[Evaluation of the capacity of elderly patients to make decisions about their health]

Determining whether someone has mental capacity to make a decision: clinical guidance based on a review of the evidence

Valid consent to healthcare treatments depends upon a person having the capacity to give it. The Mental Health Act not only requires a presumption of capacity but also expects clinicians to take reasonable steps to establish whether the patient lacks capacity. The facts are that (1) lack of capacity is common among hospital inpatients and people in the community needing care, but is often not recognized. (2) Capacity must not be judged on the basis of the decision made: an unwise decision is not evidence of a lack of capacity, and a decision expected by the clinician is not evidence of capacity. Capacity is decision-specific and must be considered critically without preconceptions. There is no valid other test. (3) Clinically people will fall into four groups: (a) obviously lack capacity and will not recover it, (b) obviously lack capacity but will recover soon, (c) obviously have capacity, (d) capacity is in doubt and major healthcare decision needed. Only the last group need more detailed attention. (4) Capacity is (a) relative to the complexity of the information; (b) on a spectrum, not categorical; (c) decided using clinical judgement; and (d) subject to disagreement among assessors. The recommendations are as follows: (1) capacity should always be considered within the decision-making process, and the outcome should be documented, with sufficient information to understand the opinion given. (2) Detailed assessment should be reserved for situations when (a) a major decision is needed and (b) there is time to assess and discuss the assessment.

[Facilitators and barriers regarding end of life care at nursing homes: A focus group study]

AIM

To identify the facilitators and barriers experienced by professional related to end of life care in nursing homes.

DESIGN

Descriptive qualitative research with phenomenological orientation, through content analysis.

PLACEMENT

Nursing Homes at Primary Care District in Granada (Spain).

PARTICIPANTS

Fifteen clinical professionals with, at least 6 months of experience in nursing homes, without specific background in palliative care.

METHODS

Three focus groups were undertaken with professionals of different disciplines and nursing homes. Interviews were recorded and transcribed literally. An open and axial coding was performed to identify relevant categories.

RESULTS

Professionals identified difficulties in the communication with families related to relatives' feelings of guilt, difficulty in understanding the deterioration of their relative, and addressing too late the issue of death. Regarding decision making, professionals recognized that they do not encourage participation of patients. Advance directives are valued as a necessary tool, but they do not contemplate implementing them systematically. Other difficulties that professionals highlighted are lack of coordination with other professionals, related to misunderstanding of patients' needs, as well as lack of training, and lack of material and human resources. Facilitators include relationships with primary care teams.

CONCLUSION

It is necessary to improve communication among nursing homes professionals, families, patients and other health workers.