Patient participation in treatment decision-making in the nursing home: the issue of competence

Colorectal cancer screening in 3 racial groups

OBJECTIVES

To understand predictors of colorectal cancer (CRC) screening in African Americans, European Americans, and Native Americans as these groups differ in CRC incidence and mortality.

METHODS

Participants were surveyed for knowledge, beliefs, and behaviors related to CRC.

RESULTS

Predictive regression modeling found, after adjusting for race, CRC risk, and CRC worry, the odds of screening within guidelines were increased for men, those receiving doctor's recommendation, those with polyp/tumor history, those under 70, those with more knowledge about CRC, and those with fewer barriers to screening. CRC screening rates did not differ by race.

CONCLUSIONS

These results reiterate the importance of knowledge, barriers, and physician recommendation for CRC screening in all racial groups.

Physician and staff perceptions of barriers to colorectal cancer screening in Appalachian Kentucky

BACKGROUND

Data indicate that in 1997 to 1999, only 44% of Appalachian Kentuckians underwent colorectal cancer screening consistent with guidelines. We investigated the reasons for, barriers to, and follow-up of colorectal cancer (CRC) screening recommendations in primary care practices seeing patients from Appalachian Kentucky.

METHODS

A mixed-methods [qualitative (focus group) and quantitative (survey)] approach was used to gather and analyze data in five primary care practices. A total of 34 participated in the focus groups.

RESULTS

In focus groups, physicians and office staff reported a number of indicators for CRC screening; physician, patient, and procedural barriers to CRC screening; and strategies to overcome these barriers to screening. Most physicians used personal experience to guide screening, but it was unclear what was meant by personal experience. Commonly cited patient barriers to screening were fear and embarrassment. Physicians reported several approaches to overcome these barriers, including establishing trust and educating patients. Survey data identified a number of resources to assist practices in promoting screening, most commonly, patient educational materials. Finally, fecal occult blood test was most commonly recommended because it is inexpensive and easy to administer.

CONCLUSIONS

Our mixed methods approach not only helped to understand the physicians' perceptions of the problems and barriers to CRC screening in Appalachian Kentucky, but also elucidated how practices endeavor to overcome these barriers and identified the additional resources practices would like in order to promote CRC screening.

Obtaining informed consent from continuing care residents: issues and recommendations

As the number of older adults residing in continuing care facilities increases, mental health professionals will provide more services and conduct more research in this setting. Mental health professionals working with continuing care residents will find themselves regularly challenged by ethical issues, particularly obtaining informed consent. Characteristics of the continuing care setting and residents make obtaining informed consent especially challenging. Mental health professionals must overcome these challenges in order to fulfill the following three requirements of informed consent: (1) the client is competent, (2) the client is provided with sufficient information, and (3) the client has not been coerced and/or the consent is voluntary. This article will examine the issues surrounding the fulfillment of these requirements in a continuing care facility, and will provide suggestions and guidelines that mental health professionals can utilize during the informed consent process.

Family members' preferences for nutrition interventions to improve nursing home residents' oral food and fluid intake

OBJECTIVES

To measure family members' preferences for nutrition interventions to improve the oral food and fluid intake of their relatives in a nursing home.

DESIGN

Cross-sectional descriptive.

SETTING

Three skilled nursing facilities in Southern California.

PARTICIPANTS

One hundred five residents from the three skilled nursing facilities and their respective family members.

MEASUREMENTS

A mailed questionnaire to family members that consisted of 15 forced-choice comparisons between six nutrition interventions. An assessment of oral food and fluid intake during mealtime for 3 days (nine meals) for each participant using direct observations and estimations of percentage consumed (0% to 100%) by trained research staff.

RESULTS

In order of most to least desirable, the family members preferred the following interventions to improve their relative's oral food and fluid intake: (1) improve quality of food; (2) improve quality and quantity of feeding assistance; (3) provide multiple small meals and snacks throughout the day; (4) place resident in preferred dining location; (5) provide an oral liquid nutritional supplement between meals; and (6) provide a medication to stimulate appetite. The average +/- standard deviation total percentage intake for residents whose family members reported that they thought their relative had a problem with their intake was 50%+/- 16%.

CONCLUSIONS

Family members prefer that other nutrition interventions be attempted before the use of oral supplements or pharmacological approaches. Family members perceive a need for interventions when residents consume, on average, only half of the food and fluid items provided during mealtime.

Advance directives and dementia

Since the 1990 Patient Self-Determination Act, increasing numbers of adults are completing advance directives (ADs), but unfortunately many adults seen in a dementia evaluation program have not completed an AD. This article discusses the issue of individuals with dementia completing ADs. Situational factors that frame this issue are the stage of dementia, degree of certainty of an individual's wishes for end-of-life care, the decision-making act required by care providers, and the degree of contentment or distress experienced by an individual with dementia. Several investigators have demonstrated successful completion of ADs by individuals with mild and moderate dementia. A nurse's knowledge about the stages of dementia is essential to helping an individual through the AD decision-making process. Nurses caring for individuals with dementia should assess decision-making context; recognize the emotions of family, friends, and staff; understand the substance and logic of AD requests; and support individuals and their decisions.

Attention: neuropsychological predictor of competency in Alzheimer's disease

This study was undertaken to examine the relationship between two different competencies, financial and medical decision making, and explore whether neuropsychological testing can identify a common underlying cognitive operation impaired in patients with AD. The objective was to examine the neuropsychological predictors of financial and medical decision-making competencies in patients with Alzheimer's disease (AD). Twenty individuals with mild to moderate AD and 20 control subjects matched for age and education were evaluated at a university medical center. All participants were administered a financial competency questionnaire, a competency test for medical decision making, and a set of standardized neuropsychological tests selected to reflect cognitive processes theoretically related to competency. In addition, an informant provided information regarding banking history for each participant. AD patients performed more poorly on all measures, including both measures of competency, which were highly related (R = .718, P < .001). Two tests, Trails A and Word List Recall, were significantly correlated with both competency measures, with Trails A predicting over 85% of the variance in competency scores. Trails A discriminated competent from not competent participants with an accuracy ranging from 77% to 82%. Measures of financial and medical decision-making competency were significantly correlated among patients with AD. One brief neuropsychological test of attention, Trails A, proved to be highly predictive of performance on both competency measures and useful in the discrimination of competent performance on these measures and by informant report.

Assessing treatment decision-making capacity in elderly nursing home residents

Clinicians usually employ indirect measures of cognitive and physical function in order to assess medical decision-making capacity. We tested a reference group of well elderly (Mini-Mental State Exam [MMSE] score = 29.1 +/- 0.8, mean +/- SD), for their understanding of three increasingly complex, hypothetical treatment situations or "vignettes"--use of a hypnotic, need for thoracocentesis, and desire for CPR. From this, we have developed a more direct, Guttman-like assessment of decision-making capacity. Of 51 Veterans Affairs nursing home residents (MMSE score = 22.4 +/- 6.9), only 33.3% demonstrated intact decision-making capacity by this method, whereas 77% were felt by their primary physicians to be capable of giving consent for oral surgery; 37.3% had very impaired decision-making capacity; and 29.4% were intermediate in this ability. Judged against our more direct assessment of decision-making capacity, primary physicians' judgment of capacity for consent was 31% to 39% sensitive in identifying impaired decision-making and the MMSE was 53% to 63% sensitive. These measures were 100% and 82% to 83% specific in identifying intact decision-making capacity, respectively. We conclude that (1) more directly assessed decision-making capacity varies noticeably among elderly nursing home residents and correlates in only limited fashion with frequently used cognitive screening methods; and (2) cognitive screening tests underestimate the prevalence of impaired decision-making capacity in this population. For informed consent and advance directives, our study suggests that decision-making capacity should be directly, rather than indirectly, assessed.