Hostname: page-component-cd9895bd7-fscjk Total loading time: 0 Render date: 2024-12-25T04:26:41.419Z Has data issue: false hasContentIssue false
  • English
  • Français

Should capacity assessments be performed routinely prior to discussing advance care planning with older people?

Published online by Cambridge University Press:  16 January 2018

Oleg Kiriaev ,
Emme Chacko ,
J. D. Jurgens ,
Meagan Ramages ,
Phillipa Malpas  and
Gary Cheung
Oleg Kiriaev
Affiliation:
Mental Health Services for Older People, Auckland District Health Board, New Zealand
Emme Chacko
Affiliation:
Mental Health Services for Older People, Auckland District Health Board, New Zealand
J. D. Jurgens
Affiliation:
Jardine Clinic, Royal Edinburgh Hospital, UK
Meagan Ramages
Affiliation:
Mental Health Services for Older Adults, Waitemata District Health Board, New Zealand
Phillipa Malpas
Affiliation:
Department of Psychological Medicine, The University of Auckland, New Zealand
Gary Cheung*
Affiliation:
Department of Psychological Medicine, The University of Auckland, New Zealand
*
Correspondence should be addressed to: Dr Gary Cheung, Senior Lecturer in Psychiatry, Department of Psychological Medicine, The University of Auckland, Private Bag 92019, Auckland Mail Centre, Auckland 1142, New Zealand. Phone: +64 21 332 823; Fax: +64 9 373 7013. Email: [email protected].
Get access

Abstract

Background:

People with dementia receive worse end of life care compared to those with cancer. Barriers to undertaking advanced care planning (ACP) in people with dementia include the uncertainty about their capacity to engage in such discussions. The primary aim of this study was to compare the Advance Care Planning–Capacity Assessment Vignette tool (ACP–CAV) with a semi-structured interview adapted from the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). The secondary aim was to identify demographic and cognitive functioning variables that may predict whether a person has capacity to discuss ACP.

Methods:

32 older people (mean age = 84.1) with a Mini-Mental State Examination of 24 or above were recruited from two retirement villages in Auckland. Participants also completed Trail Making Test Part A & Part B and Geriatric Depression Scale (GDS-15) before undertaking the two capacity assessments that were video recorded to enable further analysis by four independent old age psychiatrists.

Results:

Using the MacCAT-T as the gold standard, over half (53.1%) of the participants were considered as lacking in capacity to engage in ACP. Participants struggled with the “Understanding ACP” domain the most. Capacity was not predictable by any of the demographic or cognitive functioning variables. When compared to the gold standard, ACP–CAV was accurate in assessing capacity in 68.8% of the cases.

Conclusion:

Clinicians should routinely explain ACP to older people and ensure they fully understand it prior to an ACP discussion. If there is any concern about their understanding, further exploration and documentation of their capacity using the capacity assessment framework would be necessary. However, capacity assessment is a complex iterative process that does not easily lend itself to screening methodology and requires a high level of clinical judgment.

Keywords

dementiacapacity assessmentethics
Type
Original Research Article
Information
International Psychogeriatrics , Volume 30 , Issue 8: Issue Theme: Caregiver Stress , August 2018 , pp. 1243 - 1250
Copyright
Copyright © International Psychogeriatric Association 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Aminoff, B. Z. and Adunsky, A. (2005). Dying dementia patients: too much suffering, too little palliation. American Journal of Hospice and Palliative Medicine, 22, 344–348.Google Scholar
Appelbaum, P. S. and Grisso, T. (1988). Assessing patient's capacities to consent to treatment. New England Journal of Medicine, 319, 1635–1638.Google Scholar
Congedo, M. et al. (2010). Ethical issues in end of life treatments for patients with dementia. European Journal of Neurology, 17, 774–779.Google Scholar
De Boer, M. E., Hertogh, C. M. P. M., Dröes, R. M., Jonker, C. and Eefsting, J. A. (2010). Advance directives in dementia: issues of validity and effectiveness. International Psychogeriatrics, 22, 201–208.Google Scholar
Ditto, P. H. et al. (2001). Advance directives as acts of communication: a randomized controlled trial. Archives of Internal Medicine, 161, 421–430.Google Scholar
Douglass, A., Young, G. and McMillan, J. (2016). A Toolkit for Assessing Capacity in A Douglass “Mental Capacity: updating New Zealand's Law and Practice”. Report for the New Zealand Law Foundation. Available at: http://www.lawfoundation.org.nz/; last accessed 15 October 2017.Google Scholar
Dworkin, R. (1986). Autonomy and the demented self. The Milbank Quarterly, 64, S4–S16.Google Scholar
Etchells, E. et al. (1999). Assessment of patient capacity to consent to treatment. Journal of General Internal Medicine, 14, 27–34.Google Scholar
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1973). “Mini-Mental State”. Practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198.Google Scholar
Forbes, S., Bern-Klug, M. and Gessert, C. (2000). End-of-life decision making for nursing home residents with dementia. Journal of Nursing Scholarship, 32, 251–258.Google Scholar
Gregory, R., Roked, F., Jones, L. and Patel, A. (2007). Is the degree of cognitive impairment in patients with Alzheimer's disease related to their capacity to appoint an enduring power of attorney?. Age and Ageing, 36, 527–531.Google Scholar
Grisso, T. and Appelbaum, P. S. (1998). MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Professional Resource Press/Professional Resource Exchange.Google Scholar
Hirschman, K. B., Kapo, J. M. and Karlawish, J. H. T. (2006). Why doesn't a family member of a person with advanced dementia use a substituted judgment when making a decision for that person?. American Journal of Geriatric Psychiatry, 14, 659–667.Google Scholar
Hirschman, K. B., Xie, S. X., Feudtner, C. and Karlawish, J. H. T. (2004). How does an Alzheimer's disease patient's role in medical decision making change over time?. Journal of Geriatric Psychiatry and Neurology, 17, 55–60.Google Scholar
Kim, S. Y. H., Karlawish, J. H. T. and Caine, E. D. (2002). Current state of research on decision-making competence of cognitively impaired elderly persons. American Journal of Geriatric Psychiatry, 10, 151–165.Google Scholar
Kitamura, T. and Kitamura, F. (2000). Reliability of clinical judgment of patients' competency to give informed consent: a case vignette study. Psychiatry and Clinical Neurosciences, 54, 245–247.Google Scholar
Marson, D. C., Ingram, K. K., Cody, H. A. and Harrell, L. E. (1995). Assessing the competency of patients with Alzheimer's disease under different legal standards: a prototype instrument. Archives of Neurology, 52, 949–954.Google Scholar
Marson, D. C., McInturff, B., Hawkins, L., Bartolucci, A. and Harrell, L. E. (1997). Consistency of physician judgments of capacity to consent in mild Alzheimer's disease. Journal of the American Geriatrics Society, 45, 453–457.Google Scholar
Moye, J., Karel, M. J., Azar, A. R. and Gurrera, R. J. (2004). Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia. Gerontologist, 44, 166–175.Google Scholar
Pachet, A., Astner, K. and Brown, L. (2010). Clinical utility of the mini-mental status examination when assessing decision-making capacity. Journal of Geriatric Psychiatry and Neurology, 23, 3–8.Google Scholar
Pruchno, R. A., Smyer, M. A., Rose, M. S., Hartman-Stein, P. E. and Henderson-Laribee, D. L. (1995). Competence of long-term care residents to participate in decisions about their medical care: a brief, objective assessment. Gerontologist, 35, 622–629.Google Scholar
Reid-Proctor, G. M., Galin, K. and Cummings, M. A. (2001). Evaluation of legal competency in patients with frontal lobe injury. Brain Injury, 15, 377–386.Google Scholar
Reitan, R. M. (1958). Trail Making Manual for Administration, Scoring, and Interpretation. Indianapolis: Department of Neurology, Section of Neuropsychology, Indiana University Medical Center.Google Scholar
Robinson, L. et al. (2012). A systematic review of the effectiveness of advance care planning interventions for people with cognitive impairment and dementia. Age and Ageing, 41, 263–269.Google Scholar
Royall, D. R., Cordes, J. and Polk, M. (1997). Executive control and the comprehension of medical information by elderly retirees. Experimental Aging Research, 23, 301–313.Google Scholar
Schindler, B. A., Ramchandani, D., Matthews, M. K. and Podell, K. (1995). Competency and the frontal lobe: the impact of executive dysfunction on decisional capacity. Psychosomatics, 36, 400–404.Google Scholar
Schmand, B., Gouwenberg, B., Smit, J. H. and Jonker, C. (1999). Assessment of mental competency in community-dwelling elderly. Alzheimer Disease and Associated Disorders, 13, 80–87.Google Scholar
Sharp, T., Moran, E., Kuhn, I. and Barclay, S. (2013). Do the elderly have a voice? Advance care planning discussions with frail and older individuals: a systematic literature review and narrative synthesis. British Journal of General Practice, 63, e657–e68.Google Scholar
Sheikh, J. A. and Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): recent findings and development of a shorter version. In Brink, T. L. (ed.) Clinical Gerontology: A Guide to Assessment and Intervention. New York: Howarth Press.Google Scholar
Sudore, R. L. et al. (2017). Defining advance care planning for adults: a consensus definition from a multidisciplinary delphi panel. Journal of Pain and Symptom Management, 53, 821–832.Google Scholar
Suhl, J., Simons, P., Reedy, T. and Garrick, T. (1994). Myth of substituted judgment: surrogate decision making regarding life support is unreliable. Archives of Internal Medicine, 154, 90–96.Google Scholar
Sullivan, K. (2004). Neuropsychological assessment of mental capacity. Neuropsychology Review, 14, 131–142.Google Scholar
Uhlmann, R. F., Pearlman, R. A. and Cain, K. C. (1988). Physicians' and spouses' predictions of elderly patients' resuscitation preferences. Journals of Gerontology, 43, M115–M121.Google Scholar