When treating patients who have cognitive decline including Alzheimer’s disease and other dementias, a strong understanding of their particular care needs can greatly reduce the risk of patient safety incidents and related medico-legal liability for physicians.
1. Anticipate potential communication issues
It can be challenging to gain a full picture of a patient’s needs when their communication abilities are limited. Where appropriate, seek collateral information from the family or caregiver(s) of the patient. All updates to the patient’s care plan should be communicated with the patient or substitute decision-maker promptly. Other than a patient’s substitute decision-maker, family members and caregivers are not entitled to information about the patient’s care without the express consent of the patient.
When communicating with the patient or substitute decision-maker, be aware that misunderstandings can commonly occur around certain concepts, specifically: advance directives, goals of care, and the precise meanings of the terms “palliative care” and “do not resuscitate/DNR.”
2. Determine the patient’s capacity to provide consent
An individual who is able to understand the nature and anticipated effect of a proposed medical treatment and alternatives, and to appreciate the consequences of refusing treatment, is generally considered to have the necessary capacity to give valid consent. Furthermore, a person who is incapable of making decisions regarding certain matters might still have sufficient mental capacity to give valid consent to medical treatment.
A patient’s capacity to provide consent may fluctuate due to the variability of cognitive decline. It is important to re-evaluate previous assessments on a regular basis, and to be aware of the increased likelihood of behavioural changes over short periods of time with these patients. Note that a patient’s ability to respond emotionally to some decisions does not necessarily indicate the capacity to provide consent.
Additionally, even when a patient seems incapable of consenting or understanding the required information, it is a good practice never to make this assumption without proper assessment.
When a patient is confirmed as being incapable of giving consent, the responsibility for non-urgent care generally falls to a substitute decision-maker, who can be designated by legislation in certain jurisdictions, or by the patient through an advance directive or power of attorney for personal care.
3. Remember that transfers are high-risk points in care
Transfers to and from acute and long-term care facilities are common amongst patients with cognitive decline. The complex needs of these patients, including their reliance on caregivers and multiple health professionals to coordinate their care, can increase the risk of harm in patient transfers. In any handover process, be sure to provide complete information about advance directives, the care plan, the appropriate substitute decision maker, and current medications. Review all medications prior to transfer to decide whether medications need to be continued in the long term.
4. Take age into account
Patients with cognitive decline tend to be older and may have multiple chronic conditions for which they receive treatments. The potential for patients to be using multiple medicines simultaneously means that the risk of prescribing an inappropriate or contraindicated medication is increased.
It is also prudent to ensure thorough understanding of the goals of care; assessment of the goals of care should be performed routinely and repeatedly.
5. Know the guidelines, know the policies
As a physician, you should be familiar with current recommendations and clinical practice guidelines addressing the diagnosis and treatment of dementia, such as those published by the Canadian Geriatrics Society. Also, be aware of applicable policies of hospitals or long-term care facilities regarding levels of care. You should also consider whether the patient’s medical condition makes it unsafe for the patient to drive, and whether a reporting obligation is therefore triggered. When appropriate, inform patients of your obligation and intention to report. Document your assessments, discussions, and advice in the medical record.