JCPSLP Vol 23, Issue 1 2021

Speech pathology: An agile and responsive profession

What is best practice when conducting decision-making capacity assessment of patients in the hospital? Tracy Sheldrick, Alex Barwick, Paul Butterworth, and Nasim Salehi

Decision-making capacity in health care is central to optimise person-centred care. Impaired decision-making capacity is prevalent in hospital settings, leading to suboptimal care. This scoping review aimed to summarise current literature on practice and assessment of decision-making capacity in hospital settings with a focus on speech and language pathology. Four databases (Psychinfo, CINAHL, Scopus, and Medline) were searched for the period 2010 to March 2020, using search terms related to “assessment”, “decision-making capacity” and “patient”. Fifteen studies were included in the final analysis. Findings indicated doctors commonly assessed decision- making capacity with an informal patient interview with error rates up to 58%. Decision-making capacity assessments also rely heavily on patient communication abilities. Health care services should formalise decision-making capacity assessments and provide training to support improved assessment practices. Communication assistance should also be provided to patients, especially those with complex communication needs requiring speech and language pathology services. D ecision-making capacity (DMC) is a cognitive skill referring to a patient’s ability to understand information about their health and make reasoned decisions about their care (Gerstenecker et al., 2015) Accordingly, it is a necessity that DMC is present for informed consent to take place in health care settings (Sessums et al., 2011). Accurate assessment of DMC is crucial to ensure patient rights are respected and to determine when surrogate decision-makers need to be engaged (Wendler & Rid, 2011). This maximises a patient’s participation in their health care, minimises risks, and delays to health care (Shay & Lafata, 2015). Impaired DMC is prevalent in hospitals and frequently goes unrecognised (Wendler & Rid, 2011). The number

of people who require CDMCA is rising because of the changing demographics of patients in hospitals (Jayes, 2019). A systematic review found 26% of patients admitted to a general hospital ward had impaired DMC; this increased to 67% in a patient’s final week of life (Sessums et al., 2011). The most vulnerable were those with an intellectual disability, Alzheimer’s disease, and nursing home residents (Sessums et al., 2011; Sullivan & Heng, 2018). Similarly, Wendler and Rid (2011) reported impaired DMC in 40% of patients in the hospital, including 70% of older people and 95% those who were critically unwell. If not recognised, people without capacity may be asked to make life-altering decisions without the appropriate supports or surrogate decision-makers. DMCA is inherently complex: John et al. (2020) reported people over 65 needed to make decisions in eight domains including medical treatment, finances, consent to research, testamentary capacity, voting, sexual consent, and driving. Further complicating matters; capacity to make decisions can fluctuate and should be determined for each decision that is made (Aldous et al., 2014). DMCA can be challenging in a busy hospital setting because of the time commitment for repeated assessment. Each DMCA must consider the patient’s values, beliefs, and culture; this is a complex process (Siegal et al., 2014). As such, hospitals need to use limited resources well to identify red flags for incapacity so patients most at risk have an appropriate DMCA. Typically, the treating doctor is considered responsible for completing a DMCA. However, the role of the speech- language pathologist (SLP) given their expertise in supportive communication should be considered. Research has shown DMCA that relies solely on clinical judgement does not reliably detect impaired DMC (John et al., 2020). According to the Cochrane Library (2015) there was no single gold standard assessment of DMC, thereby creating ethical, legal, and safety risks (John et al., 2020). Impaired cognition and/or communication make DMCA more difficult. Hospitals need to treat an ageing population that is more likely to have cognitive and communication impairments (John et al., 2020). Jayes et al. (2020) found health professionals had difficulty identifying and screening for communication difficulties. Therefore, people with cognitive or communication difficulties may not get the support they require for a DMCA (Jayes et al., 2020). Hence, the role of SLP in DMCA is important. Patients with communication disabilities comprise 15% of the

KEYWORDS DECISION- MAKING CAPACITY

DELIVERY OF HEALTH CARE HEALTH CARE PROFESSIONALS SPEECH

LANGUAGE PATHOLOGY

THIS ARTICLE HAS BEEN PEER- REVIEWED

Tracy Sheldrick (top) and Alex Barwick

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JCPSLP Volume 23, Number 1 2021

www.speechpathologyaustralia.org.au