Palliative Care

Journal Article Annotations
2021, 1st Quarter

Palliative Care

Annotations by R Garrett Key, MD and Barbara Lubrano, MD
March, 2021

  1. Delirium screening tools validated in the context of palliative care: A systematic review
  2. Top Ten Tips Palliative Care Clinicians Should Know About Medical Decision-Making Capacity Assessment.

PUBLICATION #1 — Palliative Care

Delirium screening tools validated in the context of palliative care: A systematic review
Christine L Watt, Mary Scott, Colleen Webber, Lindsey Sikora, Shirley H Bush, Monisha Kabir, Jason W Boland, Rebecca Woodhouse, Megan B Sands, Peter G Lawlor


The finding:
Wide variability in sensitivity and specificity was seen in the delirium assessment tools evaluated, indicating that the overall evidence base is compromised in terms of quality. Out of 14 tools assessed, only 3 (MDAS, CAM, SQiD) appeared to have been evaluated in studies with low risk bias in the study design. Data were not sufficient to recommend a specific tool in the palliative population, however there is strong support for a need for further study of delirium assessment in this group.

Strength and weaknesses:
The article gathers validation data for many delirium screens which have been studied in palliative settings and closely evaluates the studies for rigor and compares the utility of the tools, which can help the reader select a tool for their setting. It also highlights an area of need for study highly relevant to C-L psychiatrists. A major weakness is that the authors were unable to make a clear recommendation for which screeners are preferred or which are less optimized for palliative populations.

C-L psychiatrists will benefit from broad awareness of available delirium screens and the quality of the validation data for each. Improved study of the utility of these screens in various settings/populations is important, and this study outlines an area of opportunity for high yield investigation.

Type of study:
Systematic review or meta-analysis


PUBLICATION #2 — Palliative Care

Top Ten Tips Palliative Care Clinicians Should Know About Medical Decision-Making Capacity Assessment.
Sarah E Ehrman, Kavitha P Norton, David E Karol, Meaghann S Weaver, Bethany Lockwood, Abigail Latimer, Erin Scott, Christopher A Jones, Robert Macauley


The finding:
Forty percent of hospice patients manifest impaired decision making capacity (DMC) with the percentage rising to 70% in the final days of life. To aid clinicians in the assessment of DMC, this article puts forward 10 tips intended to be best practices for capacity assessment.
Tip 1: Decision-Making Capacity implies that a person can make an autonomous choice; clinicians should use specific criteria to determine if a patient has capacity for a medical decision.
Tip 2: Capacity assessments performed by clinicians have de facto legal standing, can subsequently be reversed by clinicians if patient capacity changes, and should be documented appropriately.
Tip 3: Capacity is decision dependent and can change as a patient’s condition changes; a patient may have capacity for one decision but not another in the exact same moment
Tip 4: When a patient lacks capacity, the appropriate surrogate should be identified; decisions made by the surrogate should reflect the values of the patient, and not necessarily the values of the surrogate
Tip 5: Decision-making Capacity develops over time as the brain matures: some pediatric patients may be ready to make complex decisions well before they turn 18, and some adults may not be ready.
Tip 6: Patients with capacity have the right to make decisions that are not consistent with clinician recommendations; as such, clinicians should be extraordinarily attentive to personal and professional biases during assessments
Tip 7: When patient actions are incongruent with their stated values, further exploration is warranted and should include assessment for mental health disorders
Tip 8: Patients with chronic mental health conditions often retain complex decision-making capacity
Tip 9: Acutely altered emotional states due to trauma or suicidal ideation may temporarily affect capacity
Tip 10: Patients who lack capacity may still have the right to refuse treatment

Strength and weaknesses:
This article nicely summarize the key elements for the determination of DMC.  The 10 tips and “quick guide to capacity assessment” are an easy way to briefly review the necessary clinical, ethical, and legal components of DMC.  The article also recommends an interdisciplinary approach for those DMC assessment that are more challenging. One weakness is a lack of emphasis on delirium—which is often missed or misdiagnosed and impairs patients’ ability to engage in medical decision-making.  More emphasis should be made to encourage clinicians to assess for the presence or absence of delirium before engaging in conversation regarding decision making.

These 10 tips summarize the principles associated with the determination of DMC and guide PC clinicians, as well as other medical clinicians, on how to apply these principles in the determination of DMC

Type of study (EBM guide):