Themes and findings that emerged from the focus groups
| FACTORS | FINDINGS AND RELATED PARTICIPANT QUOTATIONS | THEMES FROM SCOPING LITERATURE REVIEW THAT THIS FACTOR APPLIES TO |
|---|---|---|
| Facilitators | ||
| • Physicians’ commitment to delivering PCC | As PCC is central to the DMCA model, many participants felt comfortable adopting it
| DMCAs will become more important as the population ages. Providing PCC will involve the administration of DMCAs to those patients for whom DMC is a concern |
| • Team-based approach to conducting comprehensive DMCAs | A team-based approach is valuable in conducting comprehensive DMCAs. Physicians are often reliant on IP team members for assessment and problem-solving expertise. In units and sites that were able to establish a collaborative IP approach to DMCAs, physicians believed they were better able to conduct a comprehensive DMCA
| Many doctors report that training is suboptimal. Doctors lack sufficient training to complete DMCAs on their own and rely greatly on other IP team members for expertise. There is no consistent approach to DMCA; physicians note that there is no method to conducting DMCAs, but note that working with an IP team is a good approach |
| • Tools associated with the DMCA model to guide the DMCA process | The DMCA model tools—in particular the worksheets—are reportedly key facilitators. Physicians appreciated that the worksheets guide the process, prompting them to cover all aspects of the DMCA. They also found that the worksheet facilitates collation of IP team findings and standardizes the problem-solving approach
| Many doctors report that training is suboptimal. Doctors lack sufficient training, but note that the worksheets associated with the DMCA model process improves their ability to complete DMCAs |
| Barriers | ||
| • Knowledge gaps regarding DMCAs | More inexperienced FPs did not think they had enough training and exposure to real-life experiences to confidently conduct DMCAs. Some felt less confident making judgments when unfamiliar with a patient, while others were worried about the serious consequences of their assessment (eg, patient’s loss of autonomy)
| Many doctors report that training is suboptimal and tension exists between ethical principles of autonomy and protection, particularly when unfamiliar with a patient |
| • Isolation from IP teams | Some participants reported that they did not have access to an IP team, felt uncomfortably isolated, and desired greater collaboration
| Many doctors report that training is suboptimal. It is difficult to make clinical judgments concerning DMC when education is lacking and there is limited access to IP teams to assist |
| • Conflicts with families | Resolving conflicts with family members residing at a distance and infrequently involved in a patient’s life was difficult, as was balancing patient medical needs while engaging with family members. Physicians noted that conflicts tend to arise over issues such as medical decisions (eg, family attempting to override their medical judgment), finances, DMCAs, facility choice, end-of-life decisions, and legal guardianship), or when family members either appear to have ulterior motives (eg, financial) or are unaware of the patient’s wishes (eg, goals of care and advance directives)
| Tension exists between ethical principles of autonomy and protection. When family members become involved, issues can arise concerning autonomy and familial wishes, regardless of motive |
| • Concerns about liability, responsibility to the patient, and lack of clarity on billing | Physicians are in a difficult position regarding DMCAs, as they often spend only short periods of time with a patient (participants reported conducting a DMCA in 0.5 to 2 hours), during which time they make a determination about a person’s DMC that might have legal implications
Knowledge gaps were evident regarding billing methods for DMCAs and financial remuneration outlined within and permissible according to local legislation
| DMCAs will become more important as the population ages and many doctors report that training is suboptimal. There will be increasing demands on doctors as their patients age, requiring additional or increased training and time to complete these assessments |
DMC—decision-making capacity, DMCA—decision-making capacity assessment, IP—interprofessional, OT—occupational therapist, PCC—person-centred care, PT—physical therapist.