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  • Guideline Summary
  • NGC:009715
  • 2008 (revised 2012)

Health care decision making. In: Evidence-based geriatric nursing protocols for best practice.

Mitty EL, Post LF. Health care decision making. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 562-78.

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

This guideline updates a previous version: Mitty EL, Post LF. Health care decision making. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p. 521-38.

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Assessment of Decisional Capacity

  • There is no gold standard instrument to assess capacity.
  • Assessment should occur over time, at different times of day, and with attention to the patient's comfort level. 
  • The Mini-Mental State Examination (MMSE) or Mini-Cog Test 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 sufficient decision making is retained in early stages of dementia (Kim, Karlawish, & Caine, 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.
  • 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.
  • Assess understanding 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 or 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

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Decision-making capacity

Guideline Category

Evaluation

Management

Clinical Specialty

Family Practice

Geriatrics

Nursing

Intended Users

Advanced Practice Nurses

Allied Health Personnel

Health Care Providers

Hospitals

Nurses

Physician Assistants

Physicians

Guideline Objective(s)

To provide a standard of practice protocol to ensure that nurses in acute care:

  • Understand the supporting bioethical and legal principles of informed consent
  • Are able to differentiate between competence and capacity
  • Understand the issues and processing of assessing decisional capacity
  • Can describe the nurse's role and responsibility as an advocate for the patient's voice in health care decision making

Target Population

Hospitalized older adults

Interventions and Practices Considered

Assessment/Evaluation

  1. Assessment of decision-making capacity
    • Tests of executive function
    • Indicators of decisional capacity

Management

  1. Communication with patient and family/caregiver
  2. Observations and documentation of patient's abilities
  3. Assessment of understanding relative to the particular decision
  4. Use of decision aids

Major Outcomes Considered

  • Number of referrals to the ethics committee or ethics consultant in situations of decision-making conflict between any of the involved parties
  • Appropriate plan of care written
  • Appropriate documentation

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

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

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397 External Web Site Policy.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

Not stated

References Supporting the Recommendations

Cea CD, Fisher CB. Health care decision-making by adults with mental retardation. Ment Retard. 2003 Apr;41(2):78-87. PubMed External Web Site Policy

Kim SY, Karlawish JH, Caine ED. Current state of research on decision-making competence of cognitively impaired elderly persons. Am J Geriatr Psychiatry. 2002 Mar-Apr;10(2):151-65. [72 references] PubMed External Web Site Policy

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Potential Benefits

  • Increased number of referrals to the ethics committee or ethics consultant in situations of decision-making conflict between any of the involved parties.
  • The use of interpreters in communication of, or decision making about, diagnostic and/or treatment interventions.
  • Plan of care: instructions regarding frequency of observation to ascertain the patient's lucid periods, if any.
  • Documentation of the following:
    • Is the process of the capacity assessment described?
    • Is the assessment specific to the decision at issue?
    • Is the informed consent and refusal interaction described?
    • Are the specifics of the patient's degree or spheres of orientation described?
    • Is the patient's language used to describe the diagnostic or treatment intervention under consideration recorded? Is the patient's demeanor during this discussion recorded?
    • Are the patient's questions and the clinician(s) answers recorded?
    • Are appropriate mental status descriptors used consistently?

Potential Harms

Not stated

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Mobile Device Resources

Resources

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

End of Life Care

Living with Illness

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

Mitty EL, Post LF. Health care decision making. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 562-78.

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2008 (revised 2012)

Guideline Developer(s)

Hartford Institute for Geriatric Nursing - Academic Institution

Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Authors: Ethel L. Mitty, EdD, RN, Adjunct Clinical Professor, New York University, New York, NY; Linda Farber Post, JD, MA, BSN, Director, Bioethics, Hackensack University Medical Center, Hackensack, NJ

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Mitty EL, Post LF. Health care decision making. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p. 521-38.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com External Web Site Policy.

Availability of Companion Documents

The following are available:

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 13, 2008. The information was verified by the guideline developer on August 4, 2008. This NGC summary was updated by ECRI Institute on June 25, 2013. The updated information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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