Long-Term Care Survey Alert

Assess the key elements of the ability to make an informed choice.

Talk about a tricky decision: Determining whether a resident with some cognitive impairment can make a reasonable choice to accept or reject specific medical interventions.

But a quick assessment tool can help quantify the person's decision-making ability, which may be higher than staff thinks it is.

Case in point: Masonic Village at Elizabethtown developed such a tool a number of years ago at a time when staff viewed about three fourths of the residents as having no decision-making ability, according to Ken Brubaker, MD, CMD, medical director for the nursing facility in Elizabethtown, PA. But by using the assessment instrument, the interdisciplinary team now identifies "more than half of residents who have limited or full decision-making capability," he says.

How the tool works: The tool is primarily for assessing a person's decision-making ability for medical care. The staff performing the assessment scores the resident's ability in five areas, including his ability to process information and recognize that he has a choice. They also determine if the resident can reason and understand the consequences of his decisions. The assessment also looks at the person's memory recall.

Someone with a score of 13-15 can make all decisions independently. Those scoring in the range of 7-12 have limited decision-making capacity but can still possess "at minimum" the capability to designate a power of attorney.

The facility team determines the resident's decision-making ability on a decision-by-decision basis,  and involves his surrogate in complex decisions. Those with a score of 0 to 6 have no decision-making ability but may express preferences for food, clothing and daily routine, as examples.

Spread the decision-making: The team uses a group decision process to agree on how the patient makes decisions, says Brubaker. "The group members usually agree fairly quickly."

Brubaker and his colleagues have done some preliminary validation of the tool and are now working on a validation study with results available this spring. "We have used the instrument in facilities in this area but have to take the next step to ensure it's doing what we say it's doing," he tells Eli.

Applying the Findings

When dealing with a resident with no decision-making capability, Brubaker goes to the person's power of attorney (POA) to decide what to do about the resident's medical care. But if the person has full decision-making capability, Brubaker doesn't contact the POA because "there's no role for the POA in that case."

Brubaker involves individuals with limited decision-making ability in the decision-making process. But he also goes to the POA to discuss the issue at hand -- for example, say the resident develops pneumonia and doesn't want to go to the hospital for treatment.

What if the resident and POA don't agree on what to do? Brubaker hasn't encountered that scenario so far. But if it happened, he'd side with the resident, as long as he's used the tool and believes the resident has a basic understanding of the issues, appreciates the problem, and can reason and make a choice.

Example: Brubaker had a patient with a mini-mental score of probably 18 out of 30 who had gangrene of the lower extremities. The man refused to go to the hospital and said he realized that "he'd likely die if he didn't." The man was in his 80's and had never "been one to take care of his health and now chose not to receive treatment."

The facility honored the man's decision. Brubaker says that the more "we get into end of life care," the more he's "getting to be at peace with such decisions."

Recognizing the Test's Limits st

The tool is primarily designed to assess the elderly person whereas long-term care facilities are caring for younger patients." Also, a person can do well at components of decision-making but still make dumb choices," says Brubaker. "For example, bipolar disease can have psychosis associated with it. And the tool hasn't been tested in a strictly psychiatric milieu."

Example: A young paralyzed resident wanted to go outside in his electric wheelchair during thunderstorms, which had an element of thrill seeking.

While the tool showed the resident had full decision-making ability, staff also believed the man had bipolar disease, which can impair sound decision-making, notes Brubaker. So they contracted with him not to go out during storms, and the resident has complied.

Creative idea: One way to provide the resident a substitute activity in that situation might be to offer him a videotape simulating thunderstorms, says Brubaker.