Healthcare Decision Making

1. Healthcare Decision Making Photo credit: www.newmanrh.org Cheryl Howard ~ March 2012 Ferris State University ~ NURS 314 Gerontological Nursing Nursing Standard of Practice Protocol ConsultGeriRN.org

2. Overview • Core ethical principles for clinicians are respect for autonomy, beneficence, nonmaleficence and justice. • Care professionals have an obligation to be alert for questionable or fluctuating healthcare decision making capacity. • Careful balancing of information, principles, rights and responsibilities is required in order to make clinically, legally, and ethically valid decisions. (Mitty & Post, 2008)

3. Decision Making Concepts • People with decisional capacity have a RIGHT to determine what is done to their bodies. • AUTONOMY is exercised in the process of informed consent (or refusal) of treatment and care planning. • Determining decision making capacity is VITAL because interventions have potential for benefit/risk. • Capable patients are RESPECTED when their decisions are honored; ABANDONMENT occurs when incapacitated patients’ wishes are honored. (Mitty & Post, 2008)

4. Definition of Decisional Capacity Decisional capacity: a clinical determination that an individual has the ability to understand the consequences for health decisions and that they are able to make and take responsibility for those decisions. • Patients may have the ability to make some decisions but not others • Decision making capacity may fluctuate according to factors such as clinical condition, time of day, medications, comfort and psychological status. • Delegation of decisional authority cannot be inferred & must be explicitly confirmed. (Mitty & Post, 2008)

5. Other Important Definitions • Consent: requires evidence of decisional capacity. Consent or refusal of intervention is based on disclosure, understanding, voluntary choice of options. • Competence: legal presumption of mental ability to negotiate legal tasks such as enter into contracts, make a will, etc. • Incompetence: judicial determination that a person is not able to negotiate legal tasks and should be prevented from doing so. (Mitty & Post, 2008)

6. Standards of Decision Making • Prior explicit articulation – decision based on previous expression of a capable person’s wishes • Oral or written comments or instructions • Substituted judgment – decision by others based on formerly capable person’s wishes • Can be inferred from prior behaviors or decisions • Best interested standard – decision based on what others judge to be in the best interest of a person • ONLY if this person never made known health care wishes and whose preferences cannot be inferred. • (Mitty & Post, 2008)

7. Nursing Care Strategies • Communicate with patient, family or surrogate decision maker to enhance understanding of treatment options. • Be sensitive to racial, ethnic, religious & cultural beliefs and traditions. • Be aware of available conflict resolution support systems in your health care organization. • Help the patient identify who should participate in treatment discussions and decisions. (Mitty & Post, 2008)

8. Nursing Care Strategies continued • Help the patient express what they understand about the clinical situation & outcome expectation. • Select (or construct) appropriate decision making aids. • Observe and document specific times of confusion, lucidity, and mental state in day, evening & night. • Observe, document & report patients ability to: • Articulate needs & preferences • Follow directions • Communicate consistent care wishes • Make simple choices “Do you prefer juice or water?” (Mitty & Post, 2008)

9. Nursing Care Strategies continued • Assess understanding relative to the particular decision at issue. • “Tell me in your own words what the physician explained to you.” • “Tell me which parts were confusing.” • “What do you feel you have to gain/lose by AGREEING to the proposed intervention?” • “What do you feel you have to gain/lose by REFUSING to the proposed intervention?” • “Tell me why this decision is important (difficult, frightening, etc.) to you.” (Mitty & Post, 2008)

10. Assessment of Decisional Capacity • There is no “gold standard”. • The ability to understand the CONSEQUENCES of a decision is an important indicator of decisional capacity. • Assessment should occur over a period of time at different times of day with attention to patient’s comfort level. • The Mini-mental state examination (MMSE) or Mini-Cog is NOT a test of capacity. • Tests of executive function better approximate decision making skills of reasoning and recall. There is no standardized method of testing executive function, various tests are used (NCLD, 2010). • Safe & appropriate decision making is retained in early stage dementia & mild-moderate mental retardation (Mitty & Post, 2008)

11. Best PracticeAssessment/Screening Tools • Decision Making and Dementia: Evaluation Guidelines Click here for Guidelines & instructions. • Brief Evaluation of Executive Function: Screening tools for the refined assessment of cognitive function. Click here for screening tools & instructions. • Royall’s CLOX Clock Drawing • The Controlled Oral Word Association Test • The Trail Making Test, Oral Version (Mitty & Post, 2008)

12. Nursing Evaluation & Expected Outcomes • Plan of Care: include instructions regarding frequency of observation to ascertain periods of patient lucidity. • Documentation: • Describe process of capacity assessment. Make sure assessment method is specific to issue at hand. • Describe specifics of patients orientation. • Consistently use appropriate mental status descriptors. • Describe interaction with informed consent & refusal. • Record patient’s language used to describe intervention under consideration. Record patient’s demeanor. • Record patient’s questions & clinicians answers. • Referral: refer to ethics committee or consultant in situations of decision making conflict. (Mitty & Post, 2008)

13. Application to Practice “Decision making concepts are an important part of my job as an RN case manager for MiChoice Waiver Nursing Home Transition Program. First and foremost, I must ensure who the legal decision maker is for participants referred to the program. In over half my cases, the participant “is their own person” which is another way of saying that they are legally able to make their own decisions. The other times there is a guardian who makes all the decisions for the person. Sometimes there is a conservator or financial durable power of attorney (DPOA) over financial matters only. There could also be a DPOA only over medical issues. It can be complicated because paperwork isn’t always clear. Something that is important to me is that even when someone is not “their own person”, I feel that the opinions and wishes of that participant should still be taken under consideration if it all possible. I have thoroughly embraced the person centered planning concept and have found time after time that interventions are more successful when the participant is “on board” regardless if they are their own legal decision maker or not.

14. Application to Practice continued We often have to ask permission and involve the designated decision maker for program participation, care planning, and signing paperwork for the participant. An interesting thing that I have learned in my job is that in most cases DPOA’s are only effective if it is enacted and signed by 2 physicians OR if the participant requests that it be enacted. I have found that many participants and their families think that a DPOA is a type of “guardian” which is not an accurate assumption. I have also found that after a DPOA is enacted, it is can easily be revoked if the person verbally and in writing requests that it be revoked. Many think that once a DPOA is enacted, it takes a trip to court to change it. This is not true from what I have learned. Of course this can be a complicated topic that requires a thorough review of the exact wording of each individual designated decision maker document. This can be frustrating to deal with but it is very important to determine before I provide assessment and care management services.

15. Application to Practice continued I have not had the opportunity to use the decisional capacity assessment tools from this protocol in my practice setting. In my position as a case manager, all of the cognitive and decision capacity assessment is done by my teammate who is a social worker. Although screening and assessing for cognitive ability is certainly within my scope of practice, this is not something that is a duty in my current position. I have given printouts of these assessment tools to the social worker on my case management team. I have offered to assist her in trying them in the field. Currently there is no standardized test mandated for her assessment. I feel that our participant’s care management may benefit from an effective, easy method of screening for level of executive dysfunction and cognition. I am hopeful that my social worker partner will try these evidence based tools.” Cheryl Howard RN

16. Goals for Nursing Practice Clinicians should: • Understand the supporting bioethical and legal principles of informed consent. • Understand the issues and processing of assessing decisional capacity. • Be able to differentiate between competence and capacity. • Be able to describe the nurse’s role and responsibility as an advocate for the patient’s voice in health care decision making. (Mitty & Post, 2008)

17. References Mitty, E. L., & Post, L. F. (2008, March). Nursing standard of practice protocol: Healthcare decision making. Retrieved from Hartford Institute for Geriatric Nursing website:http://consultgerirn.org/‌topics/‌treatment_decision_making/‌want_to_know_more NCLD. (2010, December 17). What is executive function? Retrieved from National Center for Learning Disabilities website: http://www.ncld.org/‌ld-basics/‌ld-aamp-executive-functioning/‌basic-ef-facts/‌what-is-executive-function

18. Final Grade REQUIREMENTS • Brief summary of the protocol. For this presentation to peers, it is important that students select the main points. • Report the results of your trial of the protocol. • What is your professional nursing opinion of the Hartford Try This protocol (strengths and weaknesses)? • Does your usual practice setting have a standardized plan of care for this problem? Is it similar to the best-practices listed in ConsultGeriRN? • Is there any additional information you need before deciding whether or not to modify your practice in light of the presented information? How would you determine if a change in your practice was helpful to your patients (can you think of any ways to measure improvement related to the subject in your practice setting, or in general)? • Report all this in a short PowerPoint and post during your assigned week. Should include all information above with 20 slides (+ or – 5). • Focus on the essentials to report to your colleagues on this patient, presenting materials on all headings from the rubric. Narration is a plus. • Cite reference of the ConsultGeriRN.org protocol in APA format. It is not necessary to use other sources, but if used be sure to cite them! GRADE Grade= 95% Great job! Presentation is very well done and provides a lot of helpful information to students. I especially liked that you explained ethical implications. I did not see that you proposed how to evaluate of a change in practice would be beneficial to your patients, but otherwise you covered all expectations of the assignment. It is nice that your assigned protocol had relevance to your job.

19. Final Grade Rubric