Medical Decision-making Capacity Research Articles

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.

Body integrity dysphoria and moral responsibility: an interpretation of the scepticism regarding on-demand amputations

A patient who requests an amputation deemed medically unnecessary by professionals is disqualified per se from being regarded as having medical decision-making capacity. This decision is based on the assumption...

“What Is the Most Important to Them?” Swiss Health Care Proxies, Nurses, and Physicians Discuss Planning Practices for Aged Care Residents Who No Longer Have Medical Decision-Making Capacity

Introduction: Multiple morbidities, including neurodegenerative diseases such as dementia, which result in diminished decision-making capacity (DMC), make care and care planning complicated for residential aged care facility (RACF) residents. While advance care planning has been highlighted as essential for ensuring that this population receives care that is coherent with their wishes, there are few models specifically designed for this population. This study aimed to explore the current practices for care planning and decision-making for Swiss RACF residents who no longer have medical DMC. Methods: Semi-structured focus groups were conducted with 23 nurses in three RACFs and with 13 physicians working in 9 RACFs. Semi-structured interviews were conducted with 18 health care proxies of 16 residents without DMC. Thematic analysis was conducted to identify the most salient themes across the dataset. Results: Analyses identified many collaborative processes between nurses, physicians, and health care proxies including family meetings, reconstructing residents’ presumed will, making anticipatory decisions, and documenting these decisions. These processes were, however, highly variable and differed between institutions and between residents within each facility, with a lack of standardization. This variability was highlighted to be problematic for information transmission within facilities and in case of hospital or facility transfer. Conclusions: These results highlight the importance of standardized yet flexible processes of care planning for people who no longer have DMC and provide insights for the development of such models specifically designed to address this problem.

Ethical considerations for the use of artificial intelligence in medical decision-making capacity assessments

The rapid advancement of artificial intelligence (AI) and machine learning are providing new tools to clinicians. AI tools have the potential to process vast amounts of data in a short amount of time, providing new insights and changing how we approach complicated healthcare problems. AI has the potential to assist clinicians in medical decision-making capacity assessments by providing additional insights to an evaluation process that currently lacks universal objective standards. However, despite the promise of AI in this setting, there remain significant concerns making it unlikely to replace human evaluators anytime soon. AI remains highly susceptible to biased inputs and thus biased decisions, raises questions about autonomy, and creates uncertainty for who is accountable for the ultimate decision of capacity. In this paper we explore these ethical considerations of using AI for capacity assessments. While we acknowledge AI may not be ready to replace physicians in determining patient medical-decision making capacity, these new technologies have significant near-term potential as a tool to screen patients, uncover physician biases, and guide next steps after a capacity determination has been made.

Letter: Characteristics and Outcomes of Discharge Against Medical Advice and 30-Day Readmissions After Concussion: Analysis of the Nationwide Readmissions Database.

To the Editor: We read with immense interest the article by Jumah et al1 titled as “Characteristics and Outcomes of Discharge Against Medical Advice (DAMA) and 30-Day Readmissions After Concussion: Analysis of the Nationwide Readmissions Database.” It was indeed a fascinating and compelling study which attempted to assess the prevalence of DAMA and its effect on 30-day readmissions and cost in concussion using a nationally representative sample. The authors state that this is the first study to date to analyze DAMA in patients with mild traumatic brain injury (mTBI) and hence is a stepping stone in this arena. Prevalence rates reported (2.6%) were in accordance with other studies and so were the factors associated with DAMA: young men, an Elixhauser comorbidity index >3, and injuries due to assault and/or fall while higher income had a negative association with DAMA. Thirty-day readmission had an independent association with DAMA, higher comorbidity index, and self-inflicted mode of injury. Most frequently encountered cause of readmission was TBI in both routine and DAMA groups. This study can act as a reference to design interventions that can be implemented in real time at health care facilities to reduce DAMA and readmission rate and consequently morbidity and mortality associated with TBI. Although the study is very engrossing and interesting, we were hoping the authors would shed some light on a few areas that could have given more insight about the issue. The study strictly included only patients with mTBI to make sure of the patient's ability to choose DAMA, thereby excluding other patients with TBI. This was very thoughtful of the authors; however, the medical decision-making capacity of a patient with TBI, even if mild, is significantly affected for at least 1 month from injury as compared with a healthy control or patients with other mild illnesses2 and hence we feel that this might have led to confounded results. In addition, what would have been an interesting factor to study is the relationship between DAMA and patient's educational status .3 The authors have reported assault to have a significant association with DAMA. In many cases, women are a victim of assault and thereby female sex should have had an association with DAMA which was contradictory to the observed relation of male sex to DAMA. The study also failed to take into account the role of factors such as sociocultural beliefs of the patients, their family conditions, and their relation with the health care provider. This was most probably due to absence of such variables in the Nationwide Readmissions Database that was used to conduct this study. In addition, patients with mTBI have more emergency department visits which could not be captured by Nationwide Readmissions Database and hence readmission rates might have been confounded. Many studies have shown the negative impact of sociocultural practices on patients' health as they interfere with the scientific process of providing health care to the patients, especially in Asian and African communities.4 Having a child/elderly member at home to take care of or no one to accompany the patients during the stay in the hospitals could be some of the familial reasons for patients to leave against medical advice. Inclusion of ethnicity, gender identity, and the immigration status of the patients and their effect on DAMA would have been a novel addition to the study. Discrimination by the health care providers on the basis of patients' ethnicity and/or sex identity creates differences between the health care providers and the patients. Therefore, patients may feel secluded and disrespected which might be a probable cause of DAMA. For instance, African American patients were found to have 2-fold higher odds of DAMA as compared with White patients.5 Paperwork at the time of admission and the financial constraints create an obstacle for the illegal immigrants forcing them to seek health care facilities somewhere else leading to DAMA. Further analysis of these factors would have been very insightful for the readers. Such findings would also help guide health care entities to adopt a holistic approach toward reducing DAMA and improving the health outcomes.

(12) "Why the Capacity Consult?": Drivers of Hospitalists’ Utilization of Psychiatry Consultations to Determine Patient Medical Decision-Making Capacity

(12) "Why the Capacity Consult?": Drivers of Hospitalists’ Utilization of Psychiatry Consultations to Determine Patient Medical Decision-Making Capacity

Physiologic Fidelity as a Domain in Assessing Mixed Reality Trauma Simulation.

Mixed reality has been used in trauma and emergency medicine simulation for more than a decade. As mixed reality potential in trauma simulation continues to expand, so too does the need to validate it as a surrogate for real-life emergency scenarios. Validation of these simulations can occur by measuring fidelity, or the degree to which a computing system can reproduce real-world experiences. After performing a literature review, we determined that most fidelity assessments of trauma and emergency simulations focus on how the user subjectively experiences the simulation. Although subjective user assessment is an important component of determining fidelity, we pose an introductory three-part framework that may assess mixed reality trauma simulation more adequately. A literature review was conducted using Google Scholar, PubMed, and the Uniformed Services University PowerER search database. Relevant articles were assessed to identify how studies measured fidelity in trauma simulation. We then designed the three-part framework to aid researchers in assessing the fidelity of mixed reality trauma simulations. The domains we determined to best assess mixed reality emergency simulation are as follows:1. Continue assessing fidelity via subjective user assessments. This allows the researcher to know how real the simulation looked and felt to the user based on their individual report.2. Determine whether the trauma simulation changes the medical decision-making capacity of the user. If the user's decision-making capacity changes with a stress-inducing trauma simulation versus a non-stress-inducing simulation, then the stress-inducing trauma environment would be approaching greater fidelity.3. Study the domain of our newly proposed concept: physiologic fidelity. We define physiologic fidelity as the degree to which the simulation elicits a measurable, autonomic response independent of observed emotion or perceived affect. Recreating objective autonomic arousal may be the best way to ensure a trauma simulation reaches fidelity. We propose a methodology to assess mixed reality trauma simulation fidelity. Once fidelity is more fully known to the researcher and the simulation user, adjustments can be made to approach reality more closely. Improved simulators may enrich the preparedness of both junior and senior learners for real-life emergencies. We believe assessing the three domains using the Wide Area Virtual Experience at the Val G. Hemming simulation center in Bethesda, MD, will validate mixed reality-trauma simulators as invaluable surrogates for real-life emergency scenarios and ultimately contribute to improved clinical outcomes for clinicians and their patients.

The Capacity to be an Expert: Considerations of decision-making assessment for geriatric psychiatrists

Obtaining valid consent for treatment is predicated on a patient's ability to make an informed decision, and capacity decisions involve a balance between respecting patients’ autonomy with protecting those with cognitive (and other) impairments. Given the importance of informed consent and the low rates with which clinical teams identify incapacity, it is critically important for geriatric mental health providers to competently identify and evaluate patients with capacity concerns. This need is particularly acute for complex cases, where the presence of medical and cognitive comorbidities can make capacity determination challenging.Furthermore, while statutes often provide physicians with a legal means for civil commitment of patients lacking decisionmaking capacity, these mechanisms typically mandate the presence of a contributory mental illness. However not all conditions which affect medical decision-making capacity are psychiatric. Hospitalized medically ill patients frequently request discharge prior to being medically appropriate to do so, placing themselves at risk. To proceed with discharge respects a patient's right to autonomy at the expense of patient safety and provider liability. To detain the patient against their wishes may be medically justifiable, but can be detrimental. State statutes provide little guidance about how to proceed in this situation, and geriatric providers should be aware of the pertinent legal and practical considerations for clinicians facing this arduous decision.An additional challenge to geriatric mental health involves sexual decision-making and questions of incapacity. Supporting the need for intimacy remains a vital element of long-term care, and great responsibility rests upon the care team to ensure that autonomy, the right to sexual expression, and freedom of intimacy are allowed. However while these principles must be respected, they may present unique challenges in settings where one or more of the participants are diagnosed with a neurocognitive disorder and in long-term care settings. In these instances the traditional elements of informed consent required to demonstrate decision-making capacity must be expanded and adapted.

Rethinking individual autonomy in medical decision-making for young adults reliant on caregiver support: A case report and analysis

There is a gap in the clinical bioethics literature concerning the approach to assessment of medical decision-making capacity of adolescents or young adults who demonstrate diminished maturity due to longstanding reliance on caregiver support, despite having reached the age of majority. This paper attempts to address this question via the examination of a particular case involving assessment of the decision-making capacity of a young adult pregnant patient who also had a physically disabling neurological condition. Drawing on concepts from adolescent bioethics and feminist critiques of bioethical theory, we argue that limited life experience, secondary to a disabling neurological condition, can result in a lack of adult-like capacity even in a patient who is legally an adult. In such cases, it may be that autonomy, to the extent that it is to be relevant and meaningful, must be viewed through a relational lens. Furthermore, clinicians may avoid unjustifiably paternalistic practices by working with the patient help her gain a better appreciation of the consequences of her decision, thereby calling forward her capacity rather than resorting to being directive in counseling. We conclude that lessons from this case can be used to approach ethically complex instances of medical decision-making in adult patients with normal cognition but diminished experiential maturity.

Reliability of self-report versus the capacity to consent to treatment instrument to make medical decisions in brain metastasis and other metastatic cancers.

ObjectiveTo evaluate the ability of persons with metastatic cancer to self‐assess their medical decision‐making capacity (MDC). To investigate this, we compared an objective measure of MDC with self‐ratings and evaluated predictors of agreement.MethodsData were obtained from a cross‐sectional study of metastatic cancer patients at a large academic medical center. Across all standards of MDC, sensitivity, specificity, and reliability using Gwet's AC1 statistic were calculated using the objective measure as the gold standard. Logistic regression was used to evaluate predictors of agreement between the measures across all MDC standards.ResultsIn those with brain metastases, high sensitivity (greater than 0.7), but low specificity was observed for all standards. Poor reliability was observed across all standards. Higher age resulted in higher odds of disagreement for Standard 3 (appreciation) (OR: 1.07, 95% CI: 1.00, 1.15) and Standard 4 (reasoning) (OR: 1.05, 95% CI: 1.00, 1.10). For Standard 3, chemotherapy use and brain metastases compared to other metastases resulted in higher odds of disagreement (Chemotherapy: OR: 5.62, 95% CI: 1.37, 23.09, Brain Metastases: OR: 5.93, 95% CI: 1.28, 27.55). For Standard 5 (understanding), no predictors were associated with disagreement.ConclusionsFor less cognitively complex standards (e.g., appreciation), self‐report may be more valid and reliable than more cognitively complex standards (e.g., reasoning or understanding). However, overall, MDC self‐report in the current sample is suboptimal. Thus, the need for detailed assessment of MDC, especially when patients are older or used chemotherapy, is indicated. Other studies should be conducted to assess MDC agreement longitudinally.

PROLONGED, PROFOUND UNTREATED HYPOXIA IN COVID-19 ARDS WITH REFUSAL OF TREATMENT

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: The drastic contrast between relatively mild dyspnea and severe hypoxemia seen in some Covid-19 ARDS patients, dubbed "happy" or "silent" hypoxia, has been brought into the spotlight by the current pandemic. The pathophysiology behind this phenomenon is not well understood, though appears to be associated with worse outcomes.1 However, the relative lack of respiratory discomfort may embolden some patients to forego medical therapies, as is seen in this case. CASE PRESENTATION: A 66-year-old man with hypertension, diabetes type 2, chronic kidney disease, hyperlipidemia, and coronary artery disease was admitted to the ICU for acute hypoxic respiratory failure secondary to Covid-19 ARDS in October. He was treated with alternating high flow nasal cannula (HFNC) and Bi-level Positive Airway Pressure (BiPAP), 5 days of Remdesivir, and 10 days of dexamethasone. His hospital course was uneventful until day 12, when patient decided to leave the hospital against medical advice. His vitals showed hemodynamic stability with 92% saturation on HFNC 40 L/min, 65% FiO2. Following a thorough evaluation, the patient was deemed to have medical decision-making capacity. Following the patient's removal of HFNC oxygen saturations declined to 67% on room air, heart rate increased from 106 to 130, and he became visibly tachypneic. The patient denied dyspnea, declined home oxygen therapy, and left the hospital. Fifty-three hours after discharge, he returned with a primary complaint of dyspnea. Vitals showed pulse 105, respiratory rate 35, and oxygen saturation 61% on room air. Venous blood gas showed pH 7.40 and pCO2 37. HFNC was resumed at 60 L/min, 100% FiO2, and patient achieved adequate saturation. The patient was readmitted, a workup revealed no additional etiologies, and supportive care was resumed. Despite supportive care he experienced progressive respiratory failure and nine days following readmission died. DISCUSSION: Given the vitals noted on initial discharge and readmission, it can be inferred that our patient had profound hypoxia throughout the 53 hours that were spent at home. Hypoxia as profound and prolonged as this is poorly described in current literature. Comparisons can be drawn with high-altitude illnesses, even then, literature is limited. A group of mountain climbers was found to have a mean oxygen saturation of 66% when they reached 6,865 meters.2 Ascent to high altitudes triggers pulmonary vasoconstriction, which leads to increased pulmonary pressures and pulmonary edema.3 Similar pathophysiology may have been experienced by this patient and may have contributed to his decline. CONCLUSIONS: This patient suffered severe hypoxia as a result of untreated Covid-19 ARDS. Examples of similar circumstances in the current literature are rare. It remains unclear how the patient survived without treatment or what triggered his decline, though comparisons can be made with high altitude illness. REFERENCE #1: Brouqui P, Amrane S, Million M, et al. Asymptomatic hypoxia in COVID-19 is associated with poor outcome [published online ahead of print, 2020 Oct 31]. Int J Infect Dis. 2020;102:233-238. doi:10.1016/j.ijid.2020.10.067 REFERENCE #2: Bosch MM, Merz TM, Barthelmes D, Petrig BL, Truffer F, Bloch KE, Turk A, Maggiorini M, Hess T, Schoch OD, Hefti U, Sutter FK, Pichler J, Huber A, Landau K. New insights into ocular blood flow at very high altitudes. J Appl Physiol (1985). 2009 Feb;106(2):454-60. doi: 10.1152/japplphysiol.90904.2008. Epub 2008 Dec 4. PMID: 19057000. REFERENCE #3: Schoene RB. Illnesses at high altitude. Chest. 2008 Aug;134(2):402-416. doi: 10.1378/chest.07-0561. PMID: 18682459. DISCLOSURES: No relevant relationships by Dustin Krutsinger, source=Web Response No relevant relationships by Kaleb Thomas, source=Web Response

Patients’ Views of Shared Decision-making and Decisional Conflict in Otolaryngologic Surgery During the COVID-19 Pandemic

A patient's decision to undergo surgery may be fraught with uncertainty and decisional conflict. The unpredictable nature of the COVID-19 pandemic warrants further study into factors associated with patient decision-making. To assess decisional conflict and patient-specific concerns for people undergoing otolaryngologic surgery during the pandemic. This prospective cross-sectional survey study was conducted via telephone from April 22 to August 31, 2020. English-speaking adults scheduled for surgery from a single academic surgical center were invited to participate. Individuals who were non-English speaking, lacked autonomous medical decision-making capacity, scheduled for emergent surgery, or had a communication disability were excluded. For race and ethnicity reporting, participants were classified dichotomously as White according to the Behavioral Risk Factor Surveillance System from the Centers for Disease Control and Prevention or non-White as a collective term including Black or African American, American Indian or Alaska Native, Asian, or Pacific Islander race and ethnicity. The SURE Questionnaire (sure of myself, understand information, risks/benefits ratio, and encouragement) was used to screen for decisional conflict, with a total score greater than or equal to 3 indicating clinically significant decisional conflict. Participants were asked to share their specific concerns about having surgery. Decisional conflict and patient demographic data were assessed via bivariate analyses, multivariable logistic regression and conjunctive consolidation. Patient-specific concerns were qualitatively analyzed for summative themes. Of 444 patients screened for eligibility, 182 (40.9%) respondents participated. The median age was 60.5 years (interquartile range, 48-70 years). The racial and ethnic identity of the participants was classified as binary White (84% [153 of 182]) and non-White (16% [29 of 182]). The overall prevalence of decisional conflict was 19% (34 of 182). Decisional conflict was more prevalent among non-White than White participants (proportion difference 18.8%, 95% CI, 0.6%-37.0% and adjusted odds ratio 3.0; 95% CI, 1.2-7.4). Combining information from multiple variables through conjunctive consolidation, the group with the highest rate of decisional conflict was non-White patients with no college education receiving urgent surgery (odds ratio, 10.8; 95% CI, 2.6-45.0). Intraoperative and postoperative concerns were the most common themes expressed by participants. There was a clinically significant difference in the proportion of participants who screened positive for decisional conflict (30%) and expressed postoperative concerns than those who screened negative for decisional conflict (17%) (proportion difference, 13%; 95% CI, 1%-25%). Among patients reporting concerns about COVID-19, most screened positive for decisional conflict. Results of this cross-sectional survey study suggest that the COVID-19 pandemic was associated with decisional conflict in patients undergoing otolaryngologic surgery. Consistent discussion of risks and benefits is essential. The role of race and ethnicity in decisional conflict warrants further study.

Patient Safety and Quality Improvement

Introduction: The unpredictable nature of the COVID-19 pandemic portends further uncertainty in patient decisionmaking. This study explores decisional conflict and patientspecific concerns for people undergoing otolaryngologic surgery during the pandemic. Method: This was a prospective, single-institution, crosssectional study of English-speaking adults undergoing otolaryngologic surgery, conducted from April 22 to August 31, 2020. Individuals who were non-English speaking, lacked autonomous medical decision-making capacity, underwent emergent surgery, or had a communitive disability were excluded. The primary outcome of decisional conflict was measured using the validated “SURE” screening questionnaire. Relationships between decisional conflict and patient demographics were assessed via bivariate analyses, multivariable logistic regression, and conjunctive consolidation. The secondary outcome of patient-specific concerns was obtained through open-ended interview and qualitatively assessed using thematic analysis with open coding. Results: There was a 41% response rate (182 of 444 patients). The median age was 60.5 years (range 18-88);92 patients (51%) were women. Decisional conflict was more prevalent in non-White compared with White participants (difference 18%;95% CI, 0.6%-37.0% and adjusted odds ratio 3.0;95% CI, 1.2-7.4). Combining information from multiple variables through conjunctive consolidation, the group with the highest rate of decisional conflict was non- White patients with no college education, receiving urgent surgery. “Intraoperative” and “postoperative concerns” were the most common patient-specific concerns. Among those patients reporting concerns about COVID-19, the majority had decisional conflict. Conclusion: This study highlighted factors associated with decisional conflict and emphasized the need for physicians to engage in shared-decision making with patients. The COVID- 19 pandemic contributed to decisional conflict. Consistent discussion of risks and benefits is essential. The role of race and decisional conflict needs further study.

Using a MoCA Score to Predict the Probability of Medical Decision-Making Capacity in Patients with Mild Cognitive Impairment (MCI) or Dementia (1844)

Using a MoCA Score to Predict the Probability of Medical Decision-Making Capacity in Patients with Mild Cognitive Impairment (MCI) or Dementia (1844)

Pad in forensic psychiatry

IntroductionA recent court decision in Germany defined assisted suicide as a basic human right. Consequently, the discussion regarding PAD needs to be extended to people who are in forensic/secure psychiatric hospitals or prisons, sometimes without any prospects of release. Several studies have shown that long-term hospitalization and detention are associated with feelings of hopelessness, depression and suicidal ideations. Moreover, the resources for adequate therapy are often rare. This results in complex moral challenges for mental health care.ObjectivesTo review current practices in countries that allow PAD and to discuss ethical conflicts.MethodsLiterature review; international comparison of current regulations.ResultsA majority of the literature on PAD in detention refers to prisoners with terminal medical conditions. Single case reports of PAD-requests of mentally disordered offenders aroused great public interest. The resulting ethical conflicts are similar to those issues regarding PAD and mental disorder in general. However, in secure treatment settings and detention additional aspects such as adverse living conditions and inadequate access to mental health care need to be taken into account.ConclusionsIf unbearable pain is not a precondition for assisted suicide, then mentally disordered and healthy offenders have a right to request PAD, provided they have medical decision-making capacity. Considering the common insufficient mental health care for people in detention, policy and law makers need to ensure that access to PAD will not replace therapy. Professionals involved in PAD evaluations need support by specific guidelines.DisclosureNo significant relationships.

Elder Financial Abuse and Electronic Financial Instruments: Present and Future Considerations for Financial Capacity Assessments

Personal economic stability is one of the core social determinants of health and longevity, and managing one's finances is an instrumental activity of daily living. Impaired financial decision-making can lead to poor health, emotional distress, and loss of independence and safety. Older adults in the United States lose billions of dollars annually to elder financial abuse (EFA), which may be preceded by a decline of capacity to make financial decisions. A literature review regarding EFA, electronic financial instruments (EFI), medical and financial decision-making capacity evaluations, and biomedical ethics was performed. Currently, there is no gold standard clinical assessment tool for evaluating financial capacity. The instruments in use have yet to formally integrate modern EFI that present novel mechanisms through which EFA can occur. This article summarizes the current state of EFA in the United States, risk factors and strategies for prevention, and offers a clinician administered screening questionnaire for addressing EFI use along with a semi-structured approach to clinical financial capacity assessments.

The capacity to designate a surrogate is distinct from decisional capacity: normative and empirical considerations

The capacity to designate a surrogate (CDS) is not simply another kind of medical decision-making capacity (DMC). A patient with DMC can express a preference, understand information relevant to that...

Top Ten Tips Palliative Care Clinicians Should Know About Medical Decision-Making Capacity Assessment.

Palliative care (PC) clinicians treat seriously ill patients who are at increased risk for compromised decision-making capacity (DMC). These patients face profound and complex questions about which treatments to accept and which to decline. PC clinicians, therefore, have the especially difficult task of performing thorough, fair, and accurate DMC assessments in the face of the complex effects of terminal illness, which may be complicated by fluctuating acute medical conditions, mental illness, or cognitive dysfunction. This study, written by a team of clinicians with expertise in PC, ethics, psychiatry, pediatrics, and geriatrics, aims to provide expert guidance to PC clinicians on best practice for complex DMC assessment.

Reliability of the Capacity to Consent to Treatment Instrument in Metastatic Cancer

Metastatic cancer patients undergo numerous treatment strategies with known cognitive side effects. It is unclear how medical decision-making capacity (MDC) is impacted by cognitive deficits in metastatic cancer. This study examines reliability of an objective measure of MDC compared with self-report. Participants with newly diagnosed metastasis to the brain and other sites were enrolled at the University of Alabama at Birmingham over seven years. At the study visit, participants completed a comprehensive neuropsychological battery including memory and executive functioning, and the Capacity to Consent to Treatment Instrument (CCTI) assessing medico-legal domains of MDC. The CCTI is a reliable and valid instrument containing two vignettes of hypothetical medical situations assessing four standards of consent. We examined reliability between the CCTI and self-reported MDC using Gwet’s AC1 statistic. Participants with brain metastasis with impairment on the CCTI demonstrated significantly lower executive functioning and memory skills than those without impairment (Trails B Raw: 158.20±86.82 vs. 118.90±77.98 p: 0.0248; Digit-Span Raw Forward: 9.13±2.30 vs. 10.12±2.03 p: 0.0254). There were no significant differences between intact and impaired participants with other metastases. Low reliability was observed between self-report and all medico-legal standards on the CCTI across both metastatic groups [Gwet’s AC1 Appreciation: 0.70 (0.58, 0.81); Reasoning: 0.34 (0.16, 0.52); Understanding: 0.44, (0.27, 0.60)]. Self-rating of MDC is unreliable in metastatic cancer patients. Patients with metastases (particularly brain metastases) may lack awareness of deficits in their MDC, so providers must affirm proper autonomy in their decisions.