Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Standards of Decision Making
- Prior explicit articulation: decision based on the previous expression of a capable person's wishes through oral or written comments or instructions.
- Substituted judgment: decision by others based on the formerly capable person's wishes that are known or can be inferred from prior behaviors or decisions.
- Best-interest standard: decision based on what others judge to be in the best interest of an individual who never had or made known health care wishes and whose preferences cannot be inferred.
Assessment of Decisional Capacity
- There is no "gold standard" instrument to assess capacity.
- Assessment should occur over a period of time, at different times of day, and with attention to the patient's comfort level (Mezey, Mitty, & Ramsey, 1997 [Level V]).
- The Mini-Mental State Examination (MMSE) or Mini-Cog is not a test of capacity. Tests of executive function might better approximate the reasoning and recall needed to understand the implications of a decision.
- Clinicians agree that the ability to understand the consequences of a decision is an important indicator of decisional capacity.
- Safe and appropriate decision-making is retained in early-stage dementia (Kim & Karlawish, 2002 [Level V]) and by adults with mild to moderate mental retardation (Cea & Fisher, 2003 [Level IV]).
Nursing Care Strategies
- Communicate with patient and family or other/surrogate decision makers to enhance their understanding of treatment options.
- Be sensitive to racial, ethnic, religious, and cultural mores and traditions regarding end-of-life care planning, disclosure of information, and care decisions (Duffy et al., 2006 [Level IV]; Kagawa-Singer & Blackhall, 2001 [Level V]).
- Be aware of conflict resolution support and systems available in the care-providing organization.
- Observe, document, and report the patient's ability to:
- Articulate his or her needs and preferences
- Follow directions
- Make simple choices and decisions (e.g., "Do you prefer the TV on or off?", "Do you prefer orange juice or water?")
- Communicate consistent care wishes
- Observe period(s) of confusion and lucidity; document the specific time(s) when the patient seems more or less "clear." Observation and documentation of the patient's mental state should occur during the day, evening, and at night.
- Understanding is assessed relative to the particular decision at issue. The following probes and statements are useful in assessing the degree to which the patient has the skills necessary to make a health care decision:
- "Tell me in your own words what the physician explained to you."
- "Tell me which parts, if any, were confusing."
- "What do you feel you have to gain by agreeing to (the proposed intervention)?"
- "Tell me what you feel you have to lose by agreeing to (the proposed intervention)?"
- "Tell me what you feel you have to gain/lose by refusing (the proposed intervention)?"
- "Tell me why this decision is important (difficult, frightening, etc.) to you."
- Select (or construct) appropriate decision aids.
- Help the patient express what he or she understands about the clinical situation, the goals of care, the expectation of the outcomes of the diagnostic or treatment interventions.
- Help the patient identify who should participate in diagnostic and treatment discussions and decisions.
Definitions:
Levels of Evidence
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
