JCPSLP Vol 23, Issue 1 2021

Table 3. Key features and findings from narrative reviews and expert opinions

Author

Study type Participants

DMCA tools

Findings

Expert opinion

N/A

MacCAT-T ACE Understanding treatment disclosure HCAT

Barstow et al., 2018 USA

• A structured approach to DMCA should be taken • Formal assessments can increase the accuracy of DMCA

• A trend to under-diagnosis of incapacity • Cognitive assessments can aid DMCA

patients to participate in DMC (Aldous et al., 2014; Jayes, 2019; Zuscak et al., 2017). However, the role of the SLP in DMCAs was not well defined and therefore not well articulated in professional standards, legislation, or local guidelines (Aldous et al., 2014). DMC and cognition A study by Young et al. (2018) found that doctors identified cognition as the main red flag when considering the DMC of a patient. Several studies reported links between impaired cognition and incapacity, but cognitive ability did not determine capacity (Barstow et al., 2018; Gerstenecker et al., 2015; Mayo & Wallhagen, 2009; Triebel et al., 2015; Zuscak et al., 2016). Mayo and Wallhagen (2009) found that patients with dementia who had impaired memory and verbal reasoning were more likely to have impaired DMC. Similarly, Triebel et al. (2015) found in a study of patients with brain metastases that impaired reasoning and understanding correlated with impaired DMC. Gerstenecker et al. (2015) also investigated DMC of patients with brain metastases who were matched to healthy controls and found over half of the patients with brain metastasis had impaired understanding. Impaired understanding correlated with poor short-term memory, executive dysfunction, and slowed information processing (Gerstenecker et al., 2015). • Communication disorders influence the patient risk of being misunderstood • SLPs have expertise to support participation in DMCA for people with communication disorders • DMCA should involve a cognitive ability assessment and administration of a DMCA tool • The environment should optimise participation in DMCA e.g. communication barriers, consider reversible causes of incapacity and consider values and culture • Decisions must be circumstance specific • Patients should be provided with the assistance and support required to understand information related to their decision • Adults can make advanced care plans to ensure they can make their future medical care wishes clear • Information for patients must be accessible • SLPs can support those who are communicatively impaired to be involved in shared decision making • M-CAST may be a valuable tool to screen and support communication needs for a DMCA • Verbal reasoning and memory impairment were predictive of poor DMC • Poor interrater reliability between clinicians not using formal tools • Training can improve DMCA reliability • DMC should be determined and documented every time a patient undergoes hospital procedure or routine care • Health care organisations need clinical practice guidelines, policies, and procedures

MMSE MoCA

Hill & Seymour, 2010 UK

Expert opinion

N/A

Nil

Jayes, M. 2019 UK

Descriptive

N/A

M-CAST

Mayo & Wallhagen, 2009 USA Seigel et al., 2015 USA

Descriptive

Older adults with dementia

HCAT MacCAT-CR (for research) MMSE

Expert opinion

N/A

MacCAT-T

Zuscak et al., 2016 Australia

Nil

Expert opinion

Adults with communication disorders

(Barstow et al., 2018; Gerstenecker et al., 2015; Jayes, 2019; Mueller et al., 2017; Triebel et al., 2015). Triebel et al., (2015) found understanding to be the most taxing component of the DMCA. As such, communication difficulties make DMCAs more complex (Gerstenecker et al., 2015; Zuscak et al., 2016). It is not uncommon for people with additional communication needs to be excluded from studies. Bilianakis et al. (2014) excluded patients who did not speak Greek, had severe cognitive impairment or aphasia and were unable to speak verbally. Aldous et al. (2014) reported that an inaccurate understanding of communication needs and abilities could disguise capacity and incapacity. Therefore, before conducting DMCAs doctors need to ensure that there are no communication or literacy barriers to participation and that there is an evaluation of any reversible causes of incapacity such as delirium (Barstow et al., 2018). Mueller et al. (2017) recommended doctors require communication skills training so they can support patients to understand and participate in DMCA. Three studies highlighted the important but under-recognised role of the speech and language pathologist (SLP) (Aldous et al., 2014; Jayes, 2019; Zuscak et al., 2017). SLPs were found to have communication skills expertise to support

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JCPSLP Volume 23, Number 1 2021

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