JCPSLP Vol 23, Issue 1 2021

studies found using a formal DMCA tool in conjunction with clinical judgement was more reliable when making a capacity determination when compared to relying on clinical judgement alone (Barstow et al., 2018; Bilanakis et al., 2014; Zuscak et al., 2016). Barstow et al. (2018) concluded that while a patient’s capacity may often be readily apparent, using a structured approach including formal assessments to assess capacity is best. Capacity is decision- and context- dependent Capacity need be assessed only when there are concerns capacity is impaired (Barstow et al., 2018). DMC is not static, capacity can be permanently or temporarily impaired and may fluctuate across hours or days. Temporary impairment of DMC may be related to sudden illness, e.g., concussion or side effects of medications. Studies drawing on expert opinion reported a range of factors that can impact patient DMC including the complexity of the decision, context (e.g., recent trauma), patient and clinician communication skills, acute illness, and psychiatric impairment (Aldous et al., 2014; Barstow et al., 2018; Bertrand et al., 2019; Hill & Seymour, 2010; Siegal et al., 2018). As such, capacity must be assessed for each decision with consideration of the range of factors that can influence DMC (Sessums et al., 2011; Siegal et al., 2018). Assessor skills and competency Most studies reported that assessments were usually performed by a patient’s treating doctor. Two studies highlighted the importance of doctors being appropriately trained and supported to make accurate capacity determinations (Lamont et al., 2019; Young et al., 2018). However, a range of papers reported doctors had a lack of knowledge about DMCA and legislation as well as poor communication skills and low confidence regarding DMCA practices (Lamont et al., 2019; Mueller et al., 2017; Siegal et al, 2014). These findings were supported by the number of studies that noted when doctors relied on clinical judgement alone there was poor agreement between doctors and a trend to over-estimate capacity (Barstow et al., 2018; Bertrand et al., 2019; Bilianakis et al., 2014; Kolva et al., 2018; Seigal et al., 2018;). Bertrand et al. (2019) found that a doctor’s values could also bias a DMCA and the potential implications of this should not be ignored. Cognition and communication impairments were found to be the main complicating factor in the assessment of DMC, and these are difficult for many health professionals to detect (Jayes, 2019). Education and training of doctors can improve their knowledge, skills, and the reliability of DMCAs (Lamont et al., 2019; Siegal et al., 2014). However, Young et al. (2018) reported doctors had little access to DMCA training post-qualification and one-third lacked the confidence to assess capacity to a level that would stand up in court. A lack of time to properly complete and repeat DMCAs was reported as a major challenge faced by hospital doctors (Young et al., 2018). Lamont et al. (2019) advocate for DMCA to be a part of health policy and for organisations to provide clear direction and clinical governance as well as ensure that DMCA training is provided. DMC and communication It was widely reported that all health care professionals who conduct DMCAs should ensure patients understand, appreciate, reason, and can communicate a choice

Articles identified in databases (n = 299)

Articles excluded after evaluation of titles/abstract (n = 213)

Articles after duplicates removed (n = 236)

Full-text articles assessed for eligibility based on inclusion criteria (n = 23)

Additional studies identified through snowball sampling (n = 4)

Total included studies (n = 15)

Figure 1. PRISMA diagram

Results Study characteristics

A total of 15 papers met the inclusion criteria. Papers used a diverse range of designs, including narrative reviews (n = 6) (Barstow et al. 2018; Hill & Seymour, 2005; Jayes, 2019; Mayo & Wallhagen, 2009; Siegel et al, 2014; Zuscak et al., 2016) and quantitative (n = 9) designs. Of the narrative reviews, case-control (n = 4) (Gerstenecker et al., 2015; Kolva et al., 2018; Mueller et al., 2017; Triebel et al., 2015), cross-sectional (n = 2) (Aldous et al., 2014; Young et al., 2018), consecutive cohort (n = 2) (Bilanakis et al., 2014; Lamont et al., 2019) and (n = 1) prevalence designs (Bertrand, 2019) were utilised. The studies were conducted in the USA (n = 6) the UK (n = 2), Australia (n = 3), France (n = 1), Germany (n = 1), Greece (n = 1), and New Zealand (n = 1). Overall sample sizes ranged from 59-226 participants. See Table 2 for an overview of the included studies. Accuracy of the methods of capacity determination Numerous studies described the essential elements of DMCA to be a demonstrated ability to; “understand”, “appreciate”, “reason” and “express/communicate” a choice free of coercion (Barstow et al 2018; Gerstenecker et al., 2015; Jayes, 2019; Mueller et al., 2017). While DMCA practices varied widely among the studies, assessment of capacity based on clinician judgement was commonplace (Barstow et al., 2018). Multiple studies reported capacity determinations made based on clinical judgement were found to have poor interrater reliability and assessors commonly overestimated capacity when compared with the results from formal tools (Sessums et al., 2011; Barstow et al., 2019; Bertrand et al., 2019; Bilanakis et al., 2014, Kolva et al., 2018; Seigal et al., 2018). Several DMCAs used in the studies sought to assess a patient’s capacity to understand, appreciate, reason, and communicate a choice; however, a Cochrane review found there was no gold standard assessment (Cochrane Library, 2015). Some

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JCPSLP Volume 23, Number 1 2021

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