[Mental competence and neuropsychologic impairments in demented patients]

[MacCAT-T between Claim and Practice - Challenges of Assessing Capacity for Consent in Dementia]

BACKGROUND

Consent is a prerequisite for medical diagnostic and therapeutic action. There is no standardised procedure for assessing the ability to give consent. The most widely used tool for structured assessment is the MacArthur Competence Assessment Tool for Treatment (MacCAT-T).

OBJECTIVES

 People with dementia have impaired capacity to consent because of their disease. In order to answer the question to what extent structured assessment procedures can be usefully applied to people with dementia, we analyse the function, strengths and weaknesses of structured assessment procedures with a focus on the MacCAT-T and discuss suggestions for modification and further development of the tool.

METHODS

Using the PubMed literature database, a systematic literature search and analysis was conducted on papers published since 2010, following PRISMA guidelines.Results Although the MacCAT-T is a valid and reliable tool, it cannot comprehensively address memory problems in people with dementia. It primarily measures cognitive functions. However, Decisions based on emotions, intuitions and values, are not captured by the MacCAT-T. Communicative limitations in people with dementia are not taken into account.

CONCLUSIONS

 It is recommended to provide information in simple language, written down and visualised for people with dementia. The development and elaboration of a graduated procedure for the examination of capacity to consent is indicated. The gradations of the scope and depth of the assessment to be determined should be based on the severity of the cognitive impairment, the benefit/risk ratio of the proposed medical intervention and the individual profile of affective functions and value-based imprints.

[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.

[Research on humans suffering from dementia]

The urgent necessity for dementia research is justified by the prevalence and increase in dementia associated with the demographic changes, for which no causal treatment is available; however, during the progressive course dementia destroys the capacity for self-determination of persons affected and thereby an essential prerequisite for participation in research, i.e. a valid consent to a research intervention. Accordingly, not only sufficient information about all issues which are relevant for decision making by potential participants but also a flawless assessment of the capacity to consent are important; however, currently this is not satisfactorily possible. This article attempts to answer questions associated with these problems, such as how consent can be established, including that of a surrogate for consent of potential research participants by whom consent is no longer possible. In a second section the benefit-risk evaluation, which is also underdeveloped, will be dealt with using two concrete research examples, a diagnostic and a therapeutic research intervention for patients with dementia.

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.

Einwilligungsfähigkeit bei Demenz: Sensitivität des MMST in einer hypothetischen Einwilligungssituation und spezifische kognitive Korrelate

Hintergrund: In der Forschung mit Demenz-Patienten ist es entscheidend, mögliche Beeinträchtigungen der Einwilligungsfähigkeit zu ermitteln. Fragestellung: Ziel der Studie war es, zu untersuchen, ob sich der Mini-Mental-Status-Test (MMST) dazu eignet, Beeinträchtigungen der Einwilligungsfähigkeit bei einer hypothetischen Studie vorherzusagen. Methoden: Die Einwilligungsfähigkeit wurde bei 24 Demenz-Patienten und 24 gesunden Gleichaltrigen mit dem MacArthur-Competence-Assessment-Tool (MacCAT) erfasst. Zusätzlich wurden neuropsychologische Korrelate ermittelt. Ergebnisse: Der MMST konnte die Einwilligungsfähigkeit vorhersagen: MMST-Schwellenwerte unter 23 wiesen mit hoher Sicherheit auf eine Einwilligungsunfähigkeit für die hypothetische Studiensituation hin. Gedächtnis und Sprachfunktionen korrelierten hoch mit der Einwilligungsfähigkeit. Schlussfolgerungen: Kognitive Leistung als wesentliche Determinante der Einwilligungsfähigkeit ist stets hinsichtlich einer konkreten Situation zu beurteilen. Studien stimmen überein, dass die Einwilligungsfähigkeit bei MMST-Schwellenwerten unter 23 eingehender untersucht werden sollte.

[Ethical questions in clinical research with the mentally ill]

The review deals with present problems of protecting mentally ill patients who are incompetent to give informed consent to participating in clinical research, and of assessment of the capacity to consent. 1. Clinical trials of drugs on efficacy and safety in incompetent patients are ethically justified and legally admissible if the investigational drug can be expected to exert a direct potential individual benefit and if such trials will be performed under defined criteria to protect these vulnerable patients. In Germany it is questionable how far these prescriptions of the German Drug Law (AMG) are transferable to other than drug research. 2. Research with no direct potential individual benefit or only a group-specific benefit in incompetent patients is controversially discussed. However, it may be ethically justified as an exception, and is in Germany legally admissible only in minors, but not in adults. 3. However, internationally there exists a wide range of legal regulations, terms, interpretations, and practices of research with vulnerable persons. In the past years a shift seems to have developed from normatively oriented discussions to more empirically based investigations. Especially vague but clinically relevant terms in protection declarations or guidelines have been better specified, put in concrete form by anchor examples, and empirically studied. 4. In general the criteria of protecting the dignity and, even if impaired, the autonomy of incompetent patients as subjects for research appear to guarantee a high standard of protection. However, the application of these criteria must be improved by practicable procedures. This is valid particularly for the assessment of the basic criterion whether a patient is capable of consenting or not. 5. Open Questions are formulated as need of research.

Forthcoming ethical issues in biological psychiatry

Ethical issues in biological psychiatry are framed by (i) progress in the neurosciences, and (ii) a changing socio-cultural context. With regard to forthcoming neurotechniques to modify specifically defined brain functions by pharmacological substances with selective effects, by activating neuroplasticity including neurogenesis, or by implantation of neuronal tissues or computer-brain interfaces, etc., ethical problems will develop (i) at the border between therapy of diseases and enhancement of abilities in healthy people with regard to effects on society (e.g., social justice: equal access, loss of societal diversity) as well as on human value systems (e.g., personality, efforts, conditio humana), and (ii) at the border between the medical system and the wellness market with regard to financing what by whom? Ethical dilemmas in psychiatry develop (i) between the individual's best and the common good (demanded from outside medicine), (ii) among different ethical principles (inside medicine), iii) if solutions are influenced by personal reasons without observing ethical principles. Ethical guidelines are necessary for ethical orientation, but may protect against misconduct only (i) if psychiatrists are educated in ethics and (ii) if psychiatric acting is under continuous debate (by ethical review boards or the public). Thus, if we psychiatrists will become ethically sensitive by reflecting and perhaps solving our current ethical dilemmas we will be prepared to deal with forthcoming ethical issues in biological psychiatry.

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.