Making healthcare decisions in a person's best interests when they lack capacity: clinical guidance based on a review of evidence

Exploring dental treatment decision-making experiences of people living with dementia and family carers

INTRODUCTION

People living with dementia can have complex dental care needs. Dentists and patients should make treatment decisions together, yet some people living with dementia may be unable to make their own decisions about their dental care. Dental treatment decision-making and patients' experiences of this process have not been comprehensively researched.

OBJECTIVE

This study aimed to explore the dental treatment decision-making perspectives and experiences of people living with dementia and their family members.

METHODS

Semi-structured interviews were undertaken with 8 people living with dementia and 17 family caregivers. A constructivist grounded theory approach was adopted, using a maximum variation sample. Qualitative data collection and analysis occurred concurrently. Data underwent initial open coding followed by more focused coding, supported by reflexive memo writing, which supported data categorisation.

RESULTS

People living with dementia reported wanting to be understood as unique individuals with specific needs. All participants described wanting to be actively involved in dental treatment decisions. However, many felt that they were insufficiently involved in treatment decision-making. This perceived underinvolvement meant that some people living with dementia and family members felt the treatment outcomes they sought were neither discussed nor considered.

CONCLUSION

People living with dementia and carers had specific expectations of dental care yet felt passive in decision-making despite their desire to be involved in this process. Dentists should seek to actively establish patients' preferences, regardless of mental capacity and consider these in discussions and decisions about dental treatment.

Futile treatment - when is enough, enough?

Objective This paper examines two aspects of treatment decision making: withdrawal of treatment decisions made by a patient; and decisions to not proceed with treatment by a health professional. The paper aims to provide an overview of the law relating to the provision of treatment, then highlight the uncertainty as to the meaning of and costs associated with futile treatment. Methods The paper reviews the current legal and medical literature on futile treatment. Results Continuing treatment which is futile is not in the patient's best interests. Futility may be understood in both quantitative and qualitative terms. Recent legal cases have expanded the definition of futility to focus not on the nature of the treatment itself, but also on the health of the patient to whom treatment is provided. Conclusions As Australia's population ages, there is likely to be an increased focus on the allocation of scarce health resources. This will, inevitably, place constraints on the number and variety of treatments offered to patients. The level of constraint will be felt acutely where a proposed treatment offers little clinical efficacy. It is time to try to understand and agree on a workable definition of futility.

Informed consent practices for acute stroke therapy: principles, challenges and emerging opportunities

IMPORTANCE

Informed consent (IC) plays a crucial yet underexplored role in acute stroke treatment, particularly in the context of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). This narrative review examines data on current IC practices in acute ischemic stroke management, specifically for patients treated with IVT or EVT, with the aim of identifying areas for improvement and strategies to enhance the IC process.

OBSERVATIONS

IC practices for IVT vary significantly among hospitals and physicians with the frequency of always requiring consent ranging from 21 to 37%. Factors influencing IC for IVT include patient decision-making capacity, standard of care, time sensitive nature of treatments, legal and moral obligations, risk of complications, physician age and speciality, treatment delays, and hospital size. Consent requirements tend to be stricter for patients presenting within the 3-4.5-h window. The content and style of information shared as part of the IC process revealed discrepancies in the disclosure of stroke diagnosis, IVT mechanism, benefits, and risks. Research on IC practices for EVT is scarce, highlighting a concerning gap in the available evidence base.

CONCLUSIONS AND RELEVANCE

This review underscores the significant variability and knowledge gaps in IC for EVT and IVT. Challenges related to decision-making capacity assessment and the absence of standardised guidance substantially contributes to these gaps. Future initiatives should focus on simplifying information delivery to patients, developing formal tools for assessing capacity, standardising ethical frameworks to guide physicians when patients lack capacity and harmonizing IC standards across sites. The ultimate goal is to enhance IC practices and uphold patient autonomy, while ensuring timely treatment initiation.

Caring for People with Severe Brain Injuries: Improving Health Care Professional Communication and Practice Through Online Learning

INTRODUCTION

Severe brain injuries can leave people in prolonged disorder of consciousness resulting in multifaceted medical, nursing, and rehabilitative needs that can be challenging for even the most experienced multidisciplinary team. The complexities of care, communication with families, and best interest decision-making about medical interventions means there is a need for ongoing training in clinical, social, ethical, and legal aspects.

METHODS

Using a combination of group discussions, interviews, and questionnaires with learners, this article reports an evaluation of designing and delivering an interprofessional, online work-based course to health care professionals caring for prolonged disorder of consciousness patients.

RESULTS

There were challenges for staff uptake because of COVID-19, but engaging with it increased knowledge in defining and diagnosing patients' conditions, understanding multidisciplinary team roles, communicating with families, and navigating legal and ethical issues. Course participation also enhanced critical and reflective thinking skills, provided a sense of connection to other professionals, and generated plans to improve service provision.

DISCUSSION

Online learning that enables health care professionals to engage at their own pace and also come together as an interprofessional community can provide invaluable continuing professional development and help to enhance joined up, holistic patient care. However, achieving this requires significant investment in creating research-led, multimedia, learning materials, and courses that include synchronous and asynchronous delivery to combine flexible study with the opportunity for peer networks to form. It also depends on a commitment from organizations to support staff online continuing professional development.

Implementation of the Mental Capacity Act: a national observational study comparing resultant trends in place of death for older heart failure decedents with or without comorbid dementia

BACKGROUND

Heart failure (HF) is increasingly prevalent in the growing elderly population and commonly associated with cognitive impairment. We compared trends in place of death (PoD) of HF patients with/without comorbid dementia around the implementation period of the Mental Capacity Act (MCA) in October 2007, this legislation supporting patient-centred decision making for those with reduced agency.

METHODS

Analyses of death certification data for England between January 2001 and December 2018, describing the PoD and sociodemographic characteristics of all people ≥ 65 years registered with HF as the underlying cause of death, with/without a mention of comorbid dementia. We used modified Poisson regression with robust error variance to determine the prevalence ratio (PR) of the outcome in dying at home, in care homes or hospices compared to dying in hospital. Covariates included year of death, age, gender, marital status, comorbidity burden, index of multiple deprivation and urban/rural settings.

RESULTS

One hundred twenty thousand sixty-eight HF-related death records were included of which 8199 mentioned dementia as a contributory cause. The overall prevalence proportion of dementia was 6.8%, the trend significantly increasing from 5.6 to 8.0% pre- and post-MCA (Cochran-Armitage trend test p < 0.0001). Dementia was coded as unspecified (78.2%), Alzheimer's disease (13.5%) and vascular (8.3%). Demented decedents were commonly older, female, and with more comorbidities. Pre-MCA, PoD for non-demented HF patients was hospital 68.2%, care homes 20.2% and 10.7% dying at home. Corresponding figures for those with comorbid dementia were 47.6%, 48.0% and 4.2%, respectively. Following MCA enforcement, PoD for those without dementia shifted from hospital to home, 62.5% and 17.2%, respectively; PR: 1.026 [95%CI: 1.024-1.029]. While home deaths also rose to 10.0% for those with dementia, with hospital deaths increasing to 50.4%, this trend was insignificant, PR: 1.001 [0.988-1.015]. Care home deaths reduced for all, with/without dementia, PR: 0.959 [0.949-0.969] and PR: 0.996 [0.993-0.998], respectively. Hospice as PoD was rare for both groups with no appreciable change over the study period.

CONCLUSIONS

Our analyses suggest the MCA did not materially affect the PoD of HF decedents with comorbid dementia, likely reflecting difficulties implementing this legislation in real-life clinical practice.

A Typical Perplexing Life-sustaining Therapy Decision at the End of life: A Case Report from Sri Lanka with Attributes Potentially worth Adopting from the UK Legislature

In many developing parts of the world, evidence on advance care planning (ACP) is either lacking or fragmented. Lack of streamlined means for ACP is known to lead to inconveniences for the clinicians as well as the patients and their families. This case report focuses on a young male diagnosed with metastatic osteosarcoma, who explicitly verbalised his wishes to be managed conservatively without involving invasive life-sustaining measures. However, the patient faced cardiopulmonary resuscitation before his demise against his wishes, which also contradicted with the medical point of view. Sri Lankan doctors face moral, ethical and legal dilemmas as they deal with terminally ill patients at the verge of their death due to the deficiencies in the medical and legislative frameworks in the country.

The Nurse or Midwife at the Crossroads of Caring for Patients With Suicidal and Rigid Religious Ideations in Africa

Nurses and midwives are the majority of healthcare professionals globally, including Africa, and they provide care at all levels of the health system including community levels. Nurses and midwives contribute to the care of patients with rigid or dogmatic religious beliefs or those with suicidal ideations. This review paper discusses acute and chronic diseases that have suicidal tendencies such as terminal cancer, diseases with excruciating pain, physical disability, stroke, end-stage renal failure, and diabetics who are amputated. It was reiterated that nurses and midwives taking care of these patients should be alert and observant to identify their suicidal tendencies. The paper also discusses religious or spiritual inclinations that negatively affect healthcare access and adherence, especially to biomedical or western medicine. It was emphasized that some religious beliefs do not allow their followers to employ biomedical treatment and nurses and midwives should not impose their faith on patients and their families. The paper ends with a discussion on the specific roles of nurses and midwives in the care of patients with suicidal ideations such as assessment, counseling, administering medication, observation, social interaction, ensuring safety measures, and providing an enabling environment for the family to part of the care and for the observation of religious coping strategies. Nurses and midwives should enhance their knowledge and skills on suicide and increase public education on suicide prevention and identification of those at risk.

A consensus process to agree best practice for managing physical wellbeing in people with a prolonged disorder of consciousness

BACKGROUND

Current practice for physical wellbeing of people in a Prolonged Disorder of Consciousness (PDOC) is variable. A scoping literature review identified no agreed standard of care for physical management of those in a PDOC. This study addressed this deficit using a consensus process applied using nominal group technique.

AIM

The aims of this project were therefore to promote best practice for physical management in PDOC, by identifying consensus for: 1. a pathway of care and 2. current best practice recommendations.

DESIGN

A consensus process using nominal group technique.

SETTING

Representation from national, purposively selected, rehabilitation services assessing and managing people in a PDOC in the UK.

POPULATION

The population to whom the consensus process relates are people in a PDOC, requiring physical management.

METHODS

An initial meeting (1) with selected clinical experts from national centres was conducted to set terms of reference. A consensus meeting (2) using nominal group technique (n=33) then followed. Experts were initially asked to review systematic review findings reproduced as statements. Following systematic refinement they were then asked to vote on the importance and relevance of statements.

RESULTS

Following the nominal group process, 25 initial recommendations were refined to 19, which expressed the principles of physical management for people with a Prolonged Disorder of Consciousness. Statements are grouped into 'acute-care' (6-recommendations), 'post-acute care' (10-recommendations) and 'long-term care' (3-recommendations). Across the participants, agreement with the final recommendation statements ranged from 100-61% (n=33-20), 15 of the statements were supported by 85% or more experts (n=29). In addition, a clinical pathway of care, incorporating the recommendation principles was produced (agreement from 28 experts, 83%).

CONCLUSIONS

The recommendations provide a basis for standardising current practice. They provide a standard against which care and effectiveness can be evaluated. An accessible guideline document is planned for publication to enable implementation into practice, supported by online resources.

CLINICAL REHABILITATION IMPACT

Recommendations have been produced under the headings of 'acute care', 'post-acute care' and 'longterm care'. In addition, a pathway for provision of care interventions has been identified for the physical management of people in a prolonged disorder of consciousness.

Enhancing shared and surrogate decision making for people living with dementia: A systematic review of the effectiveness of interventions

BACKGROUND

Dementia can have a profound impact on decision making. People living with dementia (PLwD) often need to make decisions about health care, and, as dementia progresses, decisions may need to be made on their behalf. Specific interventions may support this process.

REVIEW QUESTION

What interventions are effective in improving shared decision making or surrogate decision making on the health care of PLwD?

METHODS

A narrative systematic review of existing literature was conducted. Seven databases, grey literature and key journals were searched. After exclusion by title, abstracts then full texts were reviewed collaboratively to manage any disagreements.

RESULTS

Eight studies met the inclusion criteria. Two articles, including one RCT, evaluated decision aids regarding the use of enteral feeding in advanced dementia. Six further articles, including five RCTs, were found which evaluated the effectiveness of interventions supporting patients or carers with advance care planning.

CONCLUSION

Decision-making interventions typically consist of multiple components which aim to establish preferences for future health care. Advance care planning interventions supported aspects of the decision-making processes but their impact on decision quality was rarely evaluated. Interventions did not increase the concordance of decisions with a person's values. The decision-specific interventions are unlikely to produce benefit in other decision contexts.

PATIENT INVOLVEMENT

Two caregivers, a public stakeholder group and a carer group were consulted in the design of the wider study to which this review relates. Six PLwD refined the research questions addressed in this paper.

Conflict before the courtroom: challenging cognitive biases in critical decision-making

Conflict is an important consideration in the intensive care unit (ICU). In this setting, conflict most commonly occurs over the 'best interests' of the incapacitated adult patient; for instance, when families seek aggressive life-sustaining treatments, which are thought by the medical team to be potentially inappropriate. Indeed, indecision on futility of treatment and the initiation of end-of-life discussions are recognised to be among the greatest challenges of working in the ICU, leading to emotional and psychological 'burnout' in ICU teams. When these disagreements occur, they may be within the clinical team or among those close to the patient, or between the clinical team and those close to the patient. It is, therefore, crucial to have a theoretical understanding of decision-making itself, as unpicking misalignments in the family's and clinical team's decision-making processes may offer strategies to resolve conflict. Here, we relate Kahneman and Tversky's work on cognitive biases and behavioural economics to the ICU environment, arguing that these biases could partly explain disparities in the decision-making processes for the two conflicting parties. We suggest that through the establishment of common ground, challenging of cognitive biases and formulation of mutually agreeable solutions, mediation may offer a pragmatic and cost-effective solution to conflict resolution. The litigation process is intrinsically adversarial and strains the doctor-patient-relative relationship. Thus an alternative external party should be considered, however mediation is not frequently used and more research is needed into its effectiveness in resolving conflicts in the ICU.

Legal and Ethical Aspects of 'Best Interests' Decision-Making for Medical Treatment of Companion Animals in the UK

Simple Summary

Making decisions about medical treatment for animal patients involves two key decision-makers, the animal owner and the veterinary surgeon. We aim to show that these decisions should and can be based on the ‘best interests’ of the animal, with both human decision-makers acting as advocates for the animal requiring treatment. We suggest that the role of the animal owner is similar to that of a parent in making decisions for a child, drawing on legal cases to demonstrate the limits of parental (and owner) decision-making. To provide a firmer basis for ‘best interests’ decision-making, we adapt the factors included in the United Nations Convention on the Rights of the Child and demonstrate how these could be used with a typical clinical situation. Finally, we analyse the decisions from an ethical point of view.

Abstract

Medical decisions for young children are made by those with parental responsibility, with legal involvement only if the decision is potentially detrimental to the child’s welfare. While legally classified as property, some argue that animals are in a similar position to children; treatment decisions are made by their owners, posing a legal challenge only if the proposed treatment has the potential to cause harm or unnecessary suffering, as defined by animal protection legislation. This paper formulates the approach to a ‘best interests’ calculation, utilising the factors included in the United Nations Convention on the Rights of the Child and relying on exchange of information between the human parties involved. Although this form of decision-making must primarily protect the animal from unnecessary suffering, it recognises that the information provided by the owner is critical in articulating the animal’s non-medical interests, and hence in formulating what is in the animal’s best overall welfare interests. While statute law does not mandate consideration of ‘best interests’ for animals, this approach might reasonably be expected as a professional imperative for veterinary surgeons. Importantly, this version of a ‘best interests’ calculation can be incorporated into existing ethical frameworks for medical decision-making and the humane treatment of animals.

Evaluation of the MCAST, a multidisciplinary toolkit to improve mental capacity assessment

Purpose: To evaluate the usability and acceptability of the Mental Capacity Assessment Support Toolkit (MCAST) in healthcare settings and whether its use was associated with increased legal compliance and assessor confidence.Materials and methods: A mixed methods convergence triangulation model was used. Multidisciplinary professionals used the MCAST during mental capacity assessments for UK hospital patients with diagnoses of stroke or acute or chronic cognitive impairment. Changes in legal compliance were investigated by comparing scores on case note audits before and after implementation of the MCAST. Changes in assessor confidence and professionals' perceptions of the MCAST's usability and acceptability were explored using surveys. Patients' and family members' views on acceptability were determined using semi-structured interviews. Data were integrated using triangulation.Results: Twenty-one professionals, 17 patients and two family members participated. Use of the MCAST was associated with significant increases in legal compliance and assessor confidence. Most professionals found the MCAST easy to use and beneficial to their practice and patients. Patients and family members found the MCAST materials acceptable.Conclusions: The MCAST is the first toolkit to support the needs of individuals with communication disabilities during mental capacity assessments. It enables assessors to deliver high quality, legally compliant and confident practice.IMPLICATIONS FOR REHABILITATIONMental capacity assessment practice needs to be improved to maximise patient autonomy, safety and well-being.The MCAST is a paper-based toolkit designed to facilitate and improve mental capacity practice in England and Wales.This study suggests the MCAST would be easy and acceptable to use in healthcare settings and could lead to improvements in assessment quality and assessor confidence.

"What Bothers Me Most Is the Disparity between the Choices that People Have or Don't Have": A Qualitative Study on the Health Systems Responsiveness to Implementing the Assisted Decision-Making (Capacity) Act in Ireland

Objective: The Assisted Decision-Making (ADM) (Capacity) Act was enacted in 2015 in Ireland and will be commenced in 2021. This paper is focused on this pre-implementation stage within the acute setting and uses a health systems responsiveness framework. Methods: We conducted face-to-face interviews using a critical incident technique. We interviewed older people including those with a diagnosis of dementia (n = 8), family carers (n = 5) and health and social care professionals (HSCPs) working in the acute setting (n = 26). Results: The interviewees reflected upon a healthcare system that is currently under significant pressures. HSCPs are doing their best, but they are often halted from delivering on the will and preference of their patients. Many older people and family carers feel that they must be very assertive to have their preferences considered. All expressed concern about the strain on the healthcare system. There are significant environmental barriers that are hindering ADM practice. Conclusions: The commencement of ADM provides an opportunity to redefine the provision, practices, and priorities of healthcare in Ireland to enable improved patient-centred care. To facilitate implementation of ADM, it is therefore critical to identify and provide adequate resources and work towards solutions to ensure a seamless commencement of the legislation.