(156) How Capable are Non-Psychiatrists at Assessing Patients' Capacity? Retrospective Review of an Institutional Experience

‎Background‎
Determining patients' decision-making capacity is critical when trying to balance respect for patient's ‎autonomy with protecting patients from making a medical decision that they do not fully understand. ‎It is known that any physician can assess decision-making capacity, with emphasis on treating ‎practitioner to evaluate capacity considering their broader knowledge of patient's medical conditions ‎and treatment alternatives. Several tools exist to improve decision-making capacity assessment and ‎documentation process. One of these, the Aid to Capacity Evaluation (ACE) is widely available. In this ‎study, we explore the internal consistency of decision-making capacity assessment and ‎documentation through evaluation of the ACE documentation.‎

‎Methods‎
We retrospectively reviewed a cohort of medically hospitalized patients whose decision-making ‎capacity was evaluated with the ACE over a 3-month period. A scoring system from 0-8 points was ‎created to code the consistency of documentation. One point was given if capacity question was ‎clearly defined, and one point was given for each of the following 7 questions if documentation ‎supported the determination of that question. Each documentation was assessed independently by ‎two general physicians. If these scores were discrepant, a specialist physician (geriatrician or ‎psychiatrist) completed a third independent scoring of the documentation. Descriptive statistics ‎included reporting categorical variables as number and percent. Categorical variables were compared ‎between groups with the use of Fisher's exact test or the chi-square test.‎

‎Results‎
A total of 31 ACE documentations were reviewed. The documentation authors were PGY-1 residents ‎‎(35%), PGY-2/3 residents (23%), attending physicians (19%), and nurse practitioners (23%) with ‎specialties of Internal Medicine (81%), psychiatry/geriatrics/palliative care (13%), and other (6%). ‎Overall, 36.48% of documentations were consistent, 9.68% were incomplete, and 54.84% were ‎inconsistent. When comparing the group of consistent documentation to the group of incomplete/ ‎inconsistent documentation, there was no difference in note author's credentials (p=0.5525) and no ‎difference between documentation authored by PGY-1 residents to all others (p=1.000). However, ‎within the group of incomplete/inconsistent documentation, there was a significant difference in ‎author's specialty with 90% authored by internal medicine practitioners, 10% authored by various ‎other specialists, and 0% by geriatricians/psychiatrists/palliative care specialists (p=0.0105). There was ‎no significant difference in patient's race between groups (p=0.7540).‎

‎Conclusion‎
Our study showed significant differences in the internal consistency of decision-making capacity ‎documentation for hospitalized patients when comparing non-specialist capacity evaluators to ‎specialist evaluators from psychiatry, geriatrics, and palliative care. Ninety percent of the incomplete or ‎inconsistent decision-making capacity documentation was completed by Internal Medicine evaluators, ‎regardless of level of training. This raises concern for deficiencies in the quality of capacity assessment ‎being performed by non-specialist note authors. However, we know that these non-specialist ‎generalists often are in a better position to assess decision-making capacity their greater knowledge of ‎the patient's medical conditions and alternative treatments. Previous studies have shown that ‎workshop trainings can increase physician and other healthcare practitioners' level of comfort and ‎understanding of decision-making capacity concepts. Future studies should investigate whether such ‎trainings increase consistency of decision-making capacity, which may have implications on required ‎training for physicians and other healthcare practitioners.‎