Transcript Healthcare Decision Making

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Healthcare Decision Making
Nursing Standard of Practice Protocol
ConsultGeriRN.org
Cheryl Howard ~ March 2012
Ferris State University ~ NURS 314 Gerontological Nursing
Overview
 Core ethical principles for clinicians
are respect for autonomy,
beneficence, nonmaleficence and
justice.
 Care professionals have an obligation
to be alert for questionable or
fluctuating healthcare decision
making capacity.
 Careful balancing of information,
principles, rights and responsibilities
is required in order to make clinically,
legally, and ethically valid decisions.
(Mitty & Post, 2008)
Decision Making Concepts
 People with decisional capacity have a RIGHT to
determine what is done to their bodies.
 AUTONOMY is exercised in the process of informed
consent (or refusal) of treatment and care planning.
 Determining decision making capacity is VITAL because
interventions have potential for benefit/risk.
 Capable patients are RESPECTED when their decisions are
honored; ABANDONMENT occurs when incapacitated
patients’ wishes are honored.
(Mitty & Post, 2008)
Definition of Decisional Capacity
Decisional capacity: a clinical determination that an
individual has the ability to understand the consequences
for health decisions and that they are able to make and
take responsibility for those decisions.
 Patients may have the ability to make
some decisions but not others
 Decision making capacity may fluctuate
according to factors such as clinical
condition, time of day, medications,
comfort and psychological status.
 Delegation of decisional authority cannot
be inferred & must be explicitly
confirmed.
(Mitty & Post, 2008)
Other Important Definitions
 Consent: requires evidence of decisional capacity.
Consent or refusal of intervention is based on
disclosure, understanding, voluntary choice of
options.
 Competence: legal presumption of mental ability to
negotiate legal tasks such as enter into contracts,
make a will, etc.
 Incompetence: judicial determination that a
person is not able to negotiate legal tasks
and should be prevented from doing so.
(Mitty & Post, 2008)
Standards of Decision Making
 Prior explicit articulation – decision based on
previous expression of a capable person’s wishes
▫ Oral or written comments or instructions
 Substituted judgment – decision by others based on
formerly capable person’s wishes
▫ Can be inferred from prior behaviors or decisions
 Best interested standard – decision based on what
others judge to be in the best interest of a person
▫ ONLY if this person never made known health care
wishes and whose preferences cannot be inferred.
◦
(Mitty & Post, 2008)
Nursing Care Strategies
1. Communicate with patient, family
or surrogate decision maker to
enhance understanding of
treatment options.
2. Be sensitive to racial, ethnic,
religious & cultural beliefs and
traditions.
3. Be aware of available conflict
resolution support systems in your
health care organization.
4. Help the patient identify who
should participate in treatment
discussions and decisions.
(Mitty & Post, 2008)
Nursing Care Strategies continued
5. Help the patient express what they understand about
the clinical situation & outcome expectation.
6. Select (or construct) appropriate decision making aids.
7. Observe and document specific times of confusion,
lucidity, and mental state in day, evening & night.
8. Observe, document & report patients ability to:




Articulate needs & preferences
Follow directions
Communicate consistent care wishes
Make simple choices
“Do you prefer juice or water?”
(Mitty & Post, 2008)
Nursing Care Strategies continued
9. Assess understanding relative to the particular decision
at issue.
 “Tell me in your own words what the physician explained
to you.”
 “Tell me which parts were confusing.”
 “What do you feel you have to gain/lose by AGREEING to
the proposed intervention?”
 “What do you feel you have to gain/lose by REFUSING to
the proposed intervention?”
 “Tell me why this decision is important
(difficult, frightening, etc.) to you.”
(Mitty & Post, 2008)
Assessment of Decisional Capacity
 There is no “gold standard”.
 The ability to understand the CONSEQUENCES of a
decision is an important indicator of decisional capacity.
 Assessment should occur over a period of time at
different times of day with attention to patient’s
comfort level.
 The Mini-mental state examination (MMSE) or Mini-Cog
is NOT a test of capacity.
▫ Tests of executive function better approximate decision making
skills of reasoning and recall. There is no standardized method of
testing executive function, various tests are used (NCLD, 2010).
▫ Safe & appropriate decision making is retained in early stage
dementia & mild-moderate mental retardation
(Mitty & Post, 2008)
Best Practice
Assessment/Screening Tools
• Decision Making and Dementia: Evaluation
Guidelines Click here for Guidelines & instructions.
• Brief Evaluation of Executive Function: Screening
tools for the refined assessment of cognitive
function. Click here for screening tools & instructions.
▫ Royall’s CLOX Clock Drawing
▫ The Controlled Oral Word Association Test
▫ The Trail Making Test, Oral Version
(Mitty & Post, 2008)
Nursing Evaluation
& Expected Outcomes
 Plan of Care: include instructions regarding frequency of
observation to ascertain periods of patient lucidity.
 Documentation:
▫ Describe process of capacity assessment. Make sure assessment
method is specific to issue at hand.
▫ Describe specifics of patients orientation.
▫ Consistently use appropriate mental status descriptors.
▫ Describe interaction with informed consent & refusal.
 Record patient’s language used to describe intervention under
consideration. Record patient’s demeanor.
 Record patient’s questions & clinicians answers.
 Referral: refer to ethics committee or consultant in
situations of decision making conflict. (Mitty & Post, 2008)
Application to Practice
“Decision making concepts are an important part of my job as an
RN case manager for MiChoice Waiver Nursing Home Transition Program.
First and foremost, I must ensure who the legal decision maker is for
participants referred to the program. In over half my cases, the
participant “is their own person” which is another way of saying that
they are legally able to make their own decisions. The other times there
is a guardian who makes all the decisions for the person. Sometimes
there is a conservator or financial durable power of attorney (DPOA) over
financial matters only. There could also be a DPOA only over medical
issues. It can be complicated because paperwork isn’t always clear.
Something that is important to me is that even when someone is
not “their own person”, I feel that the opinions and wishes of that
participant should still be taken under consideration if it all possible. I
have thoroughly embraced the person centered planning concept and
have found time after time that interventions are more successful when
the participant is “on board” regardless if they are their own legal
decision maker or not.
Application to Practice continued
We often have to ask permission and involve the designated
decision maker for program participation, care planning, and signing
paperwork for the participant.
An interesting thing that I have learned in my job is that in
most cases DPOA’s are only effective if it is enacted and signed by 2
physicians OR if the participant requests that it be enacted. I have
found that many participants and their families think that a DPOA is a
type of “guardian” which is not an accurate assumption. I have also
found that after a DPOA is enacted, it is can easily be revoked if the
person verbally and in writing requests that it be revoked. Many think
that once a DPOA is enacted, it takes a trip to court to change it.
This is not true from what I have learned. Of course this can be a
complicated topic that requires a thorough review of the exact
wording of each individual designated decision maker document. This
can be frustrating to deal with but it is very important to determine
before I provide assessment and care management services.
Application to Practice continued
I have not had the opportunity to use the decisional
capacity assessment tools from this protocol in my practice
setting. In my position as a case manager, all of the cognitive
and decision capacity assessment is done by my teammate who
is a social worker. Although screening and assessing for
cognitive ability is certainly within my scope of practice, this is
not something that is a duty in my current position.
I have given printouts of these assessment tools to the
social worker on my case management team. I have offered to
assist her in trying them in the field. Currently there is no
standardized test mandated for her assessment. I feel that our
participant’s care management may benefit from an effective,
easy method of screening for level of executive dysfunction and
cognition. I am hopeful that my social worker partner will try
these evidence based tools.”
Cheryl Howard RN
Goals for Nursing Practice
Clinicians should:
 Understand the supporting bioethical
and legal principles of informed
consent.
 Understand the issues and processing
of assessing decisional capacity.
 Be able to differentiate between
competence and capacity.
 Be able to describe the nurse’s role
and responsibility as an advocate for
the patient’s voice in health care
decision making.
(Mitty & Post, 2008)
References
Mitty, E. L., & Post, L. F. (2008, March). Nursing standard
of practice protocol: Healthcare decision making.
Retrieved from Hartford Institute for Geriatric Nursing
website:http://consultgerirn.org/topics/treatment_de
cision_making/want_to_know_more
NCLD. (2010, December 17). What is executive function?
Retrieved from National Center for Learning Disabilities
website: http://www.ncld.org/ld-basics/ld-aampexecutive-functioning/basic-ef-facts/what-isexecutive-function
Final Grade
REQUIREMENTS
• Brief summary of the protocol. For this presentation to peers, it is important that students
select the main points.
• Report the results of your trial of the protocol.
• What is your professional nursing opinion of the Hartford Try This protocol (strengths and
weaknesses)?
• Does your usual practice setting have a standardized plan of care for this problem? Is it
similar to the best-practices listed in ConsultGeriRN?
• Is there any additional information you need before deciding whether or not to modify your
practice in light of the presented information? How would you determine if a change in your
practice was helpful to your patients (can you think of any ways to measure improvement
related to the subject in your practice setting, or in general)?
• Report all this in a short PowerPoint and post during your assigned week. Should include all
information above with 20 slides (+ or – 5).
• Focus on the essentials to report to your colleagues on this patient, presenting materials on all
headings from the rubric. Narration is a plus.
• Cite reference of the ConsultGeriRN.org protocol in APA format. It is not necessary to use
other sources, but if used be sure to cite them!
GRADE
Grade= 95% Great job! Presentation is very well done and provides a lot of helpful information
to students. I especially liked that you explained ethical implications. I did not see that you
proposed how to evaluate of a change in practice would be beneficial to your patients, but
otherwise you covered all expectations of the assignment. It is nice that your assigned protocol
had relevance to your job.
Final Grade Rubric