JCPSLP Vol 23, Issue 1 2021

in particular, come to the fore with those patients who have complex communication needs (Jayes, 2019). Most studies indicated DMCA is completed only by the treating doctor, a psychiatrist, or a neuropsychologist. A more flexible approach that facilitates collaboration with the multidisciplinary team and engages health professionals with the right expertise at the right time would better meet patient needs (Jayes, 2019). As such, investment in education for health professionals is critical to improving DMCA practices in hospitals. Training needs to include information about the characteristics and red flags of incapacity, available assessments, legal requirements, local processes, and communication skills training (Lamont et al., 2019). Doctors identify their need for education regarding assessment processes and improved understanding of relevant legislation, and this is equally important for any other health professionals involved in DMCA (Lamont et al., 2019). It is critical to explore how the broader team including SLPs can be appropriately resourced and enabled to improve DMCA practices in hospitals. This review found evidence current DMCA processes relying solely on clinician judgement are unreliable and therefore unsafe. Quality and safety could be improved if organisations ensure that DMCA procedures (a) recommend formal tools to supplement clinician judgement; (b) provide specific training about DMCAs so assessors understand requirements and relevant legislation, and (c) ensure health professionals have the skills and resources to enable participation of patients with cognitive and communication difficulties (Barstow et al., 2018). Emerging research suggests other health professionals such as SLPs could play a pivotal role in improving DMCAs in hospital. There remains limited guidance on who can/cannot perform DMCA, which poses challenges for improving processes in hospitals (John et al., 2020). Translation of evidence into clinical practice is difficult in the absence of overarching clinical governance mechanisms such as clinical guidelines, legislation, or quality standards (John et al., 2020). Improved clinical governance and accountability at national and local organisational levels is important for the improvement of DMCAs in hospitals. Limitations This study limited the search criteria to the English language, and peer-reviewed research papers published 2009–2020 to access a manageable number of current papers. This review focused on patients in the hospital. The restrictions may have limited the breadth of articles and the applicability of findings across the health care continuum, such as in outpatient and community settings. The included papers varied in terms of sample size, and they focused mainly on specific patient groups, which may affect the generalisability of findings. Furthermore, this review did not investigate the validity and reliability of the specific DMCA tools and as such does not recommend a specific tool. Conclusion DMCA using clinical judgement alone is not reliable but remains the most common method used to assess DMC. It is recommended that clinicians utilise clinical judgement alongside a DMCA tool to assess DMC. Further, the addition of cognitive testing and the support of an SLP may improve assessment in this field. Finally, the development of a rigorous DMCA tool that incorporates communication needs is required to improve patient outcome.

and SLPs, in particular, are capable of assessing and providing communication supports to any patients with communication and cognitive-linguistic impairments (Jayes et al., 2020). SLPs could be an integral part of the interdisciplinary team involved in DMCA, providing communication skills training to upskill other health care professionals, supporting the development of alternative and augmentative communication (AAC), and providing direct patient assessment and support in more complex cases (Zuscak et al., 2016). Matus, Mickan and Noble (2020) found a dedicated DMCA support role in hospitals can improve the knowledge and skills of other clinicians. While in this study the DMCA support worker was an occupational therapist (OT), further exploration of how SLPs could utilise communication skills expertise in a DMCA support role would be valuable Presently patients in hospital who have communication difficulties are unlikely to receive the communication supports required to enable their participation in decision-making (Jayes et al., 2020). Although SLPs are uniquely skilled in the support of people with complex communication needs, a lack of role definition and clarity regarding legislative requirements impacts how SLPs can utlise their expertise in the hospital setting (Aldous et al., 2014; Jayes, 2019). Speech Pathology Australia predicts the role of the SLP in creating communication accessible environments will develop over the next decade. DMCA is a tangible example where SLPs could positively influence patient care. McCormick and Bose (2017) found that SLP students who participated in a DMC short course had increased knowledge and confidence and improved their capacity to train others about the SLP role in DMCA. This study highlighted an opportunity for both discipline-specific and interdisciplinary DMCA training. It is also worthwhile to consider the skills of the SLP and their expertise in the delivery of conversation partner training (CPT) as a tool for developing the supportive communication skills of others. CPT is an intervention that provides training to someone other than the person with a communication impairment and can be tailored for health professionals, families, or carers (Cherney et al., 2013). There are several CPT programs, and Supported Conversation for Adults with Aphasia (SCAA™) has been shown to increase participation of people with aphasia when communicating with trained communication partners. Interestingly, O’Halloran et al. (2011) found that patients in hospitals with communication difficulties required similar communication supports as taught in SCAA™. Improving the knowledge and skills of all health care professionals in the hospital setting could drastically improve the patient experience and improved engagement in and reliability of DMCA. Further to CPT it is important to note that many health care professionals including doctors can find it difficult to detect communication impairments (Jayes, 2019). The M-CAST is a DMCA tool in development (Jayes, 2019). The M-CAST has the addition of a communication screening tool and communication accessible resources to support DMCA conversations (Jayes, 2019). Appropriately resourcing doctors to help them properly screen and support patients who have additional communications needs should improve current processes considerably. However, this does not negate the need for the expertise of an SLP. The specialised communication skills of an SLP would be beneficial for optimising patient participation and,

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JCPSLP Volume 23, Number 1 2021

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