decision-making capacity workshop march 07, 2020 on capacity!
TRANSCRIPT
Decision-Making Capacity WorkshopMarch 07, 2020 20 / 20
on capacity!
Presenter: Lesley Charles, MBChB, CCFP(COE)ā¢ Speakers Bureau/Honoraria: Workshop Participant Fee - FMF
ā¢ Consulting Fees: N/A
ā¢ Grants/Research Support: N/A
ā¢ Patents: N/A
ā¢ Other: N/A
ā¢ The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
ā¢Learning Objectives
1. Identify when to initiate a capacity assessment2. Describe tools that should be used in a standardized approach when
conducting a capacity assessment3. Select which forms need to be completed for a capacity assessment4. Outline the legal implications/framework surrounding the documentation
Mrs C
ā¢ 59 yo lady with early onset dementia
ā¢ Lives with husband and supported by 2 kids
ā¢ Longstanding abuse both verbal and physical
ā¢ Contact by HC after an episode of physical abuse involving RCMP.
They feel Mrs C should have a capacity assessment and be placed.
ā¢ Mrs C want to stay home
What would you do?A. Complete DMCA as requested.
B. Involve Elder Abuse team.
C. Admit to hospital.
D. Gather more information.
Background
ā¢ A personās capacity to make personal/financial decisions is an important component of independence
ā¢ Adults with developmental disabilities, psychiatric, and cognitive disorders can face challenges to their autonomy.
ā¢ As the prevalence of persons 65 years and older rises, so does the incidence of dementia.
ā¢ It is anticipated that increasing numbers of individuals will experience a decline in their DMC.
WHOā¢ The World Health Organization (WHO) states that legislation should:
ā¢ ārecognize and protect the right to appropriate autonomy and self-
determination,ā
ā¢ and ensure āfree and informed consent to treatment, supported
decision-making, and procedures for implementing advance
directives.ā
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Capacity DefinitionThe ability to understand the
information that is relevant to making of a personal decision and
the ability to appreciate the
reasonable foreseeable consequences of the decision.
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Risk by Choice
ā¢ A risky decision is not necessarily an incompetent decision.
ā¢ Stockbrokers, soldiers, medical professionals and patients make them every day.
ā¢ It is the process ā or the lack of process ā by which risky decisions are made that calls into question the capacity of a patient to make that decision.
Decision-Making Capacity can affect anyoneā¦
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Relevant Legislative Acts ā Alberta Exampleā¢ Personal Directives Act
Allows adult Albertans to create a Personal Directive to name people (agent) to make decisions and describes areas in which they want decisions made for them
ā¢ Powers of Attorney ActAllows adult Albertans to create an Enduring Power of Attorney to name people (attorney) to make decisions in financial matters for them
ā¢ Adult Guardianship and Trusteeship Act ā¢ Continuum of Decisionāmaking
ā¢ Legal process for granting powers of surrogate decision making
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Personal Directive Act
ā¢ Schedules
ā¢ A process for determining incapacity
ā¢ Expanded scope of Service Providers in healthcare such as Registered Nurses, Psychiatric Nurses, SW, OT to act as the second signature
ā¢ Allow for re-assessment of capacity or determination of regained capacity
ā¢ Complaints process via OPG (similarly under AGTA)
ā¢ Tailored to different levels of capacity
ā¢ Designed to provide as much autonomy as possible
AGTA has multiple decision-making options.
Specific Decision-Making
and Emergency Decision-
Making
SupportedDecision-making
Authorization
Guardianship,
Trusteeship and
Protection
Temporary Guardianship/
TrusteeshipAdult Makes
Decisions
Co-Decision-
Making
Range of Capacity
Has Capacity Significant
Capacity
Impairment
Temporary lack
of Capacity
Lacks Capacity
Long Term
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Decision-Making Capacity Process - 3 Stages
YESAre concerns
valid?
ScreeningIdentify Triggers for
Questioning Capacity,Domains and Risks
Problem SolvingUse Team Approach ā
Cognitive/Functional Tests, Options to Reduce Risk
Capacity InterviewProceed when Risks not
resolved by Less Intrusiveor Restrictive Means
YESDecision Making Called into
Question
Collect Information and Identify
Relevant Domains
Address Medical/
PsychiatricProblems
Perform Cognitive/ Functional
Assessments as needed
Consult/Meet with
Other Team Members to
Problem-solve
Proceed with
Capacity Interview
NOProblem Solved?
NO
Assess-ment
Done &Problem Solved?
Refer to: Geriatricians, Psychologists,
DCAs, as Appropriate
Proceed with Appropriate
Forms
Education/Support Provided by Mentoring Team
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Validating Reasons and Identifying Domains
YESAre concerns
valid?
Decision Making
Called into Question
Collect Information and Identify
Relevant Domains
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Valid Reasons for Assessment
A formal capacity assessment may be necessary if the reason for assessment meets the following criteria:
1. An event or circumstance which potentially places a patient, or others, at risk that
2. seems to be caused by impaired decision-making which
3. Necessitates investigation, problem-solving (and possibly action) on the part of a health care professional
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Domains of Decision-Making
Health care Participation in social activities
Accommodation Participation in educational activities
With whom to live &
associate
Participation in employment
activities
Legal matters Financial and Estate
Identifying Domains
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Care Map ā Assessments & Problem Solving
ProblemSolved?
Address Medical/
PsychiatricProblems
Perform Cognitive/ Functional
Assessments as needed
Consult/Meet with
Other Team Members to
Problem-solve
How to Proceed?
ā¢ Treat acute medical issues, especially those affecting cognition
ā¢ Involve the interdisciplinary team for functional assessments; ask SW to initiate the Capacity Assessment Process Worksheet
ā¢ Thoroughly identify risks and investigate risk reduction measures
ā¢ Focus on problem-solving the patientās issues without resorting to capacity assessment
āForm 1ā: Capacity Assessment Process Worksheet: Datagroup # 09947
ā¢ Standardized form that ensures teams follow the Capacity Assessment Process.
ā¢ Allows teams to gather and document relevant information regarding:
ā¢ risk-factors
ā¢ areas of decision-making that are in question
ā¢ Attempts at problem solving/intervention, including education, formal/informal supports
ā¢ Assists in determining if a formal capacity interview is needed.
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Capacity Assessment
Process Worksheet
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Cognitive Testing
Types of tests used:
ā¢ MMSE
ā¢ MOCA
ā¢ Cognistat
ā¢ EXIT/FAB
ā¢ Kitchen Task Assessment
ā¢ ILS
ā¢ Psychological Testing
Testing Limitations
ā¢ Level of consciousness
ā¢ Education
ā¢ Cultural background
ā¢ Language
ā¢ Vision
ā¢ Hearing
ā¢ Comorbidities (aphasia, delirium, depression)
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Cognitive Assessment
ā¢ There is no cognitive test that will determine capacity
ā¢ Assessment of a personās cognition is not necessarily equivalent to their abilities
ā¢ Not solely used to determine oneās capacity for decision making.
A Word on Problem-solving
ā¢ Be creative !!
ā¢ Involve patients and families in problem-solving
ā¢ Seek perspectives from other team members
ā¢ Consider formal resources
ā¢ Mobilize informal resources
ā¢ Issue may be resolved by problem solving without formal capacity assessment
Complex situations unlikely to benefit from CA
ā¢ Driving
ā¢ Refusal to take medications
ā¢ Where agent/guardian will respect patientās wishes e.g. to stay home at risk
ā¢ Longstanding choices that pose risk, e.g. ETOH, Drugs āwill depend on development of cognitive impairment
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āForm 2ā: Reasons to Proceed to Formal Capacity Interview: Datagroup # 09948
ā¢ No adequate solutions from problem-solving
ā¢ Risk to patient / others too high
ā¢ Other, less intrusive methods, have failed
ā¢ Appointment of legal decision-maker may solve the problem
ā¢ Problem persists or becomes worse
ā¢ Remember: a determination of incapacity may do nothing to fix the problem
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Capacity Interview
Worksheet
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Care Map ā Capacity Interview
AssessmentDone &Problem Solved?
Proceed with Capacity Interview
Refer to: Geriatricians, Psychologists,
DCAs, as Appropriate
NO
YES
Proceed with Appropriate
Forms
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Anatomy of a Capable Decision ā The 3 Cs
ā¢ The decision-maker is aware of the problem (context), and choices that are available.
ā¢ The decision-maker understands the reasonably foreseeable effects or consequences of each choice.
ā¢ The decision-maker makes a choice after weighing the relative benefits and disadvantages of the choices available.
āForm 3ā: Paperwork after finding Patient Incapable
ā¢ Depends on 2 factors:
ā on which domain assessed
ā Paper work patient has
ā¢ Basically 3 options:
ā Schedules under PDA
ā CAR under AGTA different forms depending on is applying for CDM, guardianship/trusteeship, SDM
ā Enactment for EPOA ā no formal template
Mrs C
ā¢ 59 yo lady with early onset dementia
ā¢ Lives with husband and supported by 2 kids
ā¢ Longstanding abuse both verbal and physical
ā¢ Contact by HC after an episode of physical abuse involving RCMP. They feel Mrs C should have a capacity assessment and be placed.
ā¢ Mrs C want to stay home
What would you do?
A. Complete DMCA as requested
B. Involve Elder Abuse team
C. Admit to hospital
D. Gather more information
Liabilityā¢ The Personal Directives Act state that
ā¢ ā¦an agent or a service provider is not liable for what they do or omit to do,
ā¢ ā¦.as long as they are acting in good faith and in accordance with the Act.
Fees guideline for DCA (physicians not bound)
ā¢ s. 9 AGTR - fees for court applications for single appointments and section 96 assessments: up to $500
ā¢ For court applications for dual (G and T) appointments: up to $700
ā¢ Court, on application, may set a higher fee based on complexity of assessment, but not when Minister pays for assessment
Billing
ā¢ 03.04N Comprehensive evaluation including completion of forms to determine capacity as defined by the Personal Directives Act (PDA) (RSA 2007 s9(2)(a)) 182.59
Note: 1. Benefit includes witnessing the agents' or service providersā assessment.
2. May be claimed to determine lack of capacity or to determine that capacity has been regained.
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DMCA Model
ā¢ In summary, the decision-making capacity assessment Model was developed in Alberta and aligned with provincial legislation.
ā¢ It outlines DMCA best practices and includes
ā a care map.
ā worksheets.
ā staff training workshops.
ā Physician training workshops.
ā Grand rounds/ Educational sessions.
ā¢ It has been used by physicians and other health care professionals across the care continuum.
DMCA Education
ā¢ 3-4 hour workshop and refreshers for healthcare professionals
offered via Covenant Health, AHS, Bethany Care Society and Good Samaritans Society
ā¢ 3-hour level 1 workshop for physicians (accredited by the CFPC for 6
Group learning credits)
ā¢ 3-hour level 2 workshop for physicians (accredited by the CFPC for 6 Group learning credits)
ā¢ 2-day workshop for physicians via OPGT
Resources for Healthcare Providers
ā¢ Office of the Public Guardian and Trustee:Help for Incapable adults homepage https://www.alberta.ca/help-incapable-adults.aspx
ā¢ AHS - Adult Guardian &Trustee Act: Resources https://www.albertahealthservices.ca/info/Page853.aspx
ā¢ Covenant Health - Capacity Assessment Resourceshttps://medicalstaff.covenanthealth.ca/clinical-supportservices/capacity-assessment
ā¢ AHS- Capacity Assessment Resourceshttps://insite.albertahealthservices.ca/assets/ppc/tms-ppc-social-work-decision-making-toolkit.pdf
Contact Information
Lesley Charles, MBChB, CCFP COEAssociate Professor & Program Director
Division of Care of the ElderlyDepartment of Family Medicine
University of [email protected]
Questions