1. 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

2. 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

3. 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

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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

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

15. 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

16. 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

17. 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)

18. 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

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

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

21. 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

22. 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.

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