JCPSLP Vol 23, Issue 1 2021

Furthermore, when comparing palliative care patients with a healthy control group Kolva et al. (2018) found the terminally ill patients to be more likely to have impaired DMC. Terminally ill patients were more likely to present with impaired reasoning, appreciation, and understanding (Kolva et al., 2018). The Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) were the most commonly used cognitive assessments in the studies reviewed (Bastow et al., 2018; Bilanakis et al., 2014; Mayo & Wallhagen, 2009; Zuscak et al., 2014). Barstow et al. (2018) and Zuscak et al. (2014) both advocated for cognitive assessments to be an adjunct to but not a substitute for a DMCA. Discussion This scoping review highlighted that DMC often goes unrecognised in the hospital setting, posing risks to patient safety and autonomy (Bertrand et al., 2019). There were several key themes identified in this review. Factors that impact on DMCA include how capacity is assessed, the skills of assessors, the inherent variability of capacity, and the cognitive and communication demands of capacity assessment. Doctors commonly assess DMC relying on their clinical judgement; however, this practice is unreliable and capacity is often overestimated (Barstow et al., 2018; Bertrand et al., 2019). Commonly, doctors report that they don’t receive adequate training in the workplace to improve knowledge and skills to perform DMCAs (Lamont et al., 2091; Young et al., 2018). Furthermore, DMCA is often complicated by impaired cognition and/or communication, and several studies indicate assessors require training to develop supportive communication skills to enable patient participation in assessments (Gerstenecker et al., 2015; Mueller et al., 2017; Zuscak et al., 2016). It is timely to review and discuss current practices, barriers and consider opportunities to enhance DMCA processes in the hospital. Determinations about DMC are most commonly made by the treating doctor who relies on information obtained from an informal patient interview (Barstow et al., 2018) When doctors rely on informal interviews alone incapacity was underdiagnosed by as much as 58% and several studies reported poor interrater reliability (Barstow et al., 2019; Bertrand et al., 2019; Bilanakis et al., 2014, Kolva et al., 2018; Sessums et al., 2011; Seigal et al., 2018). The implication of relying on clinical judgement to determine capacity is that over half the patients assessed as having capacity may be asked to make critical decisions without a true understanding of the implications (John et al., 2020). Current practice is placing patients at risk of making decisions without capacity and organisations at risk by providing inadequate clinical governance structures and training, thereby impacting on patient safety. Capacity is often apparent, clinical judgement is not redundant; however, when there is uncertainty about capacity, clinical judgement alone is not reliable (Barstow et al., 2018). While there is no gold standard DMCA, applying clinical judgement alongside a formal DMCA was considered a more reliable method to determine capacity (Barstow et al., 2018; Cochrane Library, 2015; John et al., 2020; Sessums et al, 2011; Seigal et al., 2015). A range of tools were used in the studies, which makes comparing studies and their findings challenging. The most frequently used tool was the MacCAT-T which covers diagnostic categories and is standardised with certified validity and reliability. However, the CCTI, HCAT,

understanding treatment disclosure, and the ACE, were also used in a range of studies. In the absence of a gold standard assessment, Sessums et al. (2011) and Bartstow et al. (2018) recommended the ACE, because it draws on the decision at hand, has an acceptable evidence score, and can be administered in 15–30 minutes. It would be prudent for health services to review available DMCA tools to determine those most appropriate for their needs, patient population, and service context. Cognitive impairment was the main red flag for impaired capacity as reported by doctors in a study by Young et al. (2018). While many research papers reported links between cognitive impairment and capacity, it was not found to be a definitive causal link (Gerstenecker et al., 2015; Sessums et al., 2011; Triebel et al., 2015; Zuscak et al., 2016). There were indications in some studies that understanding, information processing, verbal reasoning, and memory correlated with a higher incidence of impaired DMC (Gerstenecker et al., 2015; Kolva et al., 2018; Triebel et al., 2015). However, there was no particular pattern for cognitive decline and incapacity. Cognition, as well as communication impairments, complicate the assessment of DMC, and these are difficult for many health professionals to detect (Jayes et al., 2020). Cognitive assessment is not a requirement of DMCA; however, it should be considered as an adjunct if there is uncertainty about cognitive functioning (Barstow et al., 2018; Sessums et al., 2011; Zuscak et al., 2014). The MMSE and MoCA were the most commonly used cognitive assessments; however, none of the studies referred to gold standard assessments of cognition (Bastow et al., 2018; Bilanakis et al., 2014; Mayo & Wallhagen, 2009; Zuscak et al., 2014). Caution must be given to the communication demands of cognitive assessments, which may disadvantage those with communication difficulties (Aldous et al., 2104). Some cognitive screens/assessments do have communication accessible versions, e.g., Oxford cognitive screen. It would be important to determine the needs of the patient group when selecting cognitive screening tools and assessments for use in the hospital setting. These findings should prompt clinicians to closely examine the capacity of patients presenting with these particular cognitive impairments and to conduct cognitive assessment alongside DMCA when there are concerns about DMC. However, further research is required to fully understand the impact of different cognitive impairments on capacity. Communication impairments influence the complexity of DMCAs. Several studies reported that DMC assessors needed to be able to provide communication support for patients to enable their participation and gain a true and accurate understanding of capacity (Gerstenecker et al., 2015; Mueller et al., 2017; Zuscak et al., 2016). There is a very high prevalence of patients who require additional communication supports in the hospital (Hemsley et al., 2016; McCrabb et al., 2019). Being able to facilitate the participation of people with communication and cognitive difficulties is a critical clinical skill but this study found that many doctors lacked supportive communication skills (Lamont et al., 2019; Mueller et al., 2017; Siegal et al, 2014). Doctors are reporting a lack of time, knowledge, and skills to be able to conduct DMCA. Other health care professionals within hospitals have valuable knowledge and skills that could enhance the DMCA process. DMCAs are highly cognitively and linguistically loaded tasks,

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JCPSLP Volume 23, Number 1 2021

Journal of Clinical Practice in Speech-Language Pathology