Assessment Of Decision-making Capacity Research Articles

Decision-making capacity evaluations: the role of neuropsychological assessment from a multidisciplinary perspective

Decision-making capacity (DMC) in aging adults has become increasingly salient as the number of older adults, life expectancy, and the amount of wealth to be transferred from older generations have all increased. The accurate and reliable determination of older adults’ DMC is a particularly important topic given its implication in legal, financial, and health decisions. Based upon the four-ability DMC model promulgated by Appelbaum and Grisso in the 1980’s, a number of MacArthur Competence Assessment Tools have been developed and widely utilized. However, these tools do not include cognitive testing or other sources of objective data and have limited validity in a medico-legal setting, necessitating additional options for the evaluation of DMC. This is significant from the perspective of the patient because they have a vested interest in accurate and objective assessment of their DMC across domains.Given the disparities in the assessment of DMC, the authors propose, through this debate article, that the evaluation of DMC in the aging adult population utilize a combination of traditional interview and domain specific instruments and neuropsychological testing. To achieve a consensus on the issue, medical experts in a number of fields related to capacity evaluation, including psychiatry, neurology, neuropsychology, and general medicine were consulted and recruited as authors. Experts in Swiss law and ethics were also consulted and provided input.A tendency to focus on a single capacity, and in particular, the ability to consent to medical treatment, arose in the literature. Similarly, there are many instruments purporting to evaluate a single capacity (e.g., consenting to medical treatment, managing finances), while other areas important to the evaluation of DMC received little attention (e.g., activities of daily living, the ability to live independently, to marry, to resist undue influence, and to make a will or advanced care directive). Medical and legal experts in the multidisciplinary group agreed that there is a clear need for more consistency across evaluation of DMC domains and that a combined approach of traditional methods and neuropsychological testing provides a more thorough evaluation and better serves the patient.

The Role of Parental Capacity for Medical Decision-Making in Medical Ethics and the Care of Psychiatrically Ill Youth: Case Report.

Introduction: Parents/legal guardians are medical decision-makers for their minor children. Lack of parental capacity to appreciate the implications of the diagnosis and consequences of refusing recommended treatment may impede pediatric patients from receiving adequate medical care. Child and adolescent psychiatrists (CAPs) need to appreciate the ethical considerations relevant to overriding parental medical decision-making when faced with concerns for medical neglect.Methods: Two de-identified cases illustrate the challenges inherent in clinical and ethical decision-making reflected in concerns for parental capacity for medical decision-making. Key ethical principles are reviewed.Case 1: Treatment of an adolescent with an eating disorder ethically complex due to the legal guardian's inability to adhere with treatment recommendations leading to the patient's recurrent abrupt weight loss.Case 2: Questions of parental decisional capacity amid treatment of an adolescent with schizoaffective disorder raised due to parental mistrust of diagnosis, disagreement with treatment recommendations, and lack of appreciation of the medical severity of the situation with repeated discharges against medical advice and medication nonadherence.Discussion: Decisions to question parental capacity for medical decision-making when risk of imminent harm is low but concern for medical neglect exists are controversial. Systematic review of cases concerning for medical neglect benefits from the assessment of parental decisional capacity, review of ethical standards and principles.Conclusion: Recognition of the importance of parental decision-making capacity as relates to parental autonomy and medical neglect and understanding key ethical principles will enhance the CAP's capacity in medical decision-making when stakes are high and absolute recommendations are lacking.

307 - Exploratory Study on Healthcare Decision-Making Capacity Assessment

Mild cognitive impairment (MCI) and Alzheimer’s Disease (AD) prevalence is expected to continue to increase, due to the population ageing. MCI and AD may impact patients’ decision-making capacities, which should be assessed through the disease course. These medical conditions can affect the various areas of decision-making capacity in different ways. Decision-making capacity in healthcare is particularly relevant among this population. Elders often suffer from multimorbidity and are frequently asked to make healthcare decisions, which can vary from consenting a routine diagnostic procedure to decide receiving highly risk treatments.To assess this capacity in elders with MCI or AD, we developed the Healthcare Decision-Making Capacity Assessment Instrument (IACTD-CS - Instrumento de Avaliação da Capacidade de Tomada de Decisão em Cuidados de Saúde). This project is funded by Portuguese national funding agency for science, research and technology, FCT (SFRH/BD/139344/2018). IACTD-CS was developed based on Appelbaum and Grisso four abilities model, literature review and review of international assessment instruments. After IACTD-CS first version development, an exploratory study with focus groups was conducted. This study included focus groups with healthcare professionals and nursing homes’ professionals.The focus groups main goals were: 1) understand the participants perception regarding healthcare decision-making capacity, 2) distinguish relevant aspects of decision-making, 3) discuss the abilities and items included in IACTD-CS and 4) identify new aspects or items to be added to IACTD-CS. A content analysis of the focus groups results, with resource to MAXQDA, was conducted afterwards. This exploratory study allowed to identify professionals’ perceptions on healthcare decision-making and its results were a significant contribute to IACTD-CS development. The proposed communication aims to describe the methodology used and present the results of content analysis.

Is this person with dementia (currently) competent to request euthanasia? A complicated and underexplored question

In euthanasia and/or assisted suicide (EAS) of persons with dementia, the controversy has mostly focused on decisionally incapable persons with very advanced dementia for whom the procedure must be based...

Assessment of patient decision-making capacity in the context of voluntary euthanasia for psychic suffering caused by psychiatric disorders: a qualitative study of approaches among Belgian physicians

ObjectiveIn Belgium, people with an incurable psychiatric disorder can file a request for euthanasia claiming unbearable psychic suffering. For the request to be accepted, it has to meet stringent legal...

Decision Making by People With Aphasia: A Comparison of Linguistic and Nonlinguistic Measures.

Purpose Decision making involves multiple cognitive and linguistic processes. The extent to which these processes are involved depends, in part, on the conditions under which decision making is assessed. Because people with aphasia (PWA) have impaired language abilities and may also present with cognitive deficits, they may have difficulty during decision-making tasks. Yet little research exists on the decision-making abilities of PWA. Thus, the purposes of this study were to investigate the performance of PWA on linguistic and nonlinguistic decision-making measures and to explore the relationship between decision making and cognitive test performance. Method A quasi-experimental design was used to compare the performance of PWA (n = 16) and age- and education-matched control participants (n = 16) on three decision-making tasks: Making a Decision subtest from the Functional Assessment of Verbal Reasoning and Executive Strategies (linguistic decision-making task), Iowa Gambling Task (nonlinguistic decision-making task with ambiguity), and Game of Dice Task (nonlinguistic decision-making task without ambiguity). Participants also completed assessments of language, working memory, and executive functions. Scores on the three decision-making tasks were compared between groups, and cognitive influences on decision-making performance were examined using correlation analyses. Results PWA differed significantly from control participants on linguistic decision making, particularly when required to verbalize their rationale for making their decision. PWA and control participants did not differ significantly on measures of nonlinguistic decision making. Performance on multiple cognitive measures was correlated with performance on the linguistic reasoning task, as well as one of the nonlinguistic tasks (Game of Dice Task). Conclusions Decision-making tasks that are heavily dependent on language, such as those used in capacity assessments, may disadvantage PWA. Assessments of decision-making capacity should include communication supports for people with acquired communication disorders; further investigation in the areas of decision making and aphasia is needed.

An Audit of Documentation relating to Decision-Making Capacity at an Old Age Psychiatric Hospital in England

<p>The Mental Capacity Act 2005 (MCA) guides clinicians in England and Wales in how to support patients to make a capacitous decision. Documentation of patients’ capacity is mandatory for certain decisions in psychiatric hospitals so as to evidence the use of the MCA guidance. Given the importance of decisions such as where to live and what medication to take, the quality of clinician interview and documentation is important to monitor.</p><p><br />Method: The quality and quantity of decision-making capacity (DMC) documentation was reviewed in a psychiatric hospital in England for older adults. The clinical records of 49 discharged patients were examined retrospectively. All DMC documentation found was compared with existing legal guidance on capacity assessment.</p><p><br />Results: 46/58 DMC documents were found to be insufficient. There was little evidence of what information had been given to patients to enable autonomous decision making, what actions had been undertaken to optimise capacity and what alternative decision options were presented.</p><p><br />Conclusions: Consideration should be given by hospital managers to support DMC assessment by staff. Further reflection is needed on the part of regulators regarding the optimum DMC documentation standard, particularly regarding physical health medication for psychiatric inpatients. Guidance and training for all staff involved in the assessment and documentation of DMC should be made available.</p>

Decision-making capacity assessment for confused patients in a regional hospital: A before and after study.

Clinicians are challenged to decide when and how to conduct decision-making capacity assessment and guardianship applications for confused hospitalised older patients. This study aimed to understand the characteristics of confused hospitalised older patients who require decision-making capacity assessment and guardianship applications and to determine the impact of a locally introduced capacity testing procedure on the conduct of decision-making capacity assessment and guardianship application in a regional hospital setting. Before and after study. Regional New South Wales hospital. Twenty-four confused hospitalised older patients who had decision-making capacity assessment during November 2014-April 2015 and November 2015-April 2016. The impact of a standardised capacity testing procedure on the conduct of decision-making capacity assessment. After capacity testing procedure implementation, there were significant improvements in the number of multidisciplinary team meetings, documentation of decision-making capacity assessment process and length of stay. The majority of patients who required guardianship application was aged over 70years, had a medical history of dementia, >20days of acute hospital admission and had no evidence of future care-planning. Implementation of capacity testing procedure is likely to have contributed to the positive changes in the conduct of decision-making capacity assessment and guardianship application process for confused hospitalised older patients. This study provides some evidence of decision-making capacity assessment process gaps; and indicates clinical and demographic characteristics of confused hospitalised older patients who might require decision-making capacity assessment and guardianship applications. The evidence of lack of appropriate future care-planning for ageing patients and increasing hospital admissions of confused hospitalised older patients presents future challenges in rural health.

Developing occupational therapists' capabilities for decision-making capacity assessments: how does asupport role facilitate workplace learning?

IntroductionHealthcare practitioners are required to develop capabilities in an effective and efficient manner. Yet, developing capabilities in healthcare settings can be challenging due to the unpredictable nature of practice and increasing workloads. Unsurprisingly, healthcare practitioner development is often situated outside of practice, for example in formal teaching sessions. Supporting practitioners to develop capabilities through engagement with day-to-day practice, whilst advantageous in terms of authenticity and being highly valued, remains a key challenge for healthcare educators. This qualitative interview study aimed to explain, from the learner’s perspective, how a dedicated support role develops occupational therapists’ capability to contribute to decision-making capacity assessments.MethodsIndividual semi-structured interviews were conducted with a purposive sample of 12 occupational therapists. Informed by workplace learning theory, interview transcripts were analyzed using thematic analysis process.ResultsParticipants provided rich descriptions of how they developed in their capability to engage in decision-making capacity assessments. Participants reported that their learning was facilitated by the dedicated support role in three key ways: 1) structuring a journey of learning, 2) providing tailored guidance, and 3) fostering a supportive learning environment.DiscussionParticipants valued the authentic workplace learning opportunities afforded by the dedicated support role. Findings suggest that capabilities, such as decision-making capacity assessment, can be developed through practice when enriched by a dedicated support role. However, further research examining the sustainability and transferability of this model and its application to other capabilities are warranted.

General practitioners and decision-making capacity assessment: the experiences and educational needs of New Zealand general practitioners

Assessing decision-making capacity to health care is within the scope of practice for all doctors, yet the experience of GPs in this area is unknown. To explore the experiences, perspectives, approaches and challenges for GPs in New Zealand when conducting decision-making capacity assessments. Qualitative study design comprising individual in-depth semi-structured interviews conducted with a convenience sample of GPs. Interview transcripts were transcribed verbatim and analysed using a thematic analysis approach. Twelve participants were recruited. The following themes emerged: (i) GPs' roles and responsibilities in decision-making capacity assessments; (ii) GPs lack formal training, knowledge, and confidence in decision-making capacity assessments; (iii) the legal interface of decision-making capacity assessments; (iv) GPs' relationships with specialists and the resulting impact on their confidence in decision-making capacity assessments; and (v) opportunities to improve GPs' knowledge and confidence in decision-making capacity assessments. GPs take responsibility for decision-making capacity assessments; however, assessments can be complex. There is a need to develop specific curriculum and training resources for GPs to improve their clinical skills and legal knowledge in decision-making capacity assessments.

Pilot Study of an Online Self-Directed Learning Module for Medical Decision-Making Capacity.

This study assessed the impact of an online, self-directed learning module on medical student knowledge and attitudes regarding decision-making capacity. The authors created a 15-min didactic video on decision-making capacity and sorted medical students on the psychiatry clerkship to teaching as usual or teaching as usual plus watching the video. The authors assessed student knowledge about and attitudes toward decisional capacity assessment using a pre/posttest design. Thirty-eight students completed the study (24% of all psychiatry clerkship students in one academic year). Students who watched the video (n = 14) achieved higher scores on the posttest compared with students who did not watch the video (n = 24) (90% vs 84% on general knowledge and case examples), though this difference was small and not statistically significant. The degree of improvement from pretest to posttest was higher for students who watched the video but did not reach statistical significance. Overall, students found the online teaching module to be a helpful augmentation strategy for learning decisional capacity assessment. The authors incorporated student feedback and additional review to create an enhanced video, which is available on ADMSEP's Clinical Simulation Initiative website.

Understanding the Breadth and Depth of C-L Psychiatry: Decisional Capacity Assessments

Understanding the Breadth and Depth of C-L Psychiatry: Decisional Capacity Assessments

The U-ARE Protocol: A Pragmatic Approach to Decisional Capacity Assessment for Clinical Research.

With increased longevity and growth in the number of older adults comes rising rates of individuals with cognitive impairment and dementia. The expansion of this population has important implications for research on aging and dementia syndromes, namely increased enrollment of older individuals in clinical research. Ethical prerogatives, as well as historical underrepresentation of persons with dementia in research studies due to the perceived burden of traditional decisional capacity evaluations, necessitates the development of pragmatic approaches to ascertain decisional abilities in research settings. We outline a protocol used in the Wisconsin Alzheimer's Disease Research Center (ADRC) that adopts a stepped approach to the evaluation of decisional capacity meant to maximize study visit efficiency while preserving participant safety and autonomy. The protocol specifies the structure of the consent process and incorporates a brief semi-structured interview based on Appelbaum & Grisso's theoretical model for evaluating a patient's decisional capacity to provide informed consent to participate in research. This protocol is easily implemented in a research study visit and is designed to minimize participant burden and ensure reliable assessment of decisional capacity in older adults across a wide range of research protocols. The protocol emphasizes capacity optimization, using memory aids and other compensatory strategies to preserve participant autonomy while protecting welfare.

Assessing patients decision-making capacity in the hospital setting: A literature review.

Decision-making capacity assessments for hospital settings are challenging as it is dominated by the ethical and legal principles of maintaining autonomy and protection. Health clinicians, especially in rural areas, are challenged with a lack of a standardised processes and pathways for decision-making capacity assessment. A literature review was conducted to determine what measurement tools clinicians are utilising in the hospital setting for decision-making capacity assessment and how decisions relating to consent to treatment, independent living and finances are made. Literature review. A search of MEDLINE, EMBASE and PsycINFO databases from January 2006 to April 2019 was conducted for peer-reviewed articles to determine how decision-making capacity assessments are conducted and the tools clinicians are utilising in the hospital setting. Five main themes were identified from this review: (a) domains of capacity; (b) capacity assessment; (c) capacity assessment instruments; (d) who performs capacity assessment; and (e) challenges and limitations to capacity assessment in the hospital setting. Currently, there is no gold standard for capacity assessment. This review shows that there is currently a lack of a uniform approach or a singular test to determine capacity. It is proposed that a multidisciplinary approach to decision-making capacity assessment could be an effective model in the hospital setting, especially in rural health due to limited access to aged care specialists. It is important that clinicians receive ongoing training in decision-making capacity assessment and further research is recommended in this specialised area of practice.

Occupational therapy and decision-making capacity assessment: A survey of practice in Ireland.

The aim of the study was to explore occupational therapy practices regarding decision-making capacity assessment and to examine factors that impact on engagement in this area. Occupational therapists in Ireland were invited to participate in a cross-sectional online questionnaire. One hundred and seventy-two occupational therapists responded. 65.77% (n=98) reported that occupational therapy plays an important role in capacity assessment in their workplace. Occupational therapists most frequently contributed to decision-making capacity assessment for independent living (79.19%, n=118), driving (45.89%, n=67) and financial management (44.44%, n=64). Many participants reported that this is more difficult than other aspects of practice and that they are not satisfied with decision-making capacity assessment proceduresin their workplace. A large majority (91.86%, n=113) reported occupational therapists would benefit from additional training and practice guidelines in the area of decision-making capacity assessment. The study confirms that occupational therapists have a role to play in the multi-disciplinary assessment of decision-making capacity. The results of the survey suggest that decision-making capacity assessment is complex and challenging. Factors such as confidence, education and training impact on engagement with this area of practice. There is a need to develop education resources and guidelines for occupational therapists.

Neurological Deficits in Stroke Patients that May Impede the Capacity to Provide Informed Consent for Endovascular Treatment Trials

BackgroundWe assessed the occurrence of neurological deficits that may impede the capacity to provide consent for trial participation in patients with an acute stroke, who are eligible for endovascular treatment (EVT). MethodsWe used data from the Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective observational cohort study. We included 1526 patients with an anterior large vessel occlusion, undergoing EVT between March 2014 and June 2016. We based our assessment of decision-making capacity for trial participation on neurological symptoms influencing conditions concerning informed consent as stated in the declaration of Helsinki. We formulated a strict and a mild capacity assessment rule, using 2 different cut points in item scores on the National Institutes of Health Stroke Scale (NIHSS). ResultsApplying the strict and mild rule, respectively 1469 (96%) and 1220 (80%) patients deemed not capable of decision-making for trial participation on admission, and 1077 (79%) and 825 (60%) patients at 24-48 hours after admission. Highest frequencies of predefined scores suggesting incapacity based on the strict rule were on the NIHSS items “Level of Consciousness Questions” (59%), "Best Gaze" (68%), and “Best Language” (58%). Patients who were considered incapable were older (median 71 versus 66 years, P = .043), had higher NIHSS scores (median 16 versus 8, P < .001), and had more often left hemisphere strokes (55% versus 28%, P < .001) than patients who were presumably capable. ConclusionsIn the majority of patients with an anterior circulation stroke who are eligible for EVT, neurological deficits are present that may impede the capacity to provide informed consent for trial participation.

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).