Evaluating Decision-Making Capacity in Elderly Patients with ESKD on Hemodialysis

Background: Although the act on decisions on life-sustaining treatment including hemodialysis (HD) came into force in Korea, there is no specific mention to the assessment of the patient's decision-making capacity (DMC). We compared assessments of DMC of elderly patients with end-stage kidney disease (ESKD) on HD as provided by attending physicians, nurses, legal guardians, and a competence assessment tool. Methods: The DMC of the 94 elderly patients aged 65 and more with ESKD on HD were assessed by physicians (n = 5), nurses (n = 18), legal guardians (n = 94), and the Korean version of the Capacity-to-Consent Screen (K-CCS) as an assessment tool. We analyzed the agreement between intuitive assessments by participants and objective assessments using K-CCS for patients’ DMC. Results: The mean age and dialysis vintage of the patients were 70.2 years and 15.1 years, respectively. The concordance with capacity assessed using the K-CCS was higher in physicians- and nurses- compared with legal guardians-rated capacity (64.8% both vs. 46.3%, p = 0.003). Compared to the capacity assessed by K-CCS, legal guardians tended to underestimate the capacity (Figure 1). While physician-rated capacity showed a good agreement (α = 0.634) with the assessments using the K-CCS, assessments by nurses and legal guardians showed a moderate agreement (α = 0.580 and 0.479, respectively). A good agreement between the competence assessments of the nurses versus those of the physicians (α = 0.768), but a moderate agreement between the assessments of the physicians and nurses versus those of the patients’ legal guardians (α = 0.452 and 0.447, respectively), was observed. Conclusion: Although the intuitive assessments by nephrologists showed a good agreement with the objective evaluation using assessment tools, one-third of their assessments were inaccurate. Particularly, the tendency of legal guardians to underestimate patients' DMC raises concerns about limiting patients' autonomy. Actively utilizing competence assessment tools may help in accurately evaluating DMC of elderly patients with ESKD on HD.Comparison of the decision-making capacity of patients assessed by the competence evaluation tool with intuitive assessments by participants