Assisted decision-making and interprofessional collaboration in the care of older people: a qualitative study exploring perceptions of barriers and facilitators in the acute hospital setting

Measures of Shared Decision Making for People With Mental Disorders and Limited Decisional Capacity: A Systematic Review

OBJECTIVE

Shared decision making (SDM) is a health communication model to improve treatment decision making and is underused for people with mental health conditions and limited, impaired, or fluctuating decisional capacity. SDM measures are essential to enhancing the adoption and implementation of SDM practices, yet no tools or research findings exist that explicitly focus on measuring SDM with such patients. The aim of this review was to identify instruments that measure SDM involving individuals with mental health conditions and limited decisional capacity, their family members, and their health and social care providers.

METHODS

A systematic review was performed by searching the PubMed, Embase, Web of Science, and PsycInfo databases. The authors included peer-reviewed, quantitative articles published in English during 2009-2022 that focused on adults (≥18 years old). All authors performed the screening independently.

RESULTS

A total of 7,956 records were identified, six of which met the inclusion criteria for full-text review and five of which were analyzed (one full-text article was not available). No instruments were identified that measured forms of SDM involving patients with mental health conditions and limited, impaired, or fluctuating decisional capacity.

CONCLUSIONS

Measurement instruments to address and assess SDM in health care-related communication processes involving individuals with a mental health condition and limited decisional capacity are needed.

An examination of relational dynamics of power in the context of supported (assisted) decision-making with older people and those with disabilities in an acute healthcare setting

INTRODUCTION

Supported (assisted) healthcare decision-making (ADM) focuses attention on how people with disabilities, including cognitive impairments, can be best supported to make decisions about their health and social care on an equitable basis with others. Meaningful implementation of legal frameworks for ADM challenges long-held presumptions about who has access to valued decision-making resources, influence and power within a particular socio-cultural setting. This study aims to explore the relational power dynamics around ADM with older people in acute care settings.

METHODS

This study adopts a critical hermeneutic approach to qualitatively explore the lived experience of ADM from the perspectives of Health and Social Care Professionals (N = 26). This is supported by an exploration of the experiences of older people (N = 4), older people with a diagnosis of dementia (N = 4) and family carers (N = 5).

RESULTS

We present three themes of data analysis that represent three spaces where the relational aspects of power in ADM are manifested. The first space, centralising decision-making power within multidisciplinary teams identified the privileging of physicians in traditional hierarchical leadership models that may lead to the implicit exclusion of family carers and some Health and Social Care Professionals in the ADM process. Privileging cognitive and communication competence identified a tendency to attribute decision-making autonomy to those with cognitive and communication competency. The final space, balancing the duty of care and individual autonomy, recognises acute care settings as typically risk-averse cultures that limit autonomy for decisions that carry risk, especially for those with cognitive impairment.

CONCLUSION

Findings indicate the need to address cultural sources of power operating through social norms premised on ageist and ableist ideologies. It is necessary to challenge institutional barriers to meaningful ADM including positional power that is associated with hierarchies of influence and protectionism. Finally, meaningful ADM requires resistance to the disempowerment created by structural, economic and social circumstances which limit choices for decision-making.

PATIENT OR PUBLIC CONTRIBUTION

A public and patient involvement panel of older people were consulted in the development of the grant application (HRB: APA-2016-1878). Representatives from Alzheimer's Society Ireland and Family Carers Ireland were steering committee members guiding design and strategy.

A shared decision-making model about care for people with severe dementia: A qualitative study based on nutrition and hydration decisions in acute hospitals

OBJECTIVES

To understand the decision-making processes regarding eating and drinking for hospital patients with severe dementia and use this data to modify a decision-making model about care for people with severe dementia.

METHODS

From January to May 2021, qualitative semi-structured interviews were conducted with 29 family carers and hospital staff in England who cared for people with severe dementia during hospital admissions. Interviews were transcribed verbatim and analysed using codebook thematic analysis.

RESULTS

We demonstrated a modified decision-making model consisting of six stages of the decision-making process: (i) identify a decision to be made; (ii) exchange information and recognise emotions; (iii) clarify values and preferences of all involved; (iv) consider feasibility of each choice; (v) share preferred choice and make a final decision; and (vi) deliver the decision, monitor outcomes and renegotiation. From this study, decision-making needed to be shared among all people involved and address holistic needs and personal values of people with dementia and family carers. However, hospital staff often made assumptions about the persons' ability to eat and drink without adequate consultation with family carers. The process was impacted by ward culture, professional practice, and legal framework, which might overlook cultural and personal beliefs of the persons and families. Treatment escalation plans could help inform stepwise treatments, create realistic expectations, and guide future decisions.

CONCLUSIONS

Our decision-making model provides clear stages of decision-making processes and can be used to guide clinical practice and policy around care decisions for eating and drinking, which is often poorly supported.

Communication between the multidisciplinary team and families regarding nutrition and hydration for people with severe dementia in acute hospitals: a qualitative study

BACKGROUND

When a person with severe dementia is in hospital and has eating and drinking difficulties, communication between the multidisciplinary team and families can be challenging and lead to suboptimal care.

OBJECTIVE

To gain in-depth understanding about the experiences, views and needs of family carers and hospital staff, regarding communication and conversations about nutrition and hydration, for hospital patients with severe dementia.

DESIGN

Qualitative semi-structured interview study.

SETTING

Acute hospital in England.

METHODS

From January to May 2021, semi-structured interviews were conducted with 29 family carers and hospital staff. Interviews were transcribed verbatim and analysed using reflexive thematic methods.

RESULTS

Four overarching themes were developed: (i) prerequisites to initiating communication about eating and drinking; (ii) communication aiming to develop agreed care plans; (iii) difficulty discussing palliative and end-of-life care; and (iv) needs of information and plans about future eating and drinking difficulties. Families tended to wait for hospital staff to initiate discussions but usually experienced frustration with delays and repeated conversations with different staff. Some staff felt unprepared to manage these conversations and found it challenging to work across the multidisciplinary team. During discharge processes, key information and care plans about eating and drinking were not regularly passed on to people involved to avoid unnecessary readmissions.

CONCLUSIONS

In acute hospitals, family carers and hospital staff can have disjointed communications and conversations about nutrition and hydration for persons with severe dementia. Timely reassurance, ongoing discussions and clear information sharing will support communication between those involved.

Assessing Older Adults’ Decision-Making Capacity for Independent Living: Practice Tensions and Complexities

Decision-making capacity (DMC) is a salient issue due to increasing ageing populations and associated dementia-related diseases. Legislative and policy developments emphasise older adults’ rights to participate in decision-making. Fifty-two occupational therapists working with older adults from a range of practice settings in Ireland participated in focus groups to discuss their contribution to multidisciplinary assessments of older adult’s DMC for independent living. Findings indicate lack of shared understanding of DMC and conflicting philosophies of practice and highlight the need for a comprehensive and multidisciplinary approach. Findings also highlight that older people are often excluded from care-planning, and independent living options are determined by availability of community services rather than their preferences. Future research will attempt to inform practice in assessing and supporting older adults’ DMC for independent living.

Ambulance clinicians' attitudes to older patients' self-determination when the patient has impaired decision-making ability: A Delphi study

OBJECTIVE

The proportion of older people is increasing and reflects in the demand on ambulance services (AS). Patients can be more vulnerable and increasingly dependent, especially when their decision-making ability is impaired. Self-determination in older people has a positive relation to quality of life and can raise ethical conflicts in AS. Hence, the aim of this study was to empirically explore attitudes among Swedish ambulance clinicians (ACs) regarding older patients' self-determination in cases where patients have impaired decision-making ability, and who are in urgent need of care.

MATERIALS AND METHODS

An explorative design was adopted. A Delphi technique was used, comprising four rounds, involving a group (N = 31) of prehospital emergency nurses (n = 14), registered nurses (n = 10) and emergency medical technicians (n = 7). Focus group conversations (Round 1) and questionnaires (Rounds 2-4) generated data. Round 1 was analysed using manifest content analysis, which ultimately resulted in the creation of discrete items. Each item was rated with a five-point Likert scale together with free-text answers. Consensus (≥70%) was calculated by trichotomising the Likert scale.

RESULTS

Round 1 identified 108 items which were divided into four categories: (1) attitudes regarding the patient (n = 35), (2) attitudes regarding the patient relationship (n = 8), (3) attitudes regarding oneself and one's colleagues (n = 45), and (4) attitudes regarding other involved factors (n = 20). In Rounds 2-4, one item was identified in the free text from Round 2, generating a total of 109 items. After four rounds, 72 items (62%) reached consensus.

CONCLUSIONS

The findings highlight the complexity of ACs' attitudes towards older patients' self-determination. The respect of older patients' self-determination is challenged by the patient, other healthcare personnel, significant others and/or colleagues. The study provided a unique opportunity to explore self-determination and shared decision-making. AS have to provide continued ethical training, for example to increase the use of simulation-based training or moral case deliberations in order to strengthen the ACs' moral abilities within their professional practice.

IMPLICATIONS FOR PRACTICE

Ambulance services must develop opportunities to provide continued training within this topic. One option would be to increase the use of simulation-based training, focusing on ethical aspects of the care. Another option might be to facilitate moral case deliberations to strengthen the ACs' abilities to manage these issues while being able to share experiences with peers. These types of interventions should illuminate the importance of the topic for the individual AC, which, in turn, may strengthen and develop the caring abilities within an integrated care team.

Using a self-directed workbook to support advance care planning with long term care home residents

BACKGROUND

While advance care planning (ACP) has been shown to improve the quality of end-of-life (EOL) communication and palliative care, it is rarely practiced in long term care (LTC) homes, where staff time to support the process is limited. This study examines the potential of a publicly available self-directed ACP workbook distributed to LTC residents to encourage ACP reflection and communication.

METHODS

Recruitment took place across three LTC homes, between June 2018 and July 2019. To be eligible, residents had to have medical stability, cognitive capacity, and English literacy. The study employed a mixed methods concurrent design using the combination of ranked (quantitative) and open (qualitative) workbook responses to examine documented care preferences and ACP reflections and communications.

RESULTS

58 residents initially agreed to participate in the study of which 44 completed self-directed ACP workbooks. Our combined quantitative and qualitative results suggested that the workbooks supported the elicitation of a range of resident care preferences of relevance for EOL care planning and decision making. For example, ranked data highlighted that most residents want to remain involved in decisions pertaining to their care (70%), even though less than half expect their wishes to be applied without discretion (48%). Ranked data further revealed many residents value quality of life over quantity of life (55%) but a sizable minority are concerned they will not receive enough care at EOL (20%). Open comments affirmed and expanded on ranked data by capturing care preferences not explored in the ranked data such as preferences around spiritual care and post mortem planning. Analysis of all open comments also suggested that while the workbook elicited many reflections that could be readily communicated to family/friends or staff, evidence that conversations had occurred was less evident in recorded workbook responses.

CONCLUSIONS

ACP workbooks may be useful for supporting the elicitation of resident care preferences and concerns in LTC. Developing follow up protocols wherein residents are supported in communicating their workbook responses to families/friends and staff may be a critical next step in improving ACP engagement in LTC. Such protocols would require staff training and an organizational culture that empowers staff at all levels to engage in follow up conversations with residents.

Using a multidisciplinary approach to reveal decision-making capacity within acute care for an individual with aphasia

Formal assessments of cognition that rely on language may conceal the non-linguistic cognitive function of people with aphasia. This may have detrimental consequences for how people with aphasia are supported to reveal communicative and decision-making competence. This case report demonstrates a multidisciplinary team approach to supporting the health and social care decision-making of people with aphasia. The case is a 67-year-old woman with Wernicke's type aphasia. As the issue of long-term care arose, the speech and language therapist used a supported communication approach with the patient who expressed her wish to go home. A multidisciplinary team functional assessment of capacity was undertaken which involved functional assessments and observations of everyday tasks by allied health, nursing, catering and medical staff. In this way, the patient's decision-making capacity was revealed and she was discharged home. A collaborative multidisciplinary team approach using supported communication and functional capacity assessments may be essential for scaffolding the decision-making capacity of people with aphasia.