By Kathryn Radigan, MD

Attending Physician, Division of Pulmonary and Critical Care, Stroger Hospital of Cook County, Chicago

Dr. Radigan reports no financial relationships relevant to this field of study.

SYNOPSIS: A multicenter, one-day prevalence, prospective, observational, double-blind study in 19 ICUs revealed that the decision-making capacity of ICU patients was widely overestimated by all clinicians as compared with a capacity score measured by the Mini-Mental Status Examination and the Aid to Capacity Evaluation.

SOURCE: Bertrand PM, Pereira B, Adda M, et al. Disagreement between clinicians and score in decision-making capacity of critically ill patients. Crit Care Med 2019;47:337-344.

Decision-making capacity is a complex cognitive function defined as the ability to comprehend all pertinent information, to appreciate the scenario and its consequences, to weigh treatment options, and to communicate the final decision. Recognizing the limited data addressing decision-making capacity in the critically ill, Bertrand and colleagues performed a multicenter, one-day prevalence, prospective, observational, double-blind study in 19 ICUs in France comparing the assessment of decision-making capacity of ICU patients by clinicians (physicians, residents, and nurses) with a capacity score measured by the Mini-Mental Status Examination (MMSE) and Aid to Capacity Evaluation (ACE) if further information was needed. From May 2012 to August 2013, all clinicians who were working from 8:00 a.m. to 6:00 p.m. in the ICU on the day of the study were enrolled. The specific day chosen was different for each ICU and was determined at least two weeks in advance to ensure participation from the usual members of the ICU team. All adult ICU patients participated as long as they were hospitalized in the ICU before 10:00 a.m. on the day of the study. Patients under judicial protection were excluded. Before inclusion, written informed consent from the clinicians and from either the patient or surrogate was obtained. On the day of the study, the clinicians attended a presentation on the study that included an outline of the objectives and methods along with a 10-minute talk about the definition and usefulness of assessment of decision-making capacity according to ethical principles. After their patient visit, all attending clinicians were asked to complete an anonymous survey on the assessment of decision-making capacity. Specifically, they were asked, “What is the current status of the patient’s decision-making capacity?” They had to choose from the following responses: “patient with decision-making capacity,” “patient with probable decision-making capacity,” “probably incapacitated patient,” and “incapacitated patient.” Within an hour following the clinicians’ assessment, a single-blinded, independent ICU physician observer trained in administering capacity interviews assessed the same patients. An MMSE was administered, and those with a score of less than 20 were deemed incapacitated; those with a score greater than 24 were considered to have decision-making capacity. For patients with a score from 20 to 24, an ACE questionnaire was completed to further determine capacity status. The primary outcome was agreement between physicians’ assessments and the score. The secondary outcomes were agreement between nurses’ or residents’ assessments and the score and identification of factors associated with disagreement.

A total of 213 clinicians (57 physicians, 97 nurses, and 59 residents) assessed 206 critically ill patients. Compared to the independent observer’s score, physicians determined more patients to have decision-making capacity (45% vs. 17%; absolute difference 28%; 95% confidence interval [CI], 20-37%; P = 0.001). There was a substantial difference among all clinician assessments compared to an observer score (kappa coefficient, 0.39, 95% CI, 0.29-0.50 for physicians; 0.39, 95% CI, 0.27-0.52 for nurses; 0.46, 95% CI, 0.35-0.58 for residents). The main factor associated with disagreement was a Glasgow Coma Scale (GCS) score between 10 and 15 (odds ratio 2.92, 95% CI, 1.18-7.19, P = 0.02 for physicians; 4.97, 95% CI, 1.5-16.45, P = 0.01 for nurses; 3.39, 95% CI, 1.12-10.29, P = 0.03 for residents). For GCS scores between 10 and 15, the proportion of disagreements between score and clinician assessment did not differ. Results revealed that the decision-making capacity of ICU patients was widely overestimated by all clinicians as compared with a capacity score measured by the MMSE (and ACE, if necessary). Overestimation of capacity occurred most commonly in patients with a GCS score between 10 and 15. These results suggest that clinicians may have misinterpreted a higher level of consciousness as possession of decision-making capacity.

COMMENTARY

“No doubt I appeared perfectly competent. I was, after all, propped up in bed, reading the Guardian Weekly and the London Review of Books. I was appropriately responsive to questions. But I was a psychological mess and shouldn’t have been taken to be fit to participate in decisions.”1 These quotes came from the perspective of a patient and academic philosopher who spent weeks in an intensive care unit. The purpose of her article was to address how certain assumptions were made by her caregivers and how she felt compelled to improve these assumptions, including medical-decision making. Medical decision-making by patients is a complex process. Inappropriate decisions made by an incapacitated patient who goes unrecognized is a major ethical issue. Bertrand and his colleagues confirmed that the decision-making capacity of ICU patients was widely overestimated by all clinicians as compared with a capacity score, underlining this significant problem.

Although not formally covered within our medical educational system, assessing capacity is an important skill in clinical practice. It is important to assess capacity through a face-to-face interview with the patient using a series of open-ended questions related to the medical decision. The assessment of capacity should specifically address the patient’s understanding of the medical issues, whether the patient has an appreciation of how these issues apply to his or her life, whether the patient can reason appropriately (compare the different options and sequelae of each option), and whether the patient can express a decision that makes sense after weighing all these factors.2 This deliberate approach can take considerable time, and many clinicians will proceed with their own subjective assessment that often is clouded by their own personal values. These values may raise ethical concerns, especially in the setting of life or death decisions, such as a decision to forgo life-sustaining treatment. When clinicians are faced with complicated cases or when there is disagreement, validated instruments, such as the MacArthur Competency Assessment Tool for Treatment, Assessment of Capacity for Everyday Decisions, or the Capacity to Consent to Treatment Interview, can be used to formally assess capacity.3 Most often, the ideal methods to assess decision-making capacity in research studies have been the MMSE using two cut-offs and the ACE.4

Interestingly, the authors of this study found that a GCS score between 10 and 15 was the main factor associated with disagreement between the clinician’s assessment and an objective score. GCS is a consciousness score that quickly assesses motor, verbal, and eye responses. A score of 10 or less often is the cut-off for severe dysfunction, and moderately altered patients with a normal state of consciousness often have a GCS score between 10 and 15. Assuming that a patient in a coma does not have capacity, clinicians often will assume that recovery of consciousness after coma results in recovery of decision-making without using a rigorous and focused objective method to assess their patients.

These results should encourage all clinicians to take more time in assessing patient capacity with a face-to-face interview along with using a scoring system that objectively supports their initial subjective assessment. Within this study, 41 of the 71 patients who consented to enroll in the study because the attending physician had considered them to have decision-making capacity were identified later as incapacitated by the score. Further studies are necessary to refine how best to perform these assessments in a busy clinical environment, how they may be customized further for specific patient populations, and how best to develop these clinical skills within medical training to ensure that clinicians are proficient.

REFERENCES

  1. Misak CJ. The critical care experience: A patient’s view. Am J Respir Crit Care Med 2004;170:357-359.
  2. Lai JM, Karlawish J. Assessing the capacity to make everyday decisions: A guide for clinicians and an agenda for future research. Am J Geriatr Psychiatry 2007;15:101-111.
  3. Lamont S, Jeon YH, Chiarella M. Assessing patient capacity to consent to treatment: An integrative review of instruments and tools. J Clin Nurs 2013;22:2387-2403.
  4. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.