Assessment of treatment decision-making capacity in a medically ill patient

Should Assessments of Decision-Making Capacity Be Risk-Sensitive? A Systematic Review

Background

The concept of decision-making capacity (DMC) or competence remains controversial, despite widespread use. Risk-sensitive DMC assessment (RS-DMC)—the idea that the higher the risk involved in a decision, the greater the decisional abilities required for DMC—has been particularly controversial. We conducted a systematic, descriptive review of the arguments for and against RS-DMC to clarify the debate.

Methods

We searched PubMed/MEDLINE (National Library of Medicine), PsycInfo (American Psychological Association) and Philpapers, updating our search to February 15th, 2022. We targeted peer-reviewed publications in English that argue for or against RS-DMC. Two reviewers independently screened the publications and extracted data from each eligible manuscript.

Results

Of 41 eligible publications, 22 supported a risk-sensitive threshold in DMC assessment. Most arguments for RS-DMC rely on its intuitive appeal and practical merits. The arguments against RS-DMC primarily express concerns about paternalism and the seeming asymmetry between consent and refusal; critics of RS-DMC support epistemic, rather than substantive (i.e., variable threshold), risk-sensitivity; counterarguments responding to criticisms of RS-DMC address charges of paternalism and exhibit a notable variety of responses to the issue of asymmetry. Authors used a variety of frameworks regarding the definition of DMC, its elements, and its relation to decisional authority, and these frameworks were significantly associated with positions on RS-DMC. A limitation of our review is that the coding relies on judgment and interpretation.

Conclusion

The review suggests that some of the debate about RS-DMC stems from differences in underlying frameworks. Most defenses of RS-DMC rely on its intuitive appeal, while most criticisms reflect concerns about paternalism or the asymmetry between consent and refusal. Defenses of RS-DMC respond to the asymmetry problem in a variety of ways. Further research is needed on the implications of underlying frameworks, the asymmetry problem, and the distinction between epistemic and substantive models of RS-DMC.

Validity of a Standard Information Protocol Provided to End-Stage Renal Disease Patients and Its Effect on Treatment Selection

Objective

To evaluate the validity of a standard information package, comprising written and audiovisual aids, for end-stage renal disease (ESRD) patients in a pre-dialysis program.

Study Design

A multicenter study comprising patients entering a predialysis program. Three questionnaires were developed to gather data in this study: (1) a pre-information package questionnaire that evaluates the patient's initial knowledge of ESRD and the treatment options available (pre-informed patients); (2) a post-information package questionnaire that evaluates the patient's knowledge of ESRD and treatment options after being informed according to the protocol (post-informed patients); (3) a “start of the treatment” questionnaire that deals with the patient's choice of treatment at the time of starting dialysis, as well as the reasons leading to that choice. In all three questionnaires the patient's age, gender, level of creatinine clearance (Ccr), and hematocrit were recorded.

Inclusion Criteria

Any patient who was on a predialysis program in the participating centers.

Results

Three hundred and four patients were evaluated across 14 participating centers. Initial knowledge was assessed in 216 pre-informed patients (questionnaire 1). Patients were then guided through the information package. One hundred and fifty-eight patients answered the post-information package (questionnaire 2). During the course of the study, 174 patients (of the initial 304) started renal replacement therapy. Of these, 49.4% (86 patients) had received predialysis information according to our study protocol. All the patients who received the information throughout the trial improved their knowledge of ESRD and treatment options; this improvement was statistically significant.

Conclusions

The treatment options least well known at the start of the study were the peritoneal dialysis techniques. After receiving the information package, patients had an equal knowledge of all the different treatments, although hemodialysis was still the most familiar. This improvement in knowledge enabled patients who started a dialysis treatment to choose a therapy according to their own preferences. Their selections were as follows: 44% of the patients chose hemodialysis, 40% chose continuous ambulatory peritoneal dialysis, and 16% chose automated peritoneal dialysis. The standard information package, used as a patient education program, effectively resulted in patients having a significantly improved level of knowledge and understanding of ESRD and the different treatment options available.

Assessment of decisional capacity: Prevalence of medical illness and psychiatric comorbidities

Objective:

Studies on decisional capacity have primarily focused on cognitive disorders, whereas noncognitive disorders remain understudied. The purpose of our study was to assess decisional capacity across a wide spectrum of medical and psychiatric disorders.

Method:

More than 2,500 consecutive consults were screened for decisional capacity, and 336 consults were reviewed at Bellevue Hospital Center in New York. Sociodemographic and medical variables, medical and psychiatric diagnoses, as well as decisional capacity assessments were recorded and analyzed.

Results:

Consults for decisional capacity were most commonly called for in male patients with cognitive and substance abuse disorders. Less commonly, consults were called for patients with mood or psychotic disorders. Overall, about two thirds of patients (64.7%) were deemed not to have decisional capacity. Among medical diagnoses, neurological disorders contributed to decisional incapacity, and among the psychiatric diagnoses, cognitive disorders were most frequently documented in cases lacking decisional capacity (54.1%) and interfered more commonly with decisional capacity than substance abuse or psychotic disorders (37.2 and 25%). In contrast, patients with mood disorders usually retained their decisional capacity (32%). Generally, the primary treatment team's assessment was accurate and was confirmed by the psychiatric service.

Significance of results:

Although decisional capacity assessments were most commonly requested for patients with substance abuse and cognitive disorders, the latter generally affected the ability to make healthcare decisions the most. Further, cognitive disorders were much more likely to impair the ability to make appropriate healthcare decisions than substance abuse or psychotic disorders.

Ethical issues of compliance/adherence in the treatment of hypertension

The ethics of compliance suggests a conflict within the definition of compliance. Evidence-based medicine appears to provide clear pathways for clinical decisions, but, usually, the patient is not a part of the decision-making process. Physicians often develop a treatment plan and then attempt to make the therapy acceptable to the patient to achieve compliance. Interventions are tested to change patient behavior, but few are designed to consider the patient's point of view. Some suggest that the ideal patient is passive and obedient. However, few patients are either. The individual's perspective and goals most certainly affect adherence with a medical treatment and cannot be ignored. This article reviews the ethics of compliance/adherence issues. Future research of compliance might be improved if studies were designed to include patient preference in a partnership with physicians.

Australian lawyers' views on competency issues in older adults

Lawyers are often called upon by their older clients to draft contracts, make up wills or powers of attorney, or provide other forms of legal advice or service. With the increasing numbers of older people in the population, the numbers of older clients for legal practitioners is likely to increase. Older people are also at increased risk for impaired cognitive processes that can affect their ability to make reasoned judgements in civil contracts and other legal arrangements. Here we report on the results of a survey of 302 Australian solicitors as to their experience and practices in determining the capacity of older clients to make legal decisions. The responses, reflecting a 20.7% return rate, showed a wide range of experience in conducting capacity assessments, with a mean of 15.7 years (SD = 10.59). There was a very wide range of practices in determining capacity with no consensus. The most frequent form of questions older clients were asked related to personal and family history. Less than one-quarter asked for the rationale of the decision: the most appropriate form of question in the literature. The results suggest a need for further training of solicitors in the assessment of the capacity of older clients to make legal decisions.

Preliminary report on informed consent for mental capacity assessments

The goal of the study was to investigate the issue of informed consent for mental capacity. Seventeen clients referred to the Competency Clinic at the Baycrest Centre for Geriatric Care were interviewed after the assessment had been completed. Their responses to questions regarding the reasons for and possible consequences of the assessment indicated a range of understanding and of capacity to give informed consent. The results are discussed in terms of the appropriateness of having a fairly low threshold for informed consent in situations where other capacities are already in question.

Patients' perceptions of self-determination as expressed in the context of care

AIM

The aim of this study was to describe patients' perceptions of how self-determination finds expression in the context of care.

BACKGROUND

Self-determination is an important concept within health care as well as an important patient right. New legislation on patient rights in Sweden and Europe is aimed at increased patient self-determination.

DESIGN AND METHOD

Data were collected through semi-structured, tape-recorded interviews with 17 strategically chosen patients within somatic care and analysed using a method inspired by phenomenography.

RESULTS

The analysis found three descriptive categories of the informants' perceptions: trusting, accepting and a feeling of powerlessness. The patients expressed a great sense of trust and confidence in the care provided and they accepted the health care procedures. At the same time, they expressed a feeling of powerlessness because of not being part of decision-making, as well as lacking knowledge and information about treatment strategies. The patients wished to have the right of more self-determination but lacked the strength and knowledge to be able to influence their own care.

CONCLUSIONS

Patients' perceptions of self-determination suggest that, in their encounters with the professional care, knowledge is expressed as power. The feeling of a lack of self-determination can be reduced by help and support from a nurse who allocates time for communication in order to learn the patient's needs and reach a mutual understanding.

Preconditions for and consequences of self-determination: the psychiatric patient's point of view

In the context of an interview study concerned with self-determination in psychiatric patients, this paper describes the preconditions for and consequences of self-determination from the point of view of psychiatric patients themselves. The data were collected in semi-structured interviews with long-term psychiatric patients (n = 72) and analysed using the method of content analysis. Responses on the preconditions for self-determination were grouped into three categories: firstly, there were those who said that reference to self-determination in the case of psychiatric patients is nonsense; secondly, there were those who said that self-determination requires no preconditions; and thirdly, there were those who said that there are certain preconditions, such as the ability to think and make decisions, activity, obedience, and illness. Both positive and negative consequences were identified in situations where self-determination is maintained, but only negative consequences in situations where self-determination is lost. On the basis of these tentative results, self-determination seemed to be relevant in psychiatric nursing. We are continuing to develop and test an instrument for the evaluation of the opportunity for self-determination in clinical practice.

The psychiatric patient's right to self-determination: a preliminary investigation from the professional nurse's point of view

The aim of this preliminary empirical investigation was to explore the concept of self-determination and to discuss its applicability to psychiatric nursing. The data were collected with a questionnaire submitted to professional nurses (n = 127) working on the long-term wards in four Finnish hospitals. Data analysis combined the methods of content analysis and quantitative statistics. A tentative concept apparatus was created in order to provide nursing science with a broader understanding of the issue at hand. Nurses identified various factors that act to restrict and to support self-determination: the most common restrictive factor was the patient's illness or condition, and the most common supportive factor was nursing intervention. Views differed on the importance of self-determination in the case of psychiatric patients; over half of the nurses described the right to self-determination as very important. On the basis of the findings it is concluded that self-determination is a valid concept for the psychiatric patient. It was also thought to serve the needs of education as well as evaluation.

Self-determination in clinical practice: the psychiatric patient's point of view

This article looks at the relevance of the concept of self-determination to psychiatric patients by studying the existence, importance and manifestations of self-determination. The data were collected by interviewing long-term patients (n = 72) in one mental health care organization, which included a psychiatric hospital and an outpatient department. Self-determination was defined in terms of the right to decision-making, the right to information, the right of consent, the right to refuse treatment, and the right to be heard and taken into account. It was found that, with the exception of the right to refuse and consent, these rights are indeed present in the practice of psychiatric nursing and that they are relevant, and important to psychiatric patients. The patients typically gave ethical practical and legal reasons for a psychiatric patient's right to self-determination. The main reasons why psychiatric patients said they lacked the right to self-determination were illness and staff authority. Recommendations for educational, clinical and methodological implications for the future in nursing are discussed.

Pre-ESRD patient education: a review of the literature

The education of patients with renal disease focuses on the inevitability of reaching end-stage renal disease (ESRD) and requiring renal replacement therapy. Established education programs begin the process during the late stages of renal disease progression or after the patient reaches ESRD. Uremic symptoms negatively influence the patients' ability to learn and make decisions about their health care. Late referrals to nephrologists and patient educators often occur when the patient is physiologically compromised. Early education for the pre-ESRD patient has the potential to improve the quality of patient satisfaction, delay the onset of dialytic treatment, and increase cost-effectiveness. Despite more than 20 years experience in the treatment of ESRD patients, there are relatively few reports in the literature about early education or pre-ESRD education. The available reports describe program innovations and methods and offer some limited evaluative data and recommendations. Access to patients and lack of reimbursement are significant barriers to expansion of this field. These barriers present the nephrology community with challenges in offering patients optimum treatment and participation in treatment decisions and alternatives. Early patient education is an essential component that can contribute significantly to slowing the progression of renal disease.