Assessment Of Decision-making Capacity Research Articles

Flexibility and Innovation in Decisional Capacity Assessment.

Since the 1980s, the four skills criteria have become the most widely accepted mechanism for the assessment of decisional capacity in the United States. These criteria emerged in response to the paternalistic approach to clinical decision-making that had been widely accepted in an earlier era and offered a means of ensuring that physicians honored the rights of capacitated patients to make their own medical decisions. Unfortunately, the criteria are now applied to situations for which they are not suited and in a manner that is often highly inflexible. In an article in this issue of The Journal, Matthew Dernbach and colleagues describe one potential scenario that requires a flexible approach to using the four skills model: situations in which a patient stands at high risk of losing decisional capacity in the near future. Using Dernbach et al. as a starting point, this article offers specific ways in which the four skills model can be improved upon or augmented without abandoning its key principles. These advances include adjusting to empirical evidence, re-emphasizing the importance of autonomy maximization and restorability, and embracing novel conceptual and technological innovations.

Characteristics, Barriers, and Facilitators of Virtual Decision-Making Capacity Assessments During the COVID-19 Pandemic: Online Survey.

With a growing older adult population, the number of persons with dementia is expected to rise. Consequently, the number of persons needing decision-making capacity assessments (DMCA) will increase. The COVID-19 pandemic has impacted how we deliver patient care including DMCAs with a much more rapid shift to virtual assessments. Virtual DMCAs offer patients and health care professionals distinct advantages over in-person delivery by improving reach, access, and timely provision of health care. However, questions have arisen as to whether DMCAs can be effectively conducted virtually. This study aimed to determine the characteristics, barriers, and facilitators of conducting virtual DMCA during the COVID-19 pandemic. We conducted an online survey among health care providers who perform DMCAs in Alberta from March 2022 to February 2023. The survey consisted of 25 questions on demographics, preferences, and experience in conducting DMCAs virtually, and risks and barriers to doing virtual DMCAs. The data were analyzed using descriptive statistics. There were 31 respondents with a mean age of 51.1 (SD 12.7) years. The respondents consisted of physicians (45.2%, 14/31), occupational therapists (29%, 9/31), and social workers (16.1%, 5/31), with a majority (93.6%, 29/31) based in Edmonton. The mean number of years of experience conducting DMCAs was 12.3 (SD 10.7), with a median of 8 DMCAs (IQR 18.5) conducted per year. Most respondents conduct capacity interviews, with a majority (55.2%, 16/29) being associated primarily with acute care services. Furthermore, 54.8% (17/31) were interested in conducting DMCAs virtually; however, only 25.8% (8/31) had administered DMCAs virtually. Barriers and facilitators to virtual DMCAs relate to patients' characteristics and environment (such as communication difficulties, hearing or visual impairment, language barriers, ease of use of technology, or cognitive impairment), technology and technical support (need for technical support in both the client's and assessor's sides, the unreliability of internet connection in rural settings, and the availability of high-fidelity equipment), and assessors' ability to perform DMCA's virtually (ability to observe body language, interact with the client physically when needed, and build rapport can all be affected when conducting a DMCA virtually). In terms of implications for clinical practice, it is recommended that the patient or caregiver be familiar with technology, have a stable internet connection, use a private room, not be recorded, use a standardized assessment template, and have a backup plan in case of technical difficulties. Conducting DMCAs virtually is a relatively infrequent undertaking. Barriers and facilitators to adequate assessment need to be addressed given that virtual assessments are time-saving and expand reach.

Predictors of Decisional Capacity in Alzheimer's Disease Biomarker Test Candidates.

Deciding to learn one's Alzheimer's disease (AD) biomarker status is a high-stakes endeavor that requires comprehending and deliberating about complex and nuanced information. Assessing capacity to consent to AD biomarker testing and disclosure is further complicated when candidates have cognitive impairment and present with family care partners. The objective of this analysis was to identify predictors of decisional capacity for an amyloid Positron Emission Tomography (PET) disclosure study among persons with mild cognitive impairment (MCI) and their family care partners. This analysis used an analytical correlational design, using baseline data from a randomized controlled trial of amyloid PET results disclosure. Simple linear regression was used to examine predictors of decisional capacity. Focusing on persons with MCI, the predictor variables of interest were sociodemographic characteristics, level of knowledge of MCI/AD, global cognition, and neuropsychological tests of language and executive functioning. Dyadic analyses were conducted with data from 82 dyads of persons with MCI and care providers using the Actor Partner Interdependence Model to assess for presence of actor and partner effects among key variables. Capacity to consent scores demonstrated sufficient capacity for all participants to consent to the study. For persons with MCI, lower age, higher mental status scores, MCI/AD knowledge scores, and better performance on measures of language and executive functioning were predictors of decisional capacity. The model revealed positive actor relations for MCI/AD knowledge with decisional capacity for both persons with MCI and family care partners and negative partner relationships for family care partners MCI/AD knowledge with the decisional capacity of persons with MCI. Assessment of decisional capacity is imperative when considering participation in AD research, including studies with high-stakes procedures like biomarker results disclosure. Our findings highlight that not only do individual characteristics put persons with MCI at risk for lower decisional capacity, but dyadic effects from family care partners may also be present.

Qualitative Research on the Topic of End-of-Life Care and a Palliative Care Approach in Persons with Severe and Persistent Mental Illness: Reflections and Take-Home Messages.

Persons experiencing severe and persistent mental illness (SPMI) constitute a small but vulnerable population in healthcare and society. Nonetheless, it is advocated to involve people with SPMI in research to improve how care is provided to them. However, qualitative research with this population is challenging due to several factors, including (self-) stigma, assessment of decision-making capacity, reduced communication skills, and the (perceived) risk of adverse events, resulting in relative scarcity in academic interest and scientific publications. In this contribution, the authors share their practical experiences in conducting qualitative research among this group of people, specifically focusing on sensitive topics including end-of-life care and palliative care approaches. Both beneficial and challenging factors encountered across the different research stages are systematically delineated and reflected upon. Qualitative research involving persons with SPMI necessitates a different perspective on methodology and requires specific competencies from researchers. As might be expected, adequate preparation, thorough follow-up, and support for all involved are critical success factors. Additionally, however, it may also require adopting a somewhat unconventional approach to qualitative interviewing, encouraging creativity and ethical reflection as guiding principles. Exploring alternative methodologies and non-conventional engagement in research could provide a much-needed voice to individuals who are currently unrepresented in the research discourse.

Capacity assessment for euthanasia in dementia: A qualitative study of 60 Dutch cases.

The number of patients with dementia who are granted euthanasia or assisted suicide (EAS) increases yearly in the Netherlands. By law, patients need to be decisionally competent or have an advance directive. Assessment of decisional capacity is challenging as dementia progressively affects cognitive performance. We aimed to assess qualitatively which factors, and how, influence the judgment of decisional capacity in EAS cases with dementia. We performed a qualitative study of 60 dementia EAS case summaries published by the Dutch regional euthanasia review committees between 2012 and 2021. Included reports were evaluated using the grounded theory approach. All quotes related to decisional capacity were coded independently by two researchers and compared in an iterative process to formulate an overarching framework on the assessment of decisional capacity. We selected 20 patients who had an advance directive and were judged to be decisionally compromised, as well as a selection of 40 EAS cases judged to be decisionally competent, half of which also had an advance directive (purposive sampling). Decisional capacity was present in every case report. Predefined, external criteria were rarely described explicitly, but physicians indirectly referred to the (cognitive) criteria set by Appelbaum and Grisso. Whether the thresholds for these dimensional criteria were met was influenced by six supporting factors (level of communication, psychiatric comorbidity, personality, presence of an advance directive, consistency of the request, and, finally, the patient-physician relationship) that also directly contributed to the judgment of capacity. The involved physicians and executed investigations were the two contextual factors providing a background. Decisional capacity regarding euthanasia is a multidimensional construct, often implicitly assessed and influenced by supporting and contextual factors. The subjectivity of the final judgment poses ethical and legal issues and argues for continuous quality improvement processes.

A Roadmap for Assisted Decision-Making Capacity Assessment: Developing a Guide for Occupational Therapists in an Acute Setting

Abstract Background The Assisted Decision-Making (Capacity) Act (ADMA) has been in effect since April 2023. Under the ADMA, Occupational Therapists (OTs) are a prescribed class of healthcare professionals capable of assessing a person's decision-making capacity (DMC). OTs must adapt their practice to comply with the new legislation. OTs in an acute hospital reported poor understanding and low confidence using the ADMA. The aims were to enhance OTs knowledge and understanding of the ADMA, how to adapt their practice and to improve OTs documentation of DMC assessment in healthcare records. Methods OTs were surveyed to ascertain their current understanding of the ADMA, confidence using its guiding principles and to identify specific learning needs to address in education sessions. A multi-modal approach including tailored in-service education and 1:1 coaching sessions enhanced OTs knowledge and confidence in using the ADMA. Template documents were developed to guide OTs documentation of DMC assessment in healthcare records. A post-education survey was administered to determine if education sessions and guidance documents had benefitted OTs. Results Knowledge in using the ADMA improved post-education. 67% reported their understanding as ‘good’ compared to 14% pre-education. 0% reported knowledge as 'poor' or 'very poor' post-education compared to 24%. Confidence improved with 8% reporting they feel ‘very comfortable’ assessing DMC post-education compared with 0%. 0% reported 'not at all comfortable' post-education compared to 18%. 100% of OTs who availed of 1:1 coaching reported benefitting from mentoring. 100% of OTs reported guidance documents benefit their practice. 85% reported the education met their expectations. Conclusion OTs are continuing to learn how to use the ADMA in their practice. OTs require ongoing education and training to improve their skills in DMC assessment and documentation of this process. Changing practice in accordance with the ADMA may take time as this change needs to occur at a national and local level.

How to engage people experiencing severe and persistent mental illness in qualitative research: a descriptive and reflexive analysis

ABSTRACT Purpose People experiencing severe and persistent mental illness (SPMI) constitute a vulnerable population within the healthcare system and society. Similarly in research, there are perceived challenges in qualitative studies with this population due to several factors, including (self-)stigma, assessment of decision-making capacity, reduced communication skills and the (perceived) risk of adverse events, resulting in its scarcity. Methods In this contribution, the authors share their practical experiences of conducting qualitative research among this group of people, specifically addressing sensitive topics such as ongoing intensive care within a mental health facility and end-of-life care. Both advantageous and challenging factors that were encountered during different research phases -the preliminary phase, conducting the interviews and the concluding phase are systematically outlined. Results The findings highlight conscientious conducted in accordance with established standards, albeit with a deliberate embrace of non-conventional approaches while advocating an attitude of critical, ethical reflection. Adequate preparation, fostering creative approaches and adaptable communication to establish rapport and authentic interaction, thorough follow-up and support for all involved are equally crucial to sustain effective qualitative research. Conclusion Engaging people experiencing SPMI in research is as a cornerstone for empowerment—a feasible aspiration. Their inclusion in research endeavours is imperative, because first-hand narratives are key in shaping comprehensive and compassionate care practices for those experiencing severe and persistent mental illness.

FC28: Medical Assistance in Dying and assessment of decisional capacity in dementia: the Dutch Perspective!

Background: The Netherlands allows Medical Assistance in Dying (MAID) based on a diagnosis of dementia under strict legal conditions. The number of dementia MAID cases gradually increase every year up to 288 cases in 2022; 282 were decisionally competent and 6 were decisionally incompetent. In decisionally incompetent patients MAID has been granted based on a written advance directive. To assess decisional competence the Dutch euthanasia review committees, refer to criteria of Appelbaum and Grisso.Objectives: To examine which factors, and how, influence the judgment of decisional competence for MAID requests of patients with dementia.Methods: A qualitative analysis was performed of 60 dementia MAID case summaries as published online by the Dutch euthanasia review committees between 2012 and 2021: 20 cases had an advance directive and were decisionally compromised at time of MAID, 40 patients were decisionally competent at time of MAID, of which 20 also had an advance directive (purposive sampling). Two researchers independently coded all text related to decisional competence (thematic analysis). A theoretical framework about the assessment of decisional competence was developed.Results: The four cognitive criteria of Appelbaum and Grisso were dimensional, and cut-off points were influenced by six factors that also directly impacted on competence assessment, i.e. level of communication, psychiatric comorbidity, personality, presence of an advance directive, consistency of the request, and the patient-physician relationship.Conclusions: The framework illustrates the complex multidimensional nature of assessment of decisional competence in dementia patients requesting MAID. Subjectivity of the final judgement poses ethical and legal issues and argues for continuous quality improvement processes.

Transcultural Psychiatry in Medical Ethics: Assessing Decision-Making Capacity within the Lens of an East African Refugee.

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

Examining the approaches used to assess decision-making capacity in healthcare practice.

To examine the approaches that are being used in New Zealand when conducting decision-making capacity (DMC) assessments among the healthcare professionals that commonly conduct DMC assessments and those that are involved in, but do not conduct, the assessments. An online quantitative survey was conducted, lasting 10 minutes, including a mix of closed- and open-ended questions. The survey garnered responses from a total of n=78 participants. Bedside cognitive tests were found to be the most commonly reported tool used to assess DMC among those conducting and those contributing to DMC assessments. Nearly a third (31.9%) of participants conducting DMC assessments used a structured clinical interview as one of their most common approaches while 27.5% of this same group reported not being aware of this approach. It was reported by both those conducting and those contributing to DMC assessments that the current standards lack quality and consistency, with partial capacity being poorly understood and identified, and supported decision making often being overlooked for substitute decision making. Current approaches to DMC assessment lack standardisation and consistency, with assessment approaches being widely varied. This article serves as a call for the development of and adherence to nationally recognised standards for DMC assessments.

It’s a spiral staircase, not just two steps: An iterative approach to assessing patient capacity for medical decision-making

The assessment of medical decision-making capacity as part of the process of clinical informed consent has been considered a bioethical housekeeping matter for decades. Yet in practice, the reality bears little resemblance to what is described in the medical literature and professed in medical education. Most literature on informed consent refers to medical decision-making capacity as a precondition to the consent process. That is, a clinician must first determine if a patient has capacity, and only then may the clinician engage with the patient for the rest of informed consent. The problem with this two-step approach is that it makes no sense in actual practice. We see the assessment of medical decision-making capacity within the process of informed consent as a spiral staircase, not just two steps, requiring clinicians to keep circling up and around, making progress, until they get to where they need to be: 1. Clinicians start with a general presumption of capacity for most adults, sometimes having a provisional appraisal of capacity based on prior patient contact. 2. Then, they begin performing informed consent for the current situation and intervention options. 3. Next, they must reassess capacity during this process. 4. After that, they continue with informed consent. 5. If capacity is not yet clear, they repeat 1–4.

Assessment of Decision-Making Capacity in 97 Hospitalized Patients With Cancer: A Call for Standardization

BackgroundHospitalized patients with cancer face pivotal decisions that will affect their cancer care trajectory and quality of life, but frequently lack Decision Making Capacity (DMC). Standardization is conspicuously missing for inpatient oncology teams and for Consultation-Liaison psychiatrists performing DMC assessments for patients with cancer. This study sought to characterize a single institutional experience of psychiatric consultations to assess DMC. MethodsWe conducted a retrospective chart review of ninety-seven consecutive psychiatric consultations for DMC from 2017-2019. Demographic, hospital-based, and psychiatry consult differences were assessed based on the reasons for DMC evaluation (uncertainty, patient refusal, emergency) and whether patients had decisional capacity. ResultsOut of 97 consultations, 56 (59%) hospitalized patients with cancer were unable to demonstrate capacity. Consultations came from medical services almost exclusively. Only 5% of primary teams documented their own DMC evaluation. Only 22% of DMC evaluation by C-L psychiatrists documented four determinates of DMC. Few commented on reversibility or tenuousness of DMC, and the identification of agents/surrogates; however, psychiatry consultants were more likely to follow up on patients without DMC. One-third of patients died in the hospital and two-thirds of patients were deceased three months after the consult. ConclusionsGiven the substantial heterogeneity in the documentation of DMC evaluations in this retrospective chart review, we call for more rigor and standardization in documentation of DMC evaluations.

Age-bias in assessments of medical decision-making capacity: a cross-sectional experimental vignette study

Accurate assessments about medical decision-making capacity (DMC) are vital but could be susceptible to age-bias. We examined if client age impacts on DMC likelihood assessment. One hundred and forty-seven adults were trained to identify four cognitive abilities (i.e., understanding, appreciation, reasoning, expression). Six experimental vignettes described a person making a diabetes treatment decision with systematic variation of client age (unspecified, 50-, or 95-years-old) and abilities (demonstrated vs uncertain). The dependent variable was DMC likelihood. Standardised tests of explicit (Kogan’s Attitudes Toward Old People scale) and implicit age-bias (IAT) were administered. There was a statistically significant effect of abilities on DMC likelihood. DMC was judged more likely when cognitive abilities were demonstrated. There were no other significant effects. Age-bias, measured implicitly and explicitly, did not influence DMC likelihood. Contrary to the hypothesis, DMC likelihood was unaffected by client age. This suggests that training can mitigate age-bias in simulated clinical DMC evaluation.

Capacity Assessment Instrument – Health: Pilot Study of a New Tool for Adults with Dementia

ABSTRACT Objectives This research comprises a pilot study of the CAI-Health, a new tool for the evaluation of decision-making capacity in healthcare. It aims to analyze the instrument’s indicators of reliability and internal validity to conclude its final version. Methods A total of 89 participants were included, of which 22 had Alzheimer’s Disease; 32 had mild cognitive impairment, and 35 were controls. Cronbach’s alpha and the intercorrelation matrix were used as indicators of reliability and internal validity as well as to identify items for elimination. Repeated-measures ANOVA allowed for the analysis of differences between the vignettes that comprise CAI-Health. Results The internal consistency results were acceptable, and no items were proposed for elimination. A repeated-measures ANOVA revealed that the vignettes were unexpectedly equivalent. Despite the procedures used to develop clinical vignettes with increased levels of complexity in assessing decision-making capacity, this study showed no differences in the vignettes’ level of demand. Conclusions The extensive application of CAI-Health compromises its clinical usefulness and viability. To reduce its length while maintaining a thorough assessment of each ability, it was decided to eliminate two vignettes and retain all interview items. The final version of the CAI-Health comprises a clinical vignette and a capacity interview. Clinical implications CAI-Health was designed for the assessment of medical decision-making capacity in older adults.

Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis.

Decision-making capacity (DMC) among psychiatric inpatients is a pivotal clinical concern. A review by Okai et al. (2007) suggested that most psychiatric inpatients have DMC for treatment, and its assessment is reliable. Nevertheless, the high heterogeneity and mixed results from other studies mean there is considerable uncertainty around this topic. This study aimed to update Okai's research by conducting a systematic review with meta-analysis to address heterogeneity. We performed a systematic search across four databases, yielding 5351 results. We extracted data from 20 eligible studies on adult psychiatric inpatients, covering DMC assessments from 2006 to May 2022. A meta-analysis was conducted on 11 papers, and a quality assessment was performed. The study protocol was registered on PROSPERO (ID: CRD42022330074). The proportion of patients with DMC for treatment varied widely based on treatment setting, the specific decision and assessment methods. Reliable capacity assessment was feasible. The Mini-Mental State Examination (MMSE), Global Assessment of Function (GAF), and Brief Psychiatric Rating Scale (BPRS) predicted clinical judgments of capacity. Schizophrenia and bipolar mania were linked to the highest incapacity rates, while depression and anxiety symptoms were associated with better capacity and insight. Unemployment was the only sociodemographic factor correlated with incapacity. Assessing mental capacity is replicable, with most psychiatric inpatients able to make treatment decisions. However, this capacity varies with admission stage, formal status (involuntary or voluntary), and information provided. The severity of psychopathology is linked to mental capacity, though detailed psychopathological data are limited.

Using Conversation Analysis to explore assessments of decision-making capacity in a hospital setting.

Healthcare professionals (HCPs) have a responsibility to conduct assessments of decision-making capacity that comply with the Mental Capacity Act 2005 (MCA). Current best-practice guidance, such as the Mental Capacity Code of Practice and National Institute for Health and Care Excellence decision-making and mental capacity guidance, does not stipulate how to accomplish this in practice, for example, what questions should be asked, how options and information should be provided. In addition, HCPs struggle to assess the capacity of individuals with communication difficulties. This study was a service evaluation that aimed to objectively analyse, using Conversation Analysis (CA), how real-life capacity assessments were conducted in a hospital setting with patients with acquired brain injury (ABI)-related communication difficulties. A second aim was to establish the feasibility of using CA to advance knowledge of the conduct of capacity assessment. Four naturally occurring capacity assessments were video-recorded. Recordings involved speech and language therapists, occupational therapists, neuropsychologists and patients with communication difficulties as a result of ABI. The methods and findings of CA were used to investigate the interactional behaviours of HCPs and patients during assessments of decision-making capacity. The analysis was informed by our knowledge of the MCA best practice guidance. An overall structure of capacity assessment that enacted some of the best-practice MCA guidance was identified in one recording, consisting of six phases: (i) opening, (ii) preparation, (iii) option-listing, (iv) test, (v) decision, and (vi) close. The preparation phase consisted of two sub-components: information gathering and information giving. Variation from this structure was observed across the dataset, notably in the way in which options were (or were not) presented. CA is a feasible empirical method for exploring the structure and conduct of capacity assessments. CA identifies and provides ways of describing interactional behaviours that align with and diverge from best-practice MCA guidance. Future CA studies including a wider range of health and social care professionals and patients have the potential to inform evidence based training for HCPs who conduct assessments of decision-making capacity. What is already known on this subject The Mental Capacity Act (MCA) is poorly implemented in practice. Healthcare professionals (HCPs) find it challenging to assess the decision-making capacity of individuals with communication difficulties, and people with communication difficulties are often excluded from or insufficiently supported during capacity assessment. Research is limited to self-report methods. Observational studies of capacity assessment are required. What this study adds This is the first study to use Conversation Analysis (CA) to explore how capacity assessments are conducted in a hospital setting by HCPs with people with communication difficulties as a result of acquired brain injury. One video-recorded capacity assessment was structured in six phases that aligned with best practice MCA guidance. However, other capacity assessments deviated from this structure. One phase, option listing, varied in practice and options were not always presented. What are the clinical implications of this work? CA revealed interactional behaviours that align with and diverge from best-practice MCA guidance. Future CA studies are warranted to inform training for health and social care professionals who conduct capacity assessments.

Can We Be Creative with Communication? Assessing Decision-Making Capacity in an Adult with Selective Mutism.

Selective mutism is an anxiety disorder in which an individual is unable to speak in certain social situations though may speak normally in other settings (Hua & Major, 2016). Selective mutism in adults is rare, though people with this condition might have other methods of communicating their needs outside of verbal communication. Healthcare professionals rely on a patient's ability to communicate to establish if they have decision-making capacity. This commentary responds to a case of a young adult patient with selective mutism and social anxieties that significantly limited his ability to communicate with anyone in the healthcare team. This required a creative, patient-centered approach to engage in meaningful communication.

Local Urban Policy Councils: Assessing Decision-Making Capacity in National Metropolises

Resumo Diferentemente das áreas da saúde, educação e assistência social, os Conselhos Locais de Política Urbana permanecem como objetos pouco explorados pelo campo. Tais instâncias participativas possuem papel central na promoção do direito à cidade, contrapondo-se ao padrão histórico de urbanização desigual brasileiro. Neste contexto, a experiência de institucionalização de tais conselhos no Brasil e sua capacidade decisória permanecem por serem investigadas. O objetivo do presente artigo é avaliar o impacto de variáveis de desenho institucional e de ciclo político em sua capacidade decisória, a partir de uma abordagem longitudinal entre os anos de 2009 e 2019 em metrópoles brasileiras. O método de regressão logística binomial foi utilizado para analisar os registros de discussão, deliberação e representação em 195 reuniões, envolvendo 7.759 participantes. Os resultados desvelam desafios persistentes nos espaços de institucionalização de democracia deliberativa em relação ao cenário local de implementação da política urbana apontando para agendas renovadas de pesquisa.

DECISION-MAKING CAPACITY ASSESSMENTS FOR VULNERABLE ADULTS: LESSONS FOR SOCIAL WORK COMPETENCY

Abstract Social work approaches to the assessment of decision-making capacity (DMC) assessment have largely been informed by literature from 25 years ago. Evidence-based practices include the ACED short version and the IDA-CA 3.0. When considering this specific practice by social workers there is the UK policy supporting competent practice through legislation, the Mental Capacity Act (2017) of England and Wales. Nine practitioners practicing through guidance presented by this policy were interviewed to learn what may support practices in the United States. Findings point to the importance of foundational values and efforts to optimize the vulnerable adult’s performance. Practical methods used in the assessment are gleaned, along with the training that has informed their work. Training advice included didactic, case review, and role-playing of increasingly complex cases. Experience working with diverse populations of vulnerable adults was also highlighted. This research strives to inform steps that enhance capacity within health and social care settings to adequately assess DMC. Understanding decision-making ability aids in preventing both paternalism and the insufficiency of support and/or protection.

The Statutory Codification of Decisional Capacity Standards.

The adoption of the widely used four specific skills model of decisional capacity assessment, first proposed by Appelbaum and Grisso in 1988, has become widely accepted in clinical practice. Many jurisdictions have, through legislative action, incorporated one or more of these skills into state law as part of the legal definition of decisional capacity. These statutes pose a challenge for physicians hoping to revise these criteria, as some commentators have recently proposed. This article categorizes and analyzes existing state statutes that define decisional capacity or designate certain classes of individuals to render such assessments. Many of these statutes incorporate aspects of the four skills model into state law, such that legislative action would be required to affect significant changes in methods of capacity assessment. As a result, physicians in many jurisdictions are unable to modify these criteria on their own. Any effort to alter capacity assessment standards will have to take into account the potential challenges to enacting statutory change at the outset of such efforts.