Cognitive impairment affects older adults’ capacity to live independently and make lifestyle decisions (lifestyle decision-making capacity; LS-DMC). Cognitive screens and clinical interviews are often used to assess people’s need for living-supports prior to conducting comprehensive LS-DMC assessments in busy clinical settings. This study investigated whether the QuickSort – a brief new cognitive screen – provides efficient and accurate information regarding patients’ LS-DMC when initially interviewed.

This is an observational and diagnostic accuracy study of older inpatients (≥60 years) consecutively referred for neuropsychological assessment of LS-DMC (n = 124). The resources required by inpatients with questionable LS-DMC were quantified (length of hospital stay, living-supports). QuickSort scores, patient background information, and two common cognitive screens were used to differentiate between older inpatients (n = 124) who lacked (64%)/did not-lack (36%) LS-DMC.

Hospitalizations averaged 49 days, with 62% of inpatients being readmitted within one year. The QuickSort differentiated between those lacking/not-lacking LS-DMC better than two common cognitive screens and patient information. The likelihood that inpatients lacked LS-DMC increased by a factor of 65.26 for QuickSort scores <2 and reduced by a factor of 0.32 for scores ≥13. Modeling revealed that the post-test likelihood of lacking LS-DMC increased to 99% (scores <2) and reduced to 30% (scores ≥ 13) in settings where many inpatients lack LS-DMC.

Older adult inpatients with questionable LS-DMC have a high risk of extended hospitalization and readmission. The QuickSort provides time-efficient and sensitive information regarding patients’ LS-DMC, making it a viable alternative to longer cognitive screens that are used at the initial interview stage.

Impairment in decision-making capacity is a serious consequence of executive dysfunction secondary to serious mental disorders like schizophrenia. Functional mental capacity (FMC) refers to an individual’s ability to make and communicate legally competent decisions autonomously. Studies have shown that FMC is dependent on severity of psychosis and can improve with treatment.

To ascertain the correlation between the scores on a structured judgement tool, namely the Dundrum Capacity Ladders (DCL) with level of acuity of treatment setting and length of stay in a secure forensic hospital.

Sixty-two patients were interviewed using the DCL across three domains – healthcare, welfare and finances. Correlation between DCL scores, length of hospital stay and level of acuity of treatment setting was assessed.

As patients moved from higher to lower dependency wards, mean DCL score increased, indicating a higher level of capacity. Patients in high dependency wards were most impaired while those in the low dependency wards performed significantly better (rs=0.472, p<0.001). The longer the patients stayed in the hospital, up until five years, the higher the mean welfare domain score (rs=0.402, p=0.011) and mean DCL score (rs=0.376, p=0.018). Beyond five years of hospital stay, those who had lower DCL scores and did not improve had longer length of stay.

Patients’ FMC improve as they progress from high to low level of acuity of treatment setting. However, this is dependent on the length of hospital stay. FMC may be a measure of recovery in the forensic setting.

No significant relationships.

The study’s main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness.

This was a cross-sectional, observational study, done at Weskoppies Psychiatric Hospital, Gauteng Province, South Africa that included 100 adults older than 60 years of age and diagnosed with serious mental illness.

Socio-demographic, diagnostic, and treatment data were collected before administration of the Mini- Cog and a semi-structured clinical assessment of end-of-life decision-making capacity. Finally, the standardized interview, Assessment of Capacity to Consent to Treatment, was administered. This standardised instrument uses a hypothetical vignette to assess decision-making capacity and explores healthcare-related values.

According to the semi-structured decision-making capacity assessment, 65% of participants had decision-making capacity for end-of-life decisions. The Assessment of Capacity to Consent to Treatment scores were significant (p<0.001) when compared to decision-making capacity. Significant correlations with impaired decision-making capacity included: lower scores on the Mini-Cog (p<0.001); a duration of serious mental illness of 30-39 years (p=0025); having a diagnosis of schizophrenia spectrum disorders (p=0.0007); and being admitted involuntarily (p<0.0001).

Two thirds of older people with serious mental illness had decision-making capacity and were able to engage in end-of-life care discussions. Healthcare providers have a duty to initiate advance care discussions, optimize decision-making capacity, and protect autonomous decision-making. Chronological age or diagnostic categories should never be used as reasons for discrimination, and older people with serious mental illness should receive end-of-life care in keeping with their preferences and values.

No significant relationships.

Medical assistance in dying (MAiD), also known as physician-assisted death, is currently legal in several locations across the globe. Brain cancer or its treatments can lead to cognitive impairment, which can impact decision-making capacity for MAiD.

We sought to explore neuro-oncology clinicians’ attitudes and perspectives on MAiD, including interpretation of decision-making capacity for patient MAiD eligibility.

An online survey was distributed to members of national and international neuro-oncology societies. We asked questions about decision-making capacity and MAiD, in part using hypothetical patient scenarios. Multiple choice and free-text responses were captured.

There were 125 survey respondents. Impaired cognition was identified as the most important factor that would signal a decline in patient capacity. At least 26% of survey respondents had moral objections to MAiD. Respondents thought that different hypothetical patients had capacity to make a decision about MAiD (range 18%–58%). In other hypothetical scenarios, fewer clinicians were willing to support a MAiD decision for a patient with an oligodendroglioma (26%) vs. glioblastoma (41%–70%, depending on the scenario). Time since diagnosis, performance status, and patient age seemed to affect support for MAiD decisions (Fisher’s exact P-values 0.007, < 0.001, and 0.049, respectively).

While there are differing opinions on the moral permissibility of MAiD in general and for neuro-oncology patients, most clinicians agree that capacity must be assessed carefully before a decision is made. End-of-life discussions should happen early, before the capacity is lost. Our results can inform assessments of patient capacity in jurisdictions where MAiD is legal.

Valid consent for treatment or research participation requires that an individual has decision-making capacity (DMC), which is the ability to make a specific decision. There is evidence that the psychopathology of schizophrenia can compromise DMC. The objective of this review was to examine the presence or absence of DMC in schizophrenia and the socio-demographic/psychopathological factors associated.

We searched three databases Embase, Ovid MEDLINE(R), and PsycINFO for studies reporting data on the proportion of DMC for treatment and research (DMC-T and DMC-R), and/or socio-demographic/psychopathological associations with ability to make such decisions, in people with schizophrenia and related illnesses.

A total of 40 studies were identified. While high levels of heterogeneity limited direct comparison, meta-analysis of inpatient data showed that DMC-T was present in 48% of people. Insight was strongly associated with DMC-T. Neurocognitive deficits were strongly associated with lack of DMC-R and to a lesser extent DMC-T. With the exception of years of education, there was no evidence for an association with socio-demographic factors.

Insight and neurocognitive deficits are most closely associated with DMC in schizophrenia. The lack of an association with socio-demographic factors dispels common misperceptions regarding DMC and characteristics such as age. Although our results reveal a wide spectrum of DMC-T and DMC-R in schizophrenia, this could be partly due to the complexity of the DMC construct and the heterogeneity of existing studies. To facilitate systematic review research, there is a need for improvement within research study design and increased consistency of concepts and tools.

The use of assessment tools has been shown to improve the inter-rater reliability of capacity assessments. However, instrument-based capacity assessments of people with dementia face challenges. In dementia research, measuring capacity with instruments like the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) mostly employ hypothetical treatment vignettes that can overwhelm the abstraction capabilities of people with dementia and are thus not always suitable for this target group. The primary aim of this study was to provide a standardized real informed consent paradigm that enables the dementia-specific properties of capacity to consent to treatment in people with dementia to be identified in a real informed consent process that is both externally valid and ethically justifiable.

The sample consisted of 53 people with mild to moderate dementia and a group of 133 people without cognitive impairment. Rather than using a hypothetical treatment vignette, we used a standardized version of the MacCAT-T to assess capacity to consent to treatment with cholinesterase inhibitors in people with dementia. Inter-rater reliability, item statistics, and psychometric properties were also investigated.

Intraclass correlations (ICCs) (0.951–0.990) indicated high inter-rater reliability of the standardized real informed consent paradigm. In the dementia group, performance on different items of the MacCAT-T varied. Most people with dementia were able to express a treatment choice, and were aware of the need to take a tablet. Further information on the course of the disorder and the benefits and risks of the treatment were less understood, as was comparative reasoning regarding treatment alternatives.

The standardized real informed consent paradigm enabled us to detect dementia-specific characteristics of patients’ capacity to consent to treatment with cholinesterase inhibitors. In order to determine suitable enhanced consent procedures for this treatment, we recommend the consideration of MacCAT-T results on an item level. People with dementia seem to understand only basic information. Our data indicate that one useful strategy to enhance capacity to consent is to reduce attention and memory demands as far as possible.

Evidence of impaired decision-making capacity is a legal requirement for adult guardianship. To understand the quality of the evidence health professionals commonly provide in reports submitted to guardianship courts, a systematic review was undertaken to appraise the design and methodological quality of the published literature on health professionals’ written reports of decision-making capacity and to describe the content of these reports.

Electronic searches from 1980 to 2015 identified 1183 articles of which 11 met the inclusion criteria where each evaluated quantitatively the content of health professionals’ written reports submitted to adult guardianship proceedings. Methodological quality of the selected studies was rated using a critical appraisal tool.

Nine studies sourced files from courts in the U.S. and one from Sweden; another reported on guardianship decisions from Australia. Four studies were rated as moderately strong or strong. Strengths included the use of comparison groups and a reliable and valid instrument to code reports. The review showed a person's medical condition was often cited as evidence of impaired decision-making capacity. Cognitive, psychiatric and functional abilities were less often described, and a person's values and preferences were rarely recorded.

It is recommended health professionals describe the process by which a person makes a particular decision (their ability to understand, appreciate, reason and communicate) in addition to providing medical information, including cognitive, psychiatric and functional abilities. This approach provides support for a professional's opinion and evidence for a court. International studies of health professionals’ approach to decision-making capacity evaluation are needed.