In seeking to encourage advance care planning, clinicians in nursing homes and hospitals have become increasingly concerned about how best to determine which residents have the capacity to execute advance directives (living wills and health care proxies). The absence of professionally agreed upon clinical guidelines hamper clinicians’ ability to determine decisional capacity. People who appear confused or have dementia tend not to be given written or verbal information about advance directives. Capacity is a significant concern to the VA community as our veterans age and require more extensive and complicated therapies for adequate care. Improving the process by which "decision-specific capacity" is determined will aid in the informed consent process for the patient suspected of having diminished capacity. Directing this effort towards the ability to appoint a health care proxy will assure that at a minimum, as many patients as possible will be able to exercise a choice as to who will be making health care decisions for them when they are no longer capable of making them for themselves.
Our objectives were: 1) to identify 50 men and women age 65 and over (25 of whom were hospital patients and 25 of whom were ambulatory care patients at the Bronx VAMC) to participate in a study to determine capacity to appoint a health care proxy; 2) to determine if their responses to previously developed "Guidelines" for determining capacity in older people to execute a health care proxy in a nursing home setting were valid in other settings; and 3) to determine if responses to the "Guidelines" compared favorably to clinical and objective measures of cognition and depression, and how these conditions influence capacity.
This was a two-year, prospective, cross sectional cohort pilot study. Patients 65 and older, both male and female, were chosen from the Geriatric outpatient clinic and inpatient units at the Bronx VAMC, based on physician and nursing assessment of ability to participate. Participants’ cognitive functioning was assessed with the Folstein Mini-Mental Status Exam (MMSE). Approximately 25 percent of participants were also evaluated by a psychiatrist who assessed decision-making capacity and depression. Finally, all participants were administered the Health Care Proxy "Guidelines."
Data was collected on 23 inpatients and 35 outpatients. The mean age was 76.6 years (range 65-95 yrs). The mean MMSE was 26 (range 13-30). Approximately 20 percent of the subjects were unable to complete the "Guidelines" and appoint a proxy. Capacity to name a health care proxy as measured by the "Guidelines" was not statistically associated with the MMSE score. Six of the nine subjects with low MMSE scores (13-23) were able to complete the "Guidelines" and appoint a health care proxy. There was 85 percent agreement between the psychiatrist and the "Guidelines" in the determination of capacity. Years of school was not related to performance on the "Guidelines." Because only one patient was assessed as depressed by the psychiatrist, no inferences about the relationship among capacity, cognitive status, and depression could be made.
The psychiatric assessment of capacity correlated highly with the "Guidelines." Inasmuch as the psychiatric evaluation is the current "gold standard," this finding adds evidence for the concurrent validity of the "Guidelines." The "Guidelines" show promise as a clinical tool to assure that as many patients as possible are able to exercise a choice as to who will be making health care decisions for them when they are no longer capable of doing so for themselves.
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