(181) Empowering the Non-Psychiatrist to perform Medical Decision Making Capacity Assessments in a Medical Hospital – A Multimodal Intervention

Abstract:

Introduction:

In the medical hospital, decision making capacity assessment often falls to the psychiatric consultant rather than the primary medical service. This presents numerous patient care dilemmas along with increased demand on the psychiatric consultation service. This may be mitigated by empowering the non-psychiatrist primary provider to evaluate patient decision making capacity via standardized and structured capacity assessments. Through a multimodal intervention involving lectures and integration of a capacity assessment “worksheet” into the electronic medical record, we believe that providers will develop greater comfort in independently performing capacity assessments, and that there will be an overall reduction in psychiatric consultations for capacity evaluation.

Methods:

The combined medical nurse practitioner and physician assistant service of a large tertiary care hospital (ACP or Advanced Care Provider service) was provided a brief introductory lecture on capacity assessment. An initial survey was done to determine baseline attitudes toward capacity assessment. A version of the Aid to Capacity Evaluation (ACE) was introduced into the Electronic Medical Record (EMR) and disseminated via email and printed documents to the ACP service (Etchells, 1999). End outcomes will be obtained four months after this baseline. Primary outcome measures will be repeated survey data regarding the comfort level of the ACP’s with performing capacity assessments. The secondary outcome measure will be comparing the number of initial psychiatric consults for capacity assessment after the intervention to the same time period in the year prior.

Results:

Baseline survey data of 25 participants showed that 44% of respondents felt they “somewhat regularly” to “regularly” were concerned with a patient’s decision making capacity. Only 40% of respondents felt they were “comfortable” to “extremely comfortable” with doing capacity assessments. 80% of respondents felt that capacity assessment was “very important” to “extremely important” in their daily clinical practice.

Discussion:

We await the results of a 4 month follow up after gathering baseline data as above. There are limitations to this study as the study population is medical providers who are dependent on supervision from attending medical hospitalists who are not targeted participants. We have no survey measures from the patient’s perspective, which would be an important aspect to explore. Though the ACE was chosen for its ease of use, there may be other structured capacity assessments suited for hospital utilization. There is a paucity of studies involving the teaching of capacity assessment to non-psychiatrists, particularly involving introduction of assessment tools into EMRs. Further study into the pedagogy of medical capacity assessment may be necessary.



References:

Etchells E, Darzins P, Silberfeld M, Singer PA, McKenny J, Naglie G, Katz M, Guyatt GH, Molloy DW, Strang D. Assessment of patient capacity to consent to treatment. J Gen Intern Med. 1999 Jan;14(1):27-34. PMID: 9893088