Assessing Treatment Decision‐Making Capacity in Elderly Nursing Home Residents

Fitten, L. Jaime; Lusky, Richard A.; Hamann, Claus

doi:10.1111/j.1532-5415.1990.tb01372.x

Cited by 126 publications

(79 citation statements)

References 22 publications

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“…Our approach is more rigorous than previous studies of capacity to consent to treatment, which used single experts, 7,10,25 single panels of experts, 10 or statistically derived cutoff scores on questionnaires using hypothetical treatment decisions. 3,26 Clinicians often rely on the opinion of a single expert capacity assessment, so our study also used a more rigorous approach than would occur in usual practice. We recognize that our two experts may occasionally have both been A second strength of our study was the challenging spectrum of patients enrolled.…”

Section: Discussionmentioning

confidence: 99%

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Assessment of patient capacity to consent to treatment

et al. 1999

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OBJECTIVE:To compare results of a specific capacity assessment administered by the treating clinician, and a Standardized Mini-Mental Status Examination (SMMSE), with the results of expert assessments of patient capacity to consent to treatment. DESIGN:Cross-sectional study with independent comparison to expert capacity assessments. SETTING:Inpatient medical wards at an academic secondary and tertiary referral hospital. PARTICIPANTS:One hundred consecutive inpatients facing a decision about a major medical treatment or an invasive medical procedure. Participants either were refusing treatment, or were accepting treatment but were not clearly capable according to the treating clinician. MEASUREMENTS AND MAIN RESULTS:The treating clinician (medical resident or student) conducted a specific capacity assessment on each participant, using a decisional aid called the Aid to Capacity Evaluation. A specific capacity assessment is a semistructured evaluation of the participant's ability to understand relevant information and appreciate reasonably foreseeable consequences with regard to the specific treatment decision. Participants also received a SMMSE administered by a research nurse. Participants then had two independent expert assessments of capacity. If the two expert assessments disagreed, then an independent adjudication panel resolved the disagreement after reviewing videotapes of both expert assessments. Using the two expert assessments and the adjudication panel as the reference standard, we calculated areas under the receiver-operating characteristic curves and likelihood ratios. The areas under the receiveroperating characteristic curves were 0.90 for specific capacity assessment by treating clinician and 0.93 for SMMSE score (2 p ‫؍‬ .48). For the treating clinician's specific capacity assessment, likelihood ratios for detecting incapacity were as follows: definitely incapable, 20 (95% confidence interval [CI] 3.6, 120); probably incapable, 6.1 (95% CI 2.

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Section: Discussionmentioning

confidence: 99%

“…Existing studies indicate that these general impressions are easily biased, 2 and do not agree closely with expert assessments except when patients are obviously capable or incapable. 3,4 Better approaches to capacity assessment are needed.…”

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confidence: 99%

Assessment of patient capacity to consent to treatment

et al. 1999

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“…Nonetheless, vignette-based MDC instruments are widely used in dementia research 13,14,33 and have demonstrable face, content, and construct validities. 40 …”

Section: Effect Of Conversion To Dementia On MDC Trajectorymentioning

confidence: 99%

Medical decision-making capacity in mild cognitive impairment

et al. 2008

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Objective: To investigate longitudinal change in the medical decision-making capacity (MDC) of patients with amnestic mild cognitive impairment (MCI) under different consent standards.Methods: Eighty-eight healthy older controls and 116 patients with MCI were administered the Capacity to Consent to Treatment Instrument at baseline and at 1 to 3 (mean ϭ 1.7) annual follow-up visits thereafter. Covariate-adjusted random coefficient regressions were used to examine differences in MDC trajectories across MCI and control participants, as well as to investigate the impact of conversion to Alzheimer disease on MCI patients' MDC trajectories.Results: At baseline, MCI patients performed significantly below controls only on the three clinically relevant standards of appreciation, reasoning, and understanding. Compared with controls, MCI patients experienced significant declines over time on understanding but not on any other consent standard. Conversion affected both the elevation (a decrease in performance) and slope (acceleration in subsequent rate of decline) of MCI patients' MDC trajectories on understanding. A trend emerged for conversion to be associated with a performance decrease on reasoning in the MCI group. Conclusions: Medical decision-making capacity (MDC) decline in mild cognitive impairment (MCI)is a relatively slow but detectable process. Over a 3-year period, patients with amnestic MCI show progressive decline in the ability to understand consent information. This decline accelerates after conversion to Alzheimer disease (AD), reflecting increasing vulnerability to decisional impairment. Clinicians and researchers working with MCI patients should give particular attention to the informed consent process when conversion to AD is suspected or confirmed. Neurology ® 2008;

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“…Instruments also have been developed to assess competence to consent to medical treatment and/or research (see Fitten, Lusky, & Hamann, 1990;Grisso, Appelbaum, & HillFotouhi, 1997;Marson, Hawkins, McInturff, & Harrell, 1997;Marson, Schmitt, Ingram, & Harrell, 1994;Vellinga, Smit, van Leeuwen, van Tilburg, & Jonker, 2004). Taken together, these measures provide useful information about factors contributing to successful and unsuccessful everyday problem solving and decision making about one's medical care.…”

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confidence: 99%

Judgment in older adults: Development and psychometric evaluation of the Test of Practical Judgment (TOP-J)

Rabin

Borgos²,

Saykin³

et al. 2007

Journal of Clinical and Experimental Neuropsychology

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This article reports on the development and validation of a novel, objective test of judgment for use with older adults. The Test of Practical Judgment (TOP-J) is an open-ended measure that evaluates judgment related to safety, medical, social/ethical, and financial issues. Psychometric features were examined in a sample of 134 euthymic individuals with mild Alzheimer's disease (AD), amnestic mild cognitive impairment (MCI), or cognitive complaints but intact neuropsychological performance (CC), and demographically-matched healthy controls (HC). Measures of reliability were adequate to high, and TOP-J scores correlated with select measures of executive functioning, language, and memory. AD participants obtained impaired TOP-J scores relative to HCs, while MCI and CC participants showed an intermediate level of performance. Confirmatory factor analyses were consistent with a unidimensional structure. Results encourage further development of the TOP-J as an indicator of practical judgment skills in clinical and research settings. Longitudinal assessments are being performed to examine predictive validity of the TOP-J for cognitive progression in our clinical groups.Judgment can be defined as the capacity to assess situations and draw sound conclusions after careful consideration of the relevant circumstances. From a neuropsychological perspective, judgment falls under the domain of executive functioning (Woods, Patterson, & Whitehouse, 2000) and includes both a cognitive appraisal process (i.e., determining what to do in a situation) and the behavioral follow-through (i.e., engaging in the adaptive/safe behavior). Numerous processes are involved in the execution of good judgment including generating appropriate strategies to approach a problem, identifying suitable goals, shifting from one idea to another, evaluating the potential consequences of different courses of action, inhibiting inappropriate responses, initiating and carrying out purposeful behavior, and monitoring the progress and effectiveness of a chosen solution. In the absence of practiced routines for solving problems in unstructured situations, individuals with compromised executive functioning may exercise poor judgment for a variety or reasons. For example, they may make impulsive decisions based on inadequate exploration of pertinent issues, fixate on a single solution due to compromised mental flexibility, or fail to consider the long-term consequences of their solutions (Channon, 2004;Thornton & Dumke, 2005;Woods et al., 2000). NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptIn addition to executive functioning, judgment relies upon other cognitive processes including aspects of memory and language. For example, when making difficult decisions it is often useful to call to mind relevant past experiences and practical knowledge. Additionally, successful problem solving and good judgment rely upon the ability to comprehend complex aspects of verbal and non-verbal language and effectively communicate one's decisio...

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Assessing Treatment Decision‐Making Capacity in Elderly Nursing Home Residents

Cited by 126 publications

References 22 publications

Assessment of patient capacity to consent to treatment

Assessment of patient capacity to consent to treatment

Medical decision-making capacity in mild cognitive impairment

Judgment in older adults: Development and psychometric evaluation of the Test of Practical Judgment (TOP-J)

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