From the Guidelines
To assess a patient's capacity to provide informed consent for dialysis, clinicians should ask questions that evaluate four key domains of decision-making ability, including understanding, appreciation, reasoning, and communication of a choice, as outlined in the most recent and highest quality study 1. When evaluating a patient's capacity to provide informed consent for dialysis, it is essential to consider the patient's decision-making ability in the context of their specific situation.
Key Domains of Decision-Making Ability
The following key domains should be assessed:
- Understanding: Ask questions that assess the patient's understanding of their kidney disease and dialysis treatment, such as "Can you explain what dialysis does and why you might need it?"
- Appreciation: Evaluate their appreciation of how dialysis would affect their specific situation with questions like "How do you think dialysis will impact your daily life?"
- Reasoning: Assess reasoning ability by asking "What factors are you considering in making this decision?" and "How did you weigh the benefits and risks?"
- Communication of a choice: Test their ability to communicate a choice consistently by asking "Have you decided whether to proceed with dialysis?" and "Can you tell me what your decision is?" Additional helpful questions include asking patients to explain the alternatives to dialysis, potential complications, and the consequences of refusing treatment, as suggested by 1 and 1.
Importance of Patient Values and Preferences
It is also crucial to elicit patient's values, goals, and preferences directly from patients themselves, as recommended by 1, and to seek the input of family members and friends to better understand the patient's values, goals, and preferences. By using this structured approach, clinicians can ensure that patients are making autonomous decisions about a treatment that significantly impacts their quality of life and survival, while respecting their right to self-determination in healthcare decisions.
From the Research
Capacity Assessment for Dialysis
To assess a patient's ability to provide informed consent for dialysis, the following capacity questions should be asked:
- Can the patient demonstrate understanding of the situation, including the benefits and risks of dialysis, and the alternatives to treatment 2?
- Can the patient appreciate the consequences of their decision, including the impact of dialysis on their daily life 3?
- Can the patient reason through their thought process and communicate their wishes 2?
- Is the patient able to understand the life-long need for dialysis and the significant trade-offs that dialysis may require 3?
Factors to Consider
When assessing a patient's capacity, the following factors should be considered:
- The patient's age, as older patients may have poorer informed decision-making skills 3
- The patient's cognitive function, as impaired cognitive function may reduce their ability to adhere to complex medical regimens and participate in medical decisions 4, 5
- The patient's ability to communicate effectively with their healthcare provider 2
- The presence of any risk factors for impaired decision making, such as acute changes in mental status or readily agreeing to an invasive or risky procedure without adequately considering the risks and benefits 2
Assessment Tools
Several formal assessment tools are available to help with the capacity evaluation, including:
- Structured approaches to assessing capacity 2
- Neurocognitive tests, such as the Trail Making Test-B and the d2-Revision-Test 5
- Self-reported measures, such as the Kidney Disease Quality of Life Short Form Cognitive Function-subscale 5
Surrogate Decision Makers
If a patient is found not to have capacity, a surrogate decision maker should be identified and consulted 2. This may include a family member or other appointed representative.