Monday, 17 September 2018 Should capacity assessment be performed routinely prior to discussing advance care planning with older people? Oleg Kiriaev, Emme Chacko, JD Jurgens, Meagan Ramages, Phillipa Malpas, Gary Cheung g.cheung@auckland.ac.nz

People with dementia Generally have poorer end of life care compared to older people with cancer Higher levels of untreated symptoms experience greater level of suffering Lower quality of life Diminished capacity to express their suffering and preferences of care

Health Care Decisions in Dementia Usually made by family surrogates in consultation with health professionals But, surrogate decision makers have at best a low likelihood of reflecting the person’s decisions Tend to use a “best interest” approach Experience unresolved emotions, feel unprepared and lack the necessary support to make difficult decisions

Role of Physicians in Health Care Decision Do not perform any better than family as surrogates Tendency to under-estimate patients’ quality of life

Advance Care Planning (ACP) Grounded on the autonomous expression of a person’s wishes But, people with dementia may not have the capacity to participate in ACP discussions ?? Mild dementia may still have retain capacity

Capacity Assessment Limited by physician subjectivity Poor inter-rater reliability Lack of standardisation Conflict in role (e.g doctor involves in treatment and acts as an assessor)

Criteria for Competency Demonstrates an ability to understand the issues Shows an appreciation of how this information applies to oneself and the effects on their life Has an ability to outline their reasoning for their choices Has an ability to communicate their decisions voluntarily and without coercion

MacArthur Competence Assessment Tool – Treatment (MacCAT-T) Provides a patient with the information about the medical/psychiatric condition that needs intervention the type of treatment being recommended its risks and benefits, other possible treatments and their probable consequences prompts the assessor to ask questions that assess the patient's understanding, appreciation, and reasoning regarding treatment decisions

Study Aim To compare the performance of 2 capacity assessment tools for engaging older people without significant cognitive impairment in discussing ACP MacCAT-T two clinical vignettes To identify demographic variables and cognitive functions that may predict capacity to engage in ACP

Methods: Settings and Participants A cross-sectional convenience sample of older people from 2 large retirement villages in Auckland December 2012 to September 2013 Fluency in English language a Mini-Mental State Examination score ≥ 24 No diagnosis of active psychotic or mood disorder

Methods: Data Collection Demographics: age, gender, ethnicity and level of care MMSE Trail Making Test Part A & B Geriatric Depression Scale (GDS-15)

Methods: Capacity Assessment Tools Video-typing MacCAT-T Vignettes methods 2 clinical vignettes developed by research team Cardio-respiratory arrest requiring CPR Advanced stomach cancer requiring extensive surgery Each vignette followed by semi-structured questions to explore the person’s capacity to make the relevant treatment decision

Methods: Judging the capacity to engage in ACP and treatment decisions 4 specialist old age psychiatrists were involved in judging the participants’ capacity 1st pair watched MacCAT-T videos independently and made a judgement on competence (Yes vs No) Consensus meeting to discuss and discordance 2nd pair watched clinical vignettes videos Same judgment process as 1st pair

Methods: Statistical Analysis MacCAT-T judgement = Gold Standard Binary outcomes: Competent vs not competent Non-parametric tests Logistic regression

Competent as determined by MacCAT-T N=15 Incompetent as determined by   Competent as determined by MacCAT-T N=15 Incompetent as determined by N=17 Chi2 or Mann-Whitney U Test (p-value) Age, mean (SD) 82.3 (6.9) 85.7 (6.2) 0.295 Female, n (%) 9 (60.0) 9 (52.9) 0.688 Ethnicity, n (%) European 15 (100) 16 (94.1) 1.000+ Education level, mean (SD), years 14.3 (3.7) 13.5 (3.8) 0.478 Level of care, n (%) Independent Unit Residential Care 6 (40.0) 8 (47.1) 0.254

Competent as determined by MacCAT-T N=15 Incompetent as determined by   Competent as determined by MacCAT-T N=15 Incompetent as determined by N=17 Chi2 or Mann-Whitney U Test (p-value) MMSE, mean (SD) 28.5 (1.5) 27.1 (2.1) 0.069 Trail Making Test A, mean (SD), seconds 74.9 (58.0) 102.2 (96.3) 0.295 Trail Making Test B, mean (SD), seconds 191.9 (109.7) 182.3 (84.7) 1.000 Geriatric Depression Scale 15 items, mean (SD) 2.1 (2.5) 3.2 (1.9) 0.037

  Competent as determined by MacCAT-T N=15 Incompetent as determined by MacCAT-T N=17 Competent as determined by Vignettes, n (%) 13 (86.7) 8 (47.1) Incompetent as determined by Vignettes, n (%) 2 (13.3) 9 (52.9)

Discussion Using the MacCAT-T as the gold standard, over half (53.1%) of the participants (MMSE≥24) were considered lacking in capacity to engage in ACP MMSE/Trail not able to predict capacity Previous studies: MMSE has limited accuracy in predicting capacity when score 18-24

The vignettes based method was accurate in 69% of the cases

Should capacity assessment be performed routinely prior to discussing advance care planning with older people?

BUT Recent NZ survey: 24% GPs and 30% hospital doctors did not consider capacity assessments to be within their scope of practice 32% GPs and 33% hospital doctors felt not confident to assess capacity

Conclusion Training clinicians involved in ACP to conduct capacity assessment with older people using the gold standard method MacCAT-T may improve the uptake of ACP in older people in general and their end of life care.

Limitations Small sample size Sample included primarily European in retirement village/residential care No clinical diagnosis of dementia performed