Assessment Of Decision-making Capacity Research Articles

Anything You Do Not Say Can Be Used against You: Volitional Refusal to Engage in Decisional Capacity Assessment.

AbstractThe most widely accepted model of decisional capacity assessment requires that a patient communicate a clear and consistent choice to the evaluator. This approach works effectively when patients prove unable to express a choice owing to physical, psychological, or cognitive limitations. In contrast, the approach raises ethics concerns when applied to patients who volitionally refuse to communicate a choice. This article examines the ethical issues that arise in such cases and offers a rubric for addressing decisional capacity under such circumstances.

Assessment of adolescent decision-making capacity for pharmacy access to hormonal contraception

ObjectivesTo examine adolescents’ decision-making capacity for pharmacsist-prescribed hormonal contraception. Study DesignA subset of 60 females, ages 14–21, were recruited to complete the MacArthur Competence Assessment Tool-Treatment. Overall scores were compared by age and demographic factors and variation examined. ResultsParticipants scored high on the MacArthur Competence Assessment Tool-Treatment with little variation in the scores (18.8 [±1.9]/20 total points). Factors such as chronic illness, health literacy, and family affluence were not associated with of overall scores. ConclusionsAdolescents and young adults have the capacity to make decisions regarding contraception in the pharmacy access settings.

A Preliminary Assessment of the Psychometric Properties of a New Communication Aid to Support Assessments of Financial Decision-Making Capacity in People with Aphasia

Background Financial decision-making is complex and requires an in-depth assessment. In the presence of communication disorders, like aphasia, such assessments become challenging and require the use of a dedicated communication aid. No communication aid currently exists to support financial decision-making capacity (DMC) assessments for persons with aphasia (PWA).(1) We sought to establish the validity, reliability, and feasibility of a newly constructed communication aid desigqned for this purpose. Methods A mixed methods study was performed, divided into three phases. Phase one was aimed at capturing current understanding of DMC and communication by community-dwelling seniors, using focus groups. The second phase involved the development of a new communication aid to assist with the assessment of financial DMC for PWA. The third phase aimed to establish the psychometric properties of this new visual communication aid. Results The new communication aid is a 37-page, paper-based document, with 34 picture-based questions. Due to unforeseen difficulties in participant recruitment for evaluating the communication aid, a preliminary evaluation was performed on the results from eight participants. These indicated the com-munication aid had moderate inter-rater reliability (Gwet’s AC1 kappa of 0.51 [CI 0.4362 to 0.5816, p < .000]), good internal consistency (0.76), and was usable. Conclusions This newly developed communication aid is one of a kind, and provides essential support for PWA requiring a financial DMC assessment, which was not previously available. Preliminary evaluation of its psychometric properties is promising; however, further validation is required to confirm its validity and reliability in the proposed sample size.

A Preliminary Assessment of the Psychometric Properties of a New Communication Aid to Support Assessments of Financial Decision-Making Capacity in People with Aphasia.

Financial decision-making is complex and requires an in-depth assessment. In the presence of communication disorders, like aphasia, such assessments become challenging and require the use of a dedicated communication aid. No communication aid currently exists to support financial decision-making capacity (DMC) assessments for persons with aphasia (PWA).(1) We sought to establish the validity, reliability, and feasibility of a newly constructed communication aid desigqned for this purpose. A mixed methods study was performed, divided into three phases. Phase one was aimed at capturing current understanding of DMC and communication by community-dwelling seniors, using focus groups. The second phase involved the development of a new communication aid to assist with the assessment of financial DMC for PWA. The third phase aimed to establish the psychometric properties of this new visual communication aid. The new communication aid is a 37-page, paper-based document, with 34 picture-based questions. Due to unforeseen difficulties in participant recruitment for evaluating the communication aid, a preliminary evaluation was performed on the results from eight participants. These indicated the communication aid had moderate inter-rater reliability (Gwet's AC1 kappa of 0.51 [CI 0.4362 to 0.5816, p < .000]), good internal consistency (0.76), and was usable. This newly developed communication aid is one of a kind, and provides essential support for PWA requiring a financial DMC assessment, which was not previously available. Preliminary evaluation of its psychometric properties is promising; however, further validation is required to confirm its validity and reliability in the proposed sample size.

Children’s Developmental (Im)maturity: Aligning Conflicting Decisional Capacity Assessment Approaches in Australia

Children’s decision-making is complex. There are many factors that contribute to children’s decisional capacity including cognitive reasoning, developmental maturity, upbringing and circumstances. For healthcare decisions, Australian law acknowledges children’s autonomy, and permits mature children to consent to beneficial healthcare. Yet, it also protects them from making life-changing decisions that could contravene their best interests. The criminal law approaches to children’s decision-making in Australia’s jurisdictions involves holding older children fully responsible for their decision-making, regardless of circumstances or maturity. The two approaches conflict because health law offers a protective mechanism for children yet criminal law imposes a punitive approach to children’s decision-making. This article considers whether the dichotomous approaches for children’s capacity assessments in Australian law can be reconciled.

Decision making capacity assessment in general practice in Ireland.

It has been reported internationally that doctors have a limited understanding of the legal standard that applies to decision making capacity (DMC). No research on this has been conducted in Ireland to date. We sought to assess the understanding of legal principles relating to capacity and consent among Irish general practitioners (GPs), alongside how DMC assessments are conducted. This study utilised a cross-sectional cohort model circulating online questionnaires to Irish GPs associated with a university research network. Data were analysed using SPSS to conduct a variety of statistical tests. There were 64 participants, with 50% aged 35-44 years and 60.9% being female. Of these, 62.5% found DMC assessments time-consuming. Only 10.9% of participants felt extremely confident in their abilities; most participants (59.4%) felt 'somewhat confident' in their ability to assess DMC. Also, 90.6% of GPs routinely engaged with families when assessing capacity. GPs felt their medical training did not prepare them for DMC assessment (undergraduate 90.6%, non-consultant hospital doctor 78.1%, GP training 65.6%). 70.3% felt guidelines relating to DMC would be helpful and 65.6% felt they needed additional training. Most GPs recognise the importance of DMC assessment, and it is not considered a complex or burdensome task. There was limited knowledge of the legal instruments relevant to DMC. GPs felt there should be extra support available to assist them with DMC assessment; specific guidelines for different categories of patients was found to be the most popular resource requested.

Psychiatric Consultation When a Patient Refuses Medical Care

Psychiatry consultants are often called on by colleagues to assess a patient's capacity to refuse medical care. These situations can expand beyond the boundaries of a decision-making capacity question to become clinically, legally, ethically, and emotionally complex situations. This article provides a framework for psychiatrists to navigate these complexities when asked to evaluate a patient for the capacity to refuse medical care. We review decision-making capacity as an element of informed consent in order to clarify the psychiatrist's role in these consults. We discuss related ethical and legal questions that can arise when a patient refuses treatment. This article also addresses other skills beyond decision-making capacity assessment that psychiatrists may utilize to support nonpsychiatrist colleagues and advance the care of the hospitalized patient. [ Psychiatr Ann . 2023;53(1):17–22.]

Clinical and Ethical Dilemmas in the Involuntary Treatment of Anorexia Nervosa.

After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN. Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.

US clinicians' perspectives on advance care planning for persons with dementia: A qualitative study.

Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians. Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed. Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity. Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models.

Assessment of decisional capacity for Alzheimer’s disease PET disclosure among cognitively symptomatic individuals

AbstractBackgroundOlder adults are highly interested in learning their Alzheimer’s disease (AD) positron emission tomography (PET) amyloid‐beta (Aβ) and tau results. However, knowledge about the meaning, uses, and risks of learning personal biomarker results is variable. Tools are needed to assess decisional capacity prior to biomarker disclosure, particularly for individuals with cognitive impairment.Methods30 participants (46.7% female; 93.3% white, age = 71.9±7.14 years) diagnosed with either mild cognitive impairment (MCI; 60.0%) or dementia‐Alzheimer’s type (DAT; 40.0%) completed Aβ and tau PET, an interactive education session and results disclosure decision‐making assessment. When available, cognitively unimpaired care partners (n = 27) attended these sessions and their ability to demonstrate decisional capacity for participant biomarker disclosure was assessed. Decisional elements evaluated included understanding of the meaning of biomarker results, appreciation of risks and benefits of engaging in disclosure, communication of a choice to learn the participant’s biomarker results, and demonstration of a rationale for engaging (or not) in disclosure. Chi‐squared tests were used to assess whether successful demonstration of each element differed by diagnosis.ResultMore participants with MCI (77.8%) than participants with DAT (25.0%) demonstrated disclosure decisional capacity (χ2 = 8.17, p = .008). Across the full sample, participants had the most difficulty understanding the difference between AD and DAT (34.6% incorrect), the meaning of elevated amyloid (19.0% incorrect) or tau (10.0% incorrect), and biomarker disclosure risks (19.0% incorrect). Compared to participants with DAT, those with MCI were more likely to demonstrate understanding of biomarker results (33.3% DAT v. 77.8% MCI; χ2 = 5.93, p = .024) and appreciation of personal benefits and risks of biomarker disclosure (33.3% DAT v. 83.3% MCI; χ2 = 7.75, p = .009). There were no differences in demonstration of rationale or communication of choice by diagnosis. All care partners demonstrated adequate decisional capacity for disclosure of the participant’s PET results.ConclusionAppreciation and understanding, two elements rarely evaluated in clinical or research settings, are more challenging than rationale or choice for cognitively impaired participants to demonstrate. Prior to disclosure, education should emphasize the possible meaning, usefulness, and risks of PET amyloid and tau information. Family or care partner disclosure decision‐making assessment should be a standard part of disclosure protocols.

98 PREPARING FOR THE COMMENCEMENT OF THE DECISION MAKING “CAPACITY” ACT (2015): REVIEWING CURRENT PRACTICE WITHIN AN OCCUPATIONAL THERAPY DEPARTMENT

Abstract Background The Decision Making ‘Capacity’ Act (2015) will commence in 2022. This will have significant implications for health care professionals. Occupational therapists undertake a wide range of assessments of cognitive, physical and functional ability. There is a need to streamline the recording of comprehensive and holistic assessment outcomes for easier access and interpretation during the interdisciplinary assessment of Decision Making Capacity (DMC) for independent living. A working group was established to review current practices and formulate a document to support the assessment. Methods The model for improvement was employed, which incorporates the plan, do, study, act methodology. Current practice of the occupational therapy team was reviewed in relation to assessments used, the format of recording and the knowledge of the DMC act. A working document was formulated and reviewed with medical staff. Team education on the DMC act was provided. A qualitative questionnaire was circulated among the occupational therapy staff to ascertain the educational needs of the department. Perceptions of current practice in DMC assessment of independent living were gathered. Results 100% of questionnaire respondents identified need for further training and education on the DMC Act 2015. No respondents agreed that the relevant assessment outcomes were easily accessible. 67% of respondents were unsatisfied with the current process in place for DMC assessment of independent living. 45% of respondents do not feel confident in completing assessments contributing to DMC assessment of independent living. There was no consistency in the format of recording assessment outcomes. Conclusion The group developed a clinical document to improve easy and consistent interpretation of occupational therapy assessment in relation the DMC assessment of independent living. This ensures person centred, comprehensive assessment to enhance the patient journey. The team are better prepared for the commencement of the DMC act and have identified future training needs.

6 OLDER ADULTS’ DECISION-MAKING CAPACITY FOR INDEPENDENT LIVING: OCCUPATIONAL THERAPY CONTRIBUTIONS TO COLLABORATIVE MULTIDISCIPLINARY ASSESSMENT

Abstract Background Increasing age and life expectancy, alongside the growing prevalence of dementia-related diseases, indicate more older adults are likely to experience challenges regarding their decision-making capacity (DMC). The Assisted Decision Making (Capacity) Act 2015 provides a statuary framework for adults who are experiencing difficulties with decision-making and has implications for all healthcare professionals. Occupational therapists frequently contribute to multidisciplinary assessments of older adults’ DMC for independent living (IL). Methods Focus groups were conducted among occupational therapists working with older adults in Ireland to explore assessment practices of DMC for IL. Results Fifty-two occupational therapists, from a range of hospital and community settings, participated in nine focus groups. Therapists reported using enablement strategies and occupation-based approaches when assessing DMC to address the person’s values and preferences, cognitive-functional abilities and environmental needs for IL. However, resource issues and lack of shared understanding of DMC among the multidisciplinary team constrain DMC assessment practices. Furthermore, older people are often excluded from care-planning, and IL options are determined by availability of services rather than will and preference. Multidisciplinary education on DMC is essential in shaping a cohesive approach to assessment and to enhance older adults’ participation in decision-making. Conclusion Multidisciplinary collaboration and commitment to person-centred approaches may lead to enhanced outcomes for maximising and supporting older adult’s DMC regarding IL. A potential leadership role for occupational therapy in assessing DMC for IL is also highlighted.

Reasoning and reversibility in capacity law

A key objective of the law in the assessment of decision-making capacity in clinical settings is to allow clinicians and judges to avoid making value judgements about the reasons that...

Evidence to guide ethical decision-making in the management of older people living in squalor: a narrative review.

Older people living in squalor present healthcare providers with a set of complex issues because squalor occurs alongside a variety of medical and psychiatric conditions, and older people living in squalor frequently decline intervention. To synthesise empirical evidence on squalor to inform ethical decision‐making in the management of squalor using the bioethical framework of principlism. A systematic literature search was conducted using Medline, Embase, PsycINFO and CINAHL databases for empirical research on squalor in older people. Given the limited evidence base to date, an interpretive approach to synthesis was used. Sixty‐seven articles that met the inclusion criteria were included in the review. Our synthesis of the research evidence indicates that: (i) older people living in squalor have a high prevalence of frontal executive dysfunction, medical comorbidities and premature deaths; (ii) interventions are complex and require interagency involvement, with further evaluations needed to determine the effectiveness and potential harm of interventions; and (iii) older people living in squalor utilise more medical and social resources, and may negatively impact others around them. These results suggest that autonomous decision‐making capacity should be determined rather than assumed. The harm associated with squalid living for the older person, and for others around them, means a non‐interventional approach is likely to contravene the principles of non‐maleficence, beneficence and justice. Adequate assessment of decision‐making capacity is of particular importance. To be ethical, any intervention undertaken must balance benefits, harms, resource utilisation and impact on others.

Evaluating requests for physician-assisted suicide. A survey among German oncologists.

Cancer patients form a notable proportion of requestors for physician-assisted suicide (PAS). This manuscript provides data on German oncologists' views concerning due criteria for the assessment of requests for PAS and quality assurance. The German Society of Haematology and Medical Oncology (DGHO) has conducted a survey among its members to elicit data about practices and views on regulating PAS in March 2021. Descriptive analysis and bivariate logistic regression of quantitative data on socio-demographic and other determinants possibly associated with respondents' views on PAS as well as content analysis of qualitative data were performed. About 57.1% (n=425) of respondents (n=745) indicated that they had been asked for information about PAS by patients. Information about palliative (92.7%; n=651) and psychological care options (85.6%; n=598) was deemed most important in cases of requests for PAS. More than half of the respondents (57.6%; n=429) were in favour of a formal expert assessment of decisional capacityand about 33.4% (n=249) favoured a time span of 14 days between the counselling and prescription of a lethal drug. There was no association between participants who received more requests and a preference for disclosing publicly their willingness to assist with suicide. A majority of respondents requested measures of quality assurance (71.3%; n=531). According to respondents' views, the regulation of PAS will require diligent procedures regarding the assessment of decisional capacity and counselling. The findings suggest that the development of adequate and feasible criteria to assess the quality of practices is an important task.

Geriatric medicine learning objectives and entrustable professional activities in undergraduate medical curricula: a scoping review.

Backgroundentrustable professional activities (EPAs) have become an important component of competency-based medical education. The aim of this study is to evaluate how geriatric medicine learning objectives are addressed by undergraduate medical curricula including EPAs.Methodswe performed a scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines to identify undergraduate medical curricula that include EPAs. A content analysis was conducted to examine how these curricula address the care of older individuals. In addition, we mapped the curricula to 19 geriatric medicine learning objectives identified from the European curriculum of undergraduate medical education.Resultswe found nine curricula, each containing between 4 and 16 core EPAs. In the sections describing the EPAs, three of the nine curricula specify that all core EPAs apply to all age groups including older patients, whereas the remaining six curricula either only refer to older patients in selected EPAs or not at all. Mapping revealed that some geriatric medicine learning objectives are covered by most curricula (e.g. medication use, multidisciplinary team work), whereas others are lacking in the majority (e.g. normal ageing, geriatric assessment, cognitive assessment, nutrition assessment, decision-making capacity assessment, long-term care). Three curricula cover most geriatric learning objectives by using a matrix aligning EPAs with geriatric competencies.Conclusionsgeriatric learning objectives continue to be missing from undergraduate medical curricula, also from those adopting the novel approach of EPAs. However, this review also identified some curricula that might serve as models for how geriatric learning objectives can be successfully covered within future EPA frameworks.

(PO-047) Systematic Assessment of Decisional Capacity in Communication-Impaired Patients With Severe Psychiatric Symptoms

(PO-047) Systematic Assessment of Decisional Capacity in Communication-Impaired Patients With Severe Psychiatric Symptoms

Psychometric Properties of a New Decision-Making Capacity Assessment Tool for People with Substance Use Disorder: The CAT-CAT.

Individuals with substance use disorder (SUD) often present with cognitive impairments, which may impede their ability to make decisions for themselves, including treatment-related decisions. It is therefore important to assess whether individuals with SUD have adequate decision-making capacity. Indeed, there have not been any capacity assessment tools tailored for use with SUD populations that demonstrate adequate psychometric properties or that have the strong ethical foundation that is required of capacity assessment tools. The Compulsory Assessment and Treatment-Capacity Assessment Tool (CAT-CAT) was designed to fill this gap in the literature. Therefore, the aim of this study was to establish the interrater and test-retest reliability, and discriminative validity of the CAT-CAT. The first of this two-part study recruited healthcare professionals in New Zealand and asked them to conduct a capacity assessment on two hypothetical clients. Generally, excellent interrater reliability (ρ= .998 overall) and test-retest reliability (ρ= .996 overall) was found. The CAT-CAT has exhibited reliability that was at least comparable to widely used capacity assessment tools for other pathologies. The second part of this study involved cognitively normal individuals undergoing capacity assessments to investigate the hypothesis that individuals that do not lack capacity will obtain scores significantly higher than 50% in each section of the CAT-CAT. This hypothesis was met with highly significant results. To conclude, preliminary data suggest that the CAT-CAT has excellent reliability and correctly classifies those with capacity.

Assessing Decision-Making Capacity in Patients with Acquired Brain Injury: A Toolkit of Ethical Guidelines

<h3>Research Objectives</h3> To improve provider knowledge of the construct of capacity, clarify existing capacity assessment institutional policies, and provide recommendations for conducting capacity assessment. <h3>Design</h3> A semi-structured interview script and Likert scale survey were developed to investigate stakeholder knowledge and perspectives on decision-making capacity. Constant Comparative Method Analysis was conducted to identify themes across and within stakeholder groups. <h3>Setting</h3> Inpatient Rehabilitation Hospital. <h3>Participants</h3> Multidisciplinary stakeholder representatives, including physicians, investigators, hospital administrators, legal counsel, psychologists, case managers, nurses, social workers, caregivers, and patients (N=21), selected by the investigators using purposive sampling. <h3>Interventions</h3> Not Applicable. <h3>Main Outcome Measures</h3> Four thematic areas (i.e. clinical, research, ethical, legal) identified through application of a data reduction procedure. <h3>Results</h3> Ethically, capacity assessment promotes patients' autonomy, dignity, best interests, well-being, values, preferences and goals of care, and allows patients to maintain the right to refuse treatment. Clinically, stakeholders reported that capacity assessment ensures that patient preferences are considered in the plan of care and that unwanted procedures and treatments are prevented. Legally, capacity assessment ensures there is valid informed consent. For research, capacity assessment helps establish a point person to make decisions and allows for decisions to be made regarding patient participation in research studies. Providers identified challenges including lack of time, lack of familiarity with legal statutes, and uncertainty about the multidimensionality of capacity. Investigators identified challenges including tracking proxy/guardian status long-term and lack of consensus between clinical and research teams. Surrogate decision makers identified challenges including lack of direct contact with patients, family discord, and negative impact of personal emotions. For healthcare systems, challenges included incomplete medical records, high staff turnover, and team miscommunication. A provider toolkit for capacity assessment and monitoring was developed based on challenges identified by stakeholder groups and recommendations were proposed for refining institutional policy and procedures. <h3>Conclusions</h3> While stakeholder groups appear to have a general understanding of the concept of capacity, familiarity with specific procedures and regulations is limited. Institutions should provide supportive resources for providers directly involved in assessment of decision-making capacity. <h3>Author(s) Disclosures</h3> No Disclosures.

The values and rules of capacity assessments

This article advances two views on the role of evaluative judgment in clinical assessments of decision-making capacity. The first is that it is rationally impossible for such assessments to exclude...