUs from 24 European countries.PARTICIPANTSOlder adults admitted to European ICUs (N = 3730; median age = 84 years [interquartile range = 81‐87 y]; 51.8% male).MEASUREMENTSOverall, 24 variables available during ICU admission were included as potential predictive variables. Multivariable logistic regression was used to identify independent predictors of 30‐day mortality. Model sensitivity, specificity, and accuracy were evaluated with receiver operating characteristic curves.RESULTSThe 30‐day‐mortality was 1562 (41.9%). In multivariable analysis, these variables were selected as independent predictors of mortality: age, sex, ICU admission diagnosis, Clinical Frailty Scale, Sequential Organ Failure Score, invasive mechanical ventilation, and renal replacement therapy. The discrimination, accuracy, and calibration of the model were good: the area under the curve for a score of 10 or higher was .80, and the Brier score was .18. At a cut point of 10 or higher (75% of all patients), the model predicts 30‐day mortality in 91.1% of all patients who die.CONCLUSIONA predictive model of cumulative events predicts 30‐day mortality in patients older than 80 years admitted to ICUs. Future studies should include other potential predictor variables including functional status, presence of advance care plans, and assessment of each patient's decision‐making capacity.

Annals for Educators - 5 March 2019.

Annals for Educators - 5 March 2019.

Disagreement Between Clinicians and Score in Decision-Making Capacity of Critically Ill Patients.

To compare the assessment of decision-making capacity of ICU patients by attending clinicians (physicians, nurses, and residents) with a capacity score measured by the Mini-Mental Status Examination, completed by Aid to Capacity Evaluation if necessary. The primary outcome was agreement between physicians' assessments and the score. Secondary outcomes were agreement between nurses' or residents' assessments and the score and identification of factors associated with disagreement. A 1-day prevalence study. Nineteen ICUs in France. All patients hospitalized in the ICU on the study day and the attending clinicians. The decision-making capacity of patients was assessed by the attending clinicians and independently by an observer using the score. A total of 206 patients were assessed by 213 attending clinicians (57 physicians, 97 nurses, and 59 residents). Physicians designated more patients as having decision-making capacity (n = 92/206 [45%]) than score (n = 34/206 [17%]; absolute difference 28% [95% CI, 20-37%]; p = 0.001). There was a high disagreement between assessments of all clinicians and score (Kappa coefficient 0.39 [95% CI, 0.29-0.50] for physicians; 0.39 [95% CI, 0.27-0.52] for nurses; and 0.46 [95% CI, 0.35-0.58] for residents). The main factor associated with disagreement was a Glasgow Coma Scale score between 10 and 15 (odds ratio, 2.92 [1.18-7.19], p = 0.02 for physicians; 4.97 [1.50-16.45], p = 0.01 for nurses; and 3.39 [1.12-10.29], p = 0.03 for residents) without differentiating between the Glasgow Coma Scale scores from 10 to 15. The decision-making capacity of ICU patients was largely overestimated by all attending clinicians as compared with a score. The main factor associated with disagreement was a Glasgow Coma Scale score between 10 and 15, suggesting that clinicians confused consciousness with decision-making capacity.

The Paradox of Consent for Capacity Assessments.

The use of decision-making capacity assessments (DMCA) in clinical medicine is an underdeveloped yet quickly growing practice. Despite the ethical and clinical importance of these assessments as a means of protecting patient autonomy, clinicians, philosophers, and ethicists have identified a number of practical and theoretical hurdles which remain unresolved.2 One ethically important yet largely unaddressed issue is whether, and to what extent physicians ought to inform and obtain consent from patients prior to initiating a capacity assessment. In what follows, I address the following question: Must, or should, physicians obtain consent for capacity assessments? I argue that physicians have an ethical obligation to obtain express patient consent for capacity assessments, and in doing so, I challenge the predominant view which requires physicians to merely inform patients without obtaining consent. I then identify an underlying philosophical paradox that complicates the clinician's duty to obtain consent: in short, consent is needed for an assessment of one's ability to consent. Finally, I recommend a practical solution to this paradox of consent for capacity assessments by proposing a model of double consent from both the patient and health care representative.

Overview of the Assisted Decision-Making (Capacity) Act (2015)

PurposeIn Ireland, the Assisted Decision Making (Capacity) Act 2015 provides a statutory framework to adults who are experiencing difficulties with decision-making. This legislation has significant implications for all who work in health and social care. Increasing age and life expectancy, alongside the rising incidence of chronic health conditions and dementia-related diseases, indicates that more individuals are likely to experience challenges regarding decision-making capacity. Therefore, the need for more consistent, best-practice processes to assess decision-making capacity is likely to increase. To ensure occupational therapists are responsible in their contributions, and to ensure those with disabilities are supported, clinicians must be well-informed of the principles underscoring the Act. The purpose of this paper is to provide an overview of this multidisciplinary issue, including recent legislation, and consider how occupational therapy can contribute.Design/methodology/approachThe authors reviewed current literature and considered occupational therapy’s role in decision-making capacity assessment.FindingsOccupational therapists have potential to play a key role in multi-disciplinary assessments of decision-making capacity for clients. Further research is required to explore professional issues, identify clinical best practices and determine training and resource needs.Originality/valueThis paper seeks to provoke consideration of how occupational therapists can contribute to capacity assessment from a client-centred, occupation-based perspective that is mindful of ethical and legislative considerations.

Are Emergency Medicine Residents Prepared to Meet the Ethical Challenges of Clinical Practice? Findings from an Exploratory National Survey.

Although the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine require clinical ethics education in residency training, instruction varies widely. We assessed the educational preparedness of trainees in emergency medicine to address ethics challenges common to their field. The survey assessed two outcomes: 1) knowledge of specific ethical challenges and 2) perceived educational preparedness, across five ethics areas: 1) informed consent and decisional-capacity assessment, 2) surrogate decision making, 3) interpretation of advanced directives, 4) withdrawing and/or withholding life support, and 5) presumed consent for emergency treatment. Clinical vignettes, revised through expert panel review and pilot testing, were utilized to evaluate these areas. The final instrument was administered via Web link to emergency medicine residents and recent graduates through adverts within Emergency Medicine Residency Association and Society for Academic Emergency Medicine (SAEM) newsletters and social media platforms. Additionally, targeted e-mails through the Council of Residency Directors in Emergency Medicine, the Clerkship Directors of Emergency Medicine, and the SAEM Ethics Committee listservs encouraged survey distribution. Analyses involved one-way analysis of variance for overall knowledge scores and chi-square tests for categorical outcomes. Multivariable regression models tested associations between respondent characteristics and outcomes. There were 302 participants of which 34% reported having a dedicated ethics module within their residency curriculum. The mean (±SD) knowledge score was 59.7% (±12.8%); assessing decisional capacity was the most difficult topic for respondents as only 1% both correctly addressed the general issue and identified the correct plan of action. Participants having a dedicated ethics module perceived themselves better prepared, although there was no association between having a dedicated ethics module and knowledge scores. Gaps in clinical ethics knowledge appear prevalent among emergency medicine trainees, and few programs have dedicated ethics modules. Greater study is needed to understand and remedy clinical ethics knowledge shortfalls.

Autonomia do idoso: escala de avaliação de capacidade de decisão

Objetivou-se, através deste trabalho, criar e validar um instrumento capaz de auxiliar os juízes nas demandas relacionadas com a interdição, permitindo uma avaliação uniforme entre os casos. Para tanto, foi desenvolvido um construto com 30 questões, passando pela avaliação de expert’s. Surge, assim, a ESCADE – Escala de Avaliação de Capacidade de Decisão, com 18 questõesfinais, com confiabilidade e validade adequadas, com alfa de Cronbach de 0,814, dividido em quatro domínios: atividade diária, gestão financeira, autogestão e bem-estar. Conclui-se, assim, que se está diante de um questionário auxiliar, que busca instrumentalizar as análises judiciais, com pertinência e eficácia para tal tarefa, sendo ainda pertinente ressaltar a viabilidade de identificar, através dos domínios apresentados, a área de maior dificuldade apresentada pelo possível interdito, o que pode ensejar seu uso, também, na tomada de decisão apoiada.

The Bedside Capacity Assessment Tool: Further Development of a Clinical Tool to Assist with a Growing Aging Population with Increased Healthcare Complexities

As the population of the United States ages, chronic diseases increase and treatment options become technologically more complicated. As such, patients' autonomy, or the right of patients to accept or refuse a medical treatment, may become a more pressing and complicated issue. This autonomy rests upon a patient's capacity to make a decision. As more older, cognitively and functionally impaired individuals enter healthcare systems, quality assessments of decision-making capacity must be made. These assessments should be done in a time-efficient manner at a patient's bedside by the patient's own physician. Thus, a clinically practical tool to assist in decision-making capacity assessments could help guide physicians in making more accurate judgments. To create a clinically relevant Bedside Capacity Assessment Tool (BCAT) to help physicians make timely and accurate clinical assessments of a patient's decision-making capacity for a specific decision. The Department of Medicine, Division of Geriatrics and Palliative Medicine, Zucker School of Medicine at Hofstra/Northwell . Geriatric medicine fellows, palliative medicine fellows, and internal medicine residents (n = 30). Subjects used the BCAT to assess the decision-making capacity of patients described in 10 written, clinically complex capacity assessment vignettes. Subjects' conclusions were compared to those of experts. The subjects' and experts' assessments of capacity had a 76.1 percent rate of agreement, with a range of 50 percent to 100 percent. With removal of three complex outlier vignettes, the agreement rate reached 83.2 percent. The strong correlation between the two groups-one of physicians in training utilizing the BCAT and the other of specialists in this area-suggests that the BCAT may be a useful adjunct for clinicians who assess decision-making capacity in routine practice. The range indicates that further refinement and testing of this tool is necessary. The potential exists for this tool to improve capacity assessment skills for physicians in clinical practice.

A civic republican analysis of mental capacity law

AbstractThis paper draws upon the civic republican tradition to offer new conceptual resources for the normative assessment of mental capacity law. The republican conception of liberty as non-domination is used to identify ways in which such laws generate arbitrary power that can underpin relationships of servility and insecurity. It also shows how non-domination provides a basis for critiquing legal tests of decision making that rely upon ‘diagnostic’ rather than ‘functional’ criteria. In response, two main civic republican strategies are recommended for securing freedom in the context of the legal regulation of psychological disability: self-authorisation techniques and participatory shaping of power. The result is a series of proposals for the reform of decisional capacity law, including a transition towards purely functional assessment of decisional capacity, surer legal footing for advanced care planning, and greater control over the design and administration of decision making capacity laws by those with psychological disabilities.

Authenticity, Insight, and Impaired Decision-Making Capacity in Acquired Brain Injury

We respond to commentaries from Barton Palmer and John McMillan on our research findings concerning the assessment of decision-making capacity after brain injury. We found much to agree with and it is striking how so many of the issues relating to decision-making capacity (DMC) assessment find resonances outside of an English jurisdiction. California and New Zealand are clearly grappling with a very similar set of issues and the commentaries speak to the international nature of these discussions.

AN INNOVATIVE APPROACH TO ENHANCE THE INFORMED CONSENT PROCESS FOR PEOPLE WITH DEMENTIA: THE ENSURE PROJECT

People with dementia have the right to decide whether or not they want to participate in clinical research and to give their free, prior and informed consent. However, as dementia progresses, they can lose their ability to give informed consent to complex medical research because of an increasing loss of cognitive functions. At first sight, it seems ethically problematic to involve dementia patients in research, as people with impaired mental capacity must be protected against the risks of research participation. In contrast to informed consent to medical treatment, an individual benefit from participation in research can rarely be taken for granted. However, people with dementia also have a right to benefit from medical research in particular, so their categorical exclusion would appear to be ethically problematic too. The international, interdisciplinary ENSURE project (Enhancing the informed consent process: Supported decision-making and capacity assessment in clinical dementia research) aims to provide interdisciplinary recommendations to support the development of an action model of an informed consent process in clinical dementia research that 1) enhances the capacity to consent of people with dementia, 2) improves the assessment of decision-making capacity, 3) protects those who do not have the capacity to consent, and 4) guarantees the ethically justified inclusion of research subjects in clinical dementia research. To achieve this, four international project partners cooperate on four interdisciplinary interlinked subprojects. The disciplines involved are gerontology, ethics and law. A flow-chart of ENSURE and an overview of the first results of the subprojects will be presented. Implications for practical use in informed consent procedures will be discussed.

Refusal of Emergency Medical Treatment: Case Studies and Ethical Foundations

Informed consent is an important component of emergency medical treatment. Most emergency department patients can provide informed consent for treatment upon arrival. Informed consent should also be obtained for emergency medical interventions that may entail significant risk. A related concept to informed consent is informed refusal of treatment. Patients may refuse emergency medical treatment during their evaluation and treatment. This article addresses important considerations for patients who refuse treatment, including case studies and discussion of definitions, epidemiology, assessment of decisional capacity, information delivery, medicolegal considerations, and alternative care plans.

Clock Copying Predicts Mortality in Adult Protective Services Clients

The objective of this study was to determine if a clock copying task predicts 18-month mortality in an Adult Protective Services (APS) sample referred for a decision-making capacity assessment. The authors performed a retrospective medical record review of clients (N = 233) referred by APS for a decision-making capacity assessment during a 3-year time period. Information extracted included demographic data and neuropsychological performance on a battery sensitive to executive function, visuospatial ability, depression, memory, and general cognition. A Cox proportional hazards models was constructed to determine the relationship between Executive Clock Drawing Task Part 2 (CLOX2) performance and survival. Poor clock copying, as measured by CLOX2, predicted 18-month mortality when covaried for age, education, sex, rural dwelling status, depression, and general cognition. Clock copying is an easily administered visuospatial task that may inform survival in this vulnerable population.