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• W2051255367 abstract "To the Editor: Meaningful enhancement of patient autonomy generally, and the use of advance directives specifically, requires accurate assessment of the individual's capacity to participate in discussions of this nature. However, both methodological1-3 and procedural4-6 difficulties in determining an individual's ability to participate in formulation of advance directives persist. The implications of inconsistent or inappropriate methods for assessing capacity are significant. Empirical data indicate that substantial numbers of residents may be precluded inappropriately from participating in discussions because of lack of staff comfort initiating discussions with residents and difficulties determining decisional capacity to discuss future treatment wishes.5 That more than half of the persons living in nursing homes have some cognitive impairment7, 8 makes the issue of capacity assessment particularly important in this setting. Findings from a study regarding implementation of the Patient Self Determination Act (PSDA) in nursing homes9 raise concerns regarding potential obstacles to effective advance care planning in this setting. This cross-sectional study, conducted in 1991 and 1995 (before and after implementation of the PSDA), explored aspects of the PSDA through structured telephone interviews with administrators and directors of nursing or social services from 112 nursing homes (random 50% sample of all Connecticut homes). Data included facility philosophy and practices in advance care planning, capacity assessment, and scope of advance care planning discussions. Ninety-five percent of the sample agreed or strongly agreed that it is the nursing home's responsibility to ensure that residents are aware of and understand advance directives. Nearly 60% believed “code status” was the most important part of an advance directive. Only 20% typically discussed issues beyond narrow life support decisions, such as pain management, intravenous antibiotics, or hospitalization. About one-fourth (26%) of respondents agreed or strongly agreed that reducing potential liability suits is a primary reason for encouraging residents to complete an advance directive. More than one-third (38%) agreed or strongly agreed that residents are generally eager to complete advance directives. A primary method reported for determining capacity in a large majority of facilities (71%) was the resident's orientation to person, place, and time. The next most common approach reported was the resident's ability to understand the nature and consequences of treatment decisions (used frequently by 66% of facilities). Advance care planning activities and advance directives must be understood within the limits of assessing an individual's capacity to engage in discussions and the execution of such instruments. Whereas all respondents report that advance care planning is a desirable activity, substantial procedural shortcomings may confound this well intentioned goal. Careful development of assessment tools is in process.1, 10 Instruments must be designed with attention to feasibility for use in nursing homes and other healthcare settings. Given the current procedures to determine capacity and discuss advance directives, bridging the gap between theory and reality will be at least as challenging as the development of reliable and valid instrumentation. This study revealed at least four realities that must be considered in long-term care settings. The first is the timing and frequency of discussions; that is, half of nursing homes address advance directives only at admission and when the resident's medical condition changes rather than at routine intervals. Instruments must be administered efficiently at admission yet able to detect changes in capacity under varying circumstances. Second, the current scope of routine advance care planning discussions is fairly narrow. This study and previous data11 demonstrated that advance care planning discussions often focus on CPR and other life-support rather than preferences regarding broader and more common future medical circumstances. The third reality is that advance care planning conversations rarely involve physicians and are sometimes conducted by an administrative or clerical staff person. Finally, many facilities currently report reliance on residents' orientation to person, place, and time as a means of determining capacity. More complicated protocols, particularly if they do not have immediate or clear benefits, may not be well received by already overwhelmed staff. Kapp and Mossman describe the earnest but perhaps fruitless quest for a “capacimeter,” observing there may not be a perfect single instrument.3 Current methods both for determining decisional capacity and for conducting advance care planning in nursing homes are limited in scope and depth. An understanding of the practical realities of nursing home care is essential in the creation of a standardized tool that ensures the intent of advance care planning – to support patient expression of treatment preferences – is honored to the greatest extent possible." @default.
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• W2051255367 date "1998-08-01" @default.
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• W2051255367 title "ASSESSMENT OF CAPACITY TO DISCUSS ADVANCE CARE PLANNING IN NURSING HOMES" @default.
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• W2051255367 doi "https://doi.org/10.1111/j.1532-5415.1998.tb02772.x" @default.
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