Asking older patients’ opinion about discharge planning is not done in everyday practice, especially in the cases associated with cognitive disorders. Person-centered practice is now developed with older people and improves their rights in hospital settings as well as the meaning of the term autonomy. Current French and international policy (Programme des Nations Unies concernant les personnes handicapées, n.d.) advocates user participation, and new French laws require medical staff and hospitals to respect patients’ choices about home or nursing home discharge. To our knowledge, there is no valid instrument to evaluate the capacity of an older patient to decide whether they can, or cannot, return home after hospitalization. The Mini-Mental State Examination (MMSE) is not sufficient to determine a patient’s decision-making ability because it is not directly correlated with cognitive abilities.
We aim to investigate the relevance of a new tool (DROM-test) for assessing the four-steps of decision-making ability: understanding, reasoning, appreciation, and communicating a choice (Romdhani et al., Reference Romdhani2018). In our first prospective observational study, we included 102 patients (above the age pf 70; MMSE score of 15 to 25). We then conducted a telephone follow-up of all patients who returned home three months after hospital discharge. We compared the decisions of the medical team and the expert committee in assessing the ability to decide whether patients should return home, then the ability of the DROM-test to assess patient’s decision-making.
Of the 102 patients included in our first study, 60 returned home: mean age 83.3±6.2, MMS 20.1± 3.13, 83.3% with confirmed dementia, 41.7% anosognosia, 8.3% under legal protection. We found a discrepancy in the assessment of the medical staff in charge of the patients and the expert committee regarding who would have the capacity of returning home. Amid the four dimensions of the decision-making capacity in the DROM-test, only the score for reasoning almost achieved significance.
The patient’s view is generally not included in decision-making (Marson et al., Reference Marson, McInturff, Hawkins, Bartolucci and Harrell1997). The medical staff may dictate the post-discharge decision to the patient. One can also wonder if the practitioner may be influenced by his or her own values or emotions; hence, they might not make the most appropriate decision for the patient. Patients (Grisso et al., Reference Grisso, Appelbaum and Hill-Fotouhi1997) must understand the given information, relate this information to their personal situation, and use it correctly to make the proper decision. In some patients, deficits in reasoning and executive functions contribute to the impairment of their decision-making process. Being self-aware of one’s emotional and motivational limitations allows patients without anosognosia to understand situations where their decision-making is likely to be impaired.
Practitioners can easily get into difficulty when dealing with age-related issues, such as the risk associated with a discharge decision, and adopt “paternalist” behavior (Sheehan, Reference Sheehan2014). Moreover, few patients were under legal protection and one could argue that medical teams exceed the limits of legality by deciding for the patient without a formal legal framework.
We need tools like the DROM-test to allow patients to actively participate in the discharge planning and to complement clinical judgment.
