[Informed consent and patient competence in the psychically ill. A review of empirical studies]

[Capable or incapable of giving consent? Assessing a patient's capacity to consent: Procedures and challenges in daily clinical practice]

BACKGROUND/OBJECTIVES

The capacity of patients to give consent (CTC) is an indispensable prerequisite for informed consent to medical measures. When there is doubt about a patient's CTC, careful assessment is therefore required. Despite a broad theoretical discussion about the conception of CTC and possible procedures for its assessment, there is often a lack of orientation towards binding standardized procedural guidelines in everyday clinical practice. As a consequence, the results of CTC assessments are inconsistent, revealing both interdisciplinary and interindividual variability. In order to improve the quality of CTC assessment, more detailed knowledge about the procedures as well as the problems of CTC testing is needed. Therefore, the aim of this explorative telephone survey was to get an impression of the actual procedures that clinicians apply when in doubt about a patient's CTC. In particular, participants in the survey were asked about the weighting of individual CTC criteria and the difficulties with their application.

METHODS

Based on structured questionnaires, telephone interviews with 26 physicians working in German hospitals in the fields of neurology, anaesthesiology, surgery, internal medicine, gynaecology, and reconstructive/aesthetic surgery were conducted. The answers were documented using the paper-and-pencil method, and answers to open questions were summarized with the help of a qualitative data analysis software and a thematic coding scheme.

RESULTS

The majority of respondents reported that "sometimes to very often" they had doubts about their patients' CTC, with the examination being mostly conducted in an individual approach without formalized, standardized specifications. Regarding the question about the weighting of the seven assessment criteria proposed in the questionnaire, their importance was predominantly evaluated as being in the range of "partially important" to "very important". Difficulties in the clinical assessment were indicated in relation to the patients themselves, the relationship between physicians and patients, and the assessment situation. The perception of difficulties in the examination of CTC is apparently independent of the relevance attributed to the specific criterion for CTC.

DISCUSSION AND CONCLUSION

Overall, the results show a high level of agreement with the relevance of the seven CTC criteria included in the survey, but at the same time revealed various verification difficulties. Some of the respondents would like to have more support in determining their patients' CTC. The survey results suggest that precise training and adequate time resources are paramount to this sensitive medical context.

Assisted dying requests from people in detention: Psychiatric, ethical, and legal considerations-A literature review

The principle of equivalence of care states that prisoners must have access to the same standard of health care as the general population. If, as recent court decisions suggest, assisted dying is not limited to people with a terminal physical illness or irremediable suffering, it might also be requested by people with severe mental illness in detention. Some of the countries with legal regulations on assisted dying also have recommendations on how to handle requests from prisoners. However, detention itself can lead to psychological distress and suicidality, so we must consider whether and how people in such settings can make autonomous decisions. Ethical conflicts arise with regard to an individual's free will, right to life, and physical and personal integrity and to the right of a state to inflict punishment. Furthermore, people in prison often receive insufficient mental health care. In this review, we compare different practices for dealing with requests for assisted dying from people in prison and forensic psychiatric facilities and discuss the current ethical and psychiatric issues concerning assisted dying in such settings.

["But you know Mr. M., you won't get hospitalised" : A qualitative study on service users' experience of seeking psychiatric inpatient admission]

In a qualitative study using thematic analysis of focus group interviews with service users their perspectives and experiences concerning the process of seeking admission to psychiatric inpatient care in Austria were explored. The aim of the study was to better understand service users' motivation, decisions and actions in the process of seeking psychiatric hospitalisation. Results show that admission to psychiatric inpatient care was often sought directly without a referral from an outpatient service. An important motivation was the lack of availability of alternatives to inpatient care in situations of a severe acute crisis. In this situation service users often found themselves in a conflict between positive expectations related to symptom improvement and a protective environment, and memories of previous negative experiences, such as stigma and coercion. Coercion and involuntary admission were recurring topics in the narratives of the focus group participants, not only of those who had actually experienced such situations. Seeking hospitalisation was considered as enormously burdening, which was intensified in many cases by the experience of refusal of hospitalisation by the staff. Overall, service users stressed that they found themselves at the lower end of the decision hierarchy, with relatives, doctors, ambulance services and police having more impact on the decision about a psychiatric hospitalisation. Suggestions for improving psychiatric care derived from the analysis include a better coordination between inpatient and outpatient care and the creation of alternative services which are located between the acute inpatient services and the selective ambulatory services in the outpatient sector.

Physician-assisted suicide of patients with dementia. A medical ethical analysis with a special focus on patient autonomy

For many years there has been a controversial international debate on physician-assisted suicide (PAS). While proponents of PAS regularly refer to the unbearable suffering and the right of self-determination of incurably ill patients, critics often warn about the diverse risks of abuse. In our article, we aim to present ethical arguments for and against PAS for patients in an early stage of dementia. Our focus shall be on ethical questions of autonomy, conceptual and empirical findings on competence and the assessment of mental capacity to make health care decisions. While the capacity to make health care decisions represents an ethically significant precondition for PAS, it becomes more and more impaired in the course of the dementia process. We present conditions that should be met in order to ethically justify PAS for patients with dementia. From both a psychiatric and an ethical perspective, a thorough differential diagnosis and an adequate medical and psychosocial support for patients with dementia considering PAS and their relatives should be guaranteed. If, after due deliberation, the patient still wishes assistance with suicide, a transparent and documented assessment of competence should be conducted by a professional psychiatrist.

[Effects of a shared decision making model in psychiatric and neurologic practice]

Involving patients in medical decisions is increasingly being advocated in medical fields other than psychiatry and neurology. A model of shared decision making might prove to be an ideal way of bridging the gap between patient-centred and evidence-based medicine. This report provides a survey of this shared decision making model and a discussion of its implications in the fields of mental health and neurology.

Was ist „Neuroethik“ — eine Disziplin der Zukunft?

Progress in neuroscience leads not only to novel therapeutic opportunities but also raises several ethical problems. These problems are often subsumed under the term "neuroethics," of which the definition and purpose often remain unclear. We discuss the problems of informed consent, free will, sense of self, and personality in light of recent neuroscientific progress. Due to distinct categories and frames of reference, these philosophical-ethical terms cannot be limited only to the brain; the development of systematic relations is suggested. This accounts for the "special ethical position of the brain." It is concluded that only this sense can neuroethics account for the ethical complexity in neuropsychiatric disorders.

The cognitive based approach of capacity assessment in psychiatry: a philosophical critique of the MacCAT-T

This article gives a brief introduction to the MacArthur Competence Assessment Tool-Treatment (MacCAT-T) and critically examines its theoretical presuppositions. On the basis of empirical, methodological and ethical critique it is emphasised that the cognitive bias that underlies the MacCAT-T assessment needs to be modified. On the one hand it has to be admitted that the operationalisation of competence in terms of value-free categories, e.g. rational decision abilities, guarantees objectivity to a great extent; but on the other hand it bears severe problems. Firstly, the cognitive focus is in itself a normative convention in the process of anthropological value-attribution. Secondly, it misses the complexity of the decision process in real life. It is therefore suggested that values, emotions and other biographic and context specific aspects should be considered when interpreting the cognitive standards according to the MacArthur model. To fill the gap between cognitive and non-cognitive approaches the phenomenological theory of personal constructs is briefly introduced. In conclusion some main demands for further research to develop a multi-step model of competence assessment are outlined.