decisionmaking.PDB 5/MMNotifyץy )RCH1DTGP@J @JJ@J@J@J,@J-@J/7@J/C@J /@J /@J /@J 2@J 4J4J4J4@J8SJ:J:J<JdecisionmakingPDBץצUnfileddecisionmakingMM))   p@nn Try This Dementia Series Volume 1, Number 7, Fall 2004 Series Editor: Marie Boltz, APRN, MSN, GNP Communication Difficulties: Assessment and Interventions By: Della Frazier-Rios, RN, MS and Cora Zembrzuski, APRN, MSN, CS, PhD (cand.) *+9O2 J 8O@*+9r-1S..pring785$ Ethel Mitty, EdD, RN  &6 FffDecision-Vno-n$ooMaking and Dementia ~no   rPW ` : *n: P `p l `C   aa b  * 8p rH ` p  ` `[j r   22 J ` . >N ^ n + r~-C `is  `f~ ```^^  b.c `D+ rT  l |  Try This Dementia Series is developed by the John A. Hartford Foundation Institute for Geriatric Nursing and the Alzheimer's Association. PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the inted rnet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu. U &"   7  8:q W5 Z  l  op  no   gg  PW & 6p F[j VJ ` f ` v -C  f~  , pFurther Reading on this Topic p p p &: 8p HTry This Dementia Series Volume 1, Number 9, Spring 2005 Series Editor: Marie Boltz, APRN, MSN, GNP Decision Making and Dementia By: Ethel Mitty, EdD, RN WHY: Patients have the right to participate in decisions about their care, e.g., diagnostic work-ups, treatments, and direction of their daily care such as diet and ambulation. Consent to (or refusal of) treatment requires that the patient demonstrate that he/she can consider the: benefits, burdens and consequences treatment decision. The Capacity to make an informed decision is a clinical decision; it is not a question of legal competence. With dementia, people often have the capacity to make some, but not all, decisions. Thus, it is always better to try to ascertain the patients authentic wishes and preferences rather than to immediately default to a family member or other surrogate decision maker. TARGET POPULATION: All hospitalized patients with dementia. Some hospitalized patients with dementia will have been previously declared to be legally incompetent, and their legally appointed guardian must make decisions for them if the guardianship includes /covers health care decisions. For a patient who has not been adjudicated incompetent, the process to be followed to obtain diagnostic treatment and care decisions includes assessment of the patients capacity to make decisions. BEST PRACTICES: Patients whose cognitive status is unclear or fluctuates need protection from two types of mistakes: first, mistakenly preventing capacitated patients from directing the course of their treatment; second, failing to protect incapacitated patients from the harmful effects of their decisions. There is no gold standard by which to determine capacity to make a treatment decision. Use of a cognitive screen, such as the MMSE, is generally not predictive of decisional capacity. Patients with depression overlaying mild dementia may be inadvertently thought to lack decisional capacity. The steps in determining if a patient has sufficient decisional capacity to make an informed decision are similar to the basic elements of an informed consent and are based on a specific set of abilities. (See Guidelines for evaluating decision-making capacity). Guiding Concepts Capacity is not an all-or-nothing on-off switch. Decision-specific capacity assumes the presence or absence of capacity for a particular decision at a particular time and under a particular set of circumstances. A patient may be able to make, or indicate, some but not all decisions; e.g. a patient may be able to state (or indicate) their preferences related to daily care but not make complex treatment choices. Patients with even advanced dementia may have the capacity to appoint a health care proxy but not complete a living will. The more serious the risks or consequences of a decision, the clearer the patients capacity needs to be. For decisions about treatments with a high degree of risk or burden and/or a low potential benefit, and requiring a signed consent, patients with dementia need to evidence a fairly high degree of understanding and capacity to process information. Decision-making capacity presumes the retention of personal values and goals. The patient with dementia should be encouraged to participate in the discussion even if s/he indicates that another person can and will make the actual decision. A patients bad decision from the perspective of the healthcare professionals and/or family caregivers is not necessarily a prime indicator of lack of capacity or incompetence. Guidelines for evaluating decision-making capacity Evaluation Guidelines: The abilities that the patient must demonstrate in order for the nurse to have confidence that the patient has capacity to make a decision are: The patient appreciates and understands that s/he has the right to make a choice. The patient understands the decision he/she is being asked to make (daily care preferences, treatment, nature of the consequences of treatment consent (or refusal). The patient can communicate his/her decisions and explain in own words why a particular decision was made. The patients decision is stable and consistent over a period of time (Roth et al., 1977) Process Guidelines Information should be presented in short, simple sentences. After each input of information, ask the patient to tell you in his/her own words what was just said. Listen for accuracy of the recalled information; the patient does not have to use medical jargon. Assist the patient in considering what s/he thinks will be the benefit and burden to them of each treatment option (or refusal); e.g. what would proceeding with the test/intervention likely do to further their personal goals, interests, life style, comfort, longevity, anxiety reduction, etc. What kinds of decisions have they made in the past that were of similar significance /magnitude? The process for determining capacity should not be rushed. Most healthcare decisions are not made individually; they are made with family involvement. Yet, the person with dementias authentic wishes should be respected and not over-ruled in the interests of what family or staff feel is best for them. Decisions made by others Health Care Proxy (HCP): The Durable Power of Attorney for Health Care allows an individual to appoint someone, i.e., the health care proxy or agent, to make health care decisions if the individual loses the ability to make decisions or communicate his/her wishes. These decisions can be made as the need arises. State laws differ about who is assumed to be the surrogate decision-maker for a person who cannot make decisions for him/herself and does not have a designated HCP. State laws also differ on who is included and the order of preference in selecting a surrogate decision-maker. Contact the American Bar Association Commission for Legal Problems and the Elderly at http://www.abanet.org/aging/ for state-specific information. When a decision must be made by another person, ask: If (the patient) could join this discussion, what would he say? Faced with similar situations in the past, how did s/he decide? Try This Dementia Series is developed by the John A. Hartford Foundation Institute for Geriatric Nursing and the Alzheimer's Association. PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu. Further Reading on this Topic: Kapp, M.B. & Mossman, D. (1996). Measuring decisional capacity: Cautions on the construction of a capacimeter. Psychology and Public Policy Law, 2; 73-95. Mezey, M., Mitty, E., & Ramsey, G. (1997). Assessment of decision- making capacity: Nurses role. Journal of Gerontological Nursing, 23(3); 28-35. Midwest Bioethics Center. (1996). Ethics Committee Consortium: Guidelines for the Determination of Decisional Incapacity. Kansas City: Midwest Bioethics Center. Ramsey, G. & Mitty, M. (2003). Advance directives: Protecting patients rights. In M.D. Mezey, T. Fulmer, & I. Abraham (Eds.), Geriatric nursing protocols for best practice (2nd ed., pp. 265-291). New York: Springer Publishing. Roth, L.H., Meisel, A., & Lidz, C.W. (1997). Tests of competency to consent to treatment. American Journal of Psychiatry, 134 (3); 279-284. !+  "mU"wa`&4N 3TlZ =/ :p5@ @  b27 L nz M_C2$2[\ PV 3q W5p%b%/W- $whjg>  g.  `  " @ `  `  ` }   r3