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Olié E, Catanzaro T, Malestroit M, Guija JA, Giner L, Courtet P. The capacity to consent to treatment is altered in suicidal patients. Ann Gen Psychiatry 2023; 22:35. [PMID: 37689691 PMCID: PMC10492405 DOI: 10.1186/s12991-023-00459-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/24/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Many patients with depression refuse treatment. Moreover, suicide attempters often display low perceived need of treatment and impaired decision-making. These observations raise questions about the capacity to treatment consent in depressed suicide attempters (SA). METHODS In patients with current depressive episode (N = 33 SAs and N = 27 non-SAs), consent capacity was evaluated with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), insight with the Beck Cognitive Insight Scale, and depression severity with the Beck Depression Inventory (BDI). RESULTS The median BDI score in the whole sample (N = 60) was 21 [10;36], and was higher in SAs than non-SAs (27 [11;36] vs. 15 [10:33], p < 0.001). Consent capacity was impaired in 30% (appreciation), 53% (reasoning) and 60% (understanding) of all patients. MacCAT-T sub-scores were lower in SAs than non-SAs (understanding: 4.4 [2.35;5.8] vs. 5.3 [3.13;6]); appreciation: 3 [1;4] vs. 4 [2;4]); reasoning (4 [1;7] vs. 7 [3;8]), and ability to express a choice: 1 [0;2] vs. 2 [0;2]; all p < 0.001). In multivariate analyses, suicide attempt history and depression severity (but not insight) were negatively associated with MacCAT-T sub-scores. CONCLUSION More research is needed on the capacity to consent to treatment of patients with depression, particularly suicidal individuals, to make informed choices about their treatment. Trial registration The Montpellier University Hospital Institutional Review Board approved the study (No. 202100714).
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Affiliation(s)
- Emilie Olié
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France.
- IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France.
| | - Thomas Catanzaro
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France
| | | | - Julio A Guija
- Department of Psychiatry, Universidad de Sevilla, Seville, Spain
- Service of Psychiatry. Institute of Legal Medicine, Seville, Spain
| | - Lucas Giner
- Department of Psychiatry, Universidad de Sevilla, Seville, Spain
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France
- IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
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Law S, Stergiopoulos V, Zaheer J, Nakhost A. "Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2023; 88:101873. [PMID: 36950980 DOI: 10.1016/j.ijlp.2023.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 06/01/2023]
Abstract
In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.
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Affiliation(s)
- Samuel Law
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Psychiatry, St. Michael's Hospital, Unity Health Toronto, Ontario, Canada.
| | - Vicky Stergiopoulos
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Addictions and Mental Health, Toronto, Ontario, Canada.
| | - Juveria Zaheer
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Addictions and Mental Health, Toronto, Ontario, Canada.
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Florack J, Abele C, Baisch S, Forstmeier S, Garmann D, Grond M, Hornke I, Karakaya T, Karneboge J, Knopf B, Lindl G, Müller T, Oswald F, Pfeiffer N, Prvulovic D, Poth A, Reif A, Schmidtmann I, Theile-Schürholz A, Ullrich H, Haberstroh J. Project DECIDE, part II: decision-making places for people with dementia in Alzheimer's disease: supporting advance decision-making by improving person-environment fit. BMC Med Ethics 2023; 24:26. [PMID: 37118723 PMCID: PMC10148477 DOI: 10.1186/s12910-023-00905-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/29/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND The UN Convention on the Rights of Persons with Disabilities, and the reformed guardianship law in Germany, require that persons with a disability, including people with dementia in Alzheimer's disease (PwAD), are supported in making self-determined decisions. This support is achieved through communication. While content-related communication is a deficit of PwAD, relational aspects of communication are a resource. Research in supported decision-making (SDM) has investigated the effectiveness of different content-related support strategies for PwAD but has only succeeded in improving understanding, which, although one criterion of capacity to consent, is not sufficient to ensure overall capacity to consent. The aim of the 'spatial intervention study' of the DECIDE project is to examine an innovative resource-oriented SDM approach that focuses on relational aspects. We hypothesise that talking to PwAD in their familiar home setting (as opposed to a clinical setting) will reduce the complexity of the decision-making process and enhance overall capacity to consent. METHODS People with a suspected or confirmed diagnosis of dementia in Alzheimer's disease will be recruited from two memory clinics (N = 80). We will use a randomised crossover design to investigate the intervention effect of the decision-making place on capacity to consent. Besides reasoning capacity, which is part of overall capacity to consent and will be the primary outcome, various secondary outcomes (e.g., other aspects of capacity to consent, subjective task complexity, decisional conflict) and suspected moderating or mediating variables (e.g., meaning of home, demographic characteristics) will be assessed. DISCUSSION The results of the study will be used to develop a new SDM strategy that is based on relational resources for PwAD. If a change in location achieves the anticipated improvement in capacity to consent, future research should focus on implementing this SDM strategy in a cost-effective manner in clinical practice. TRIAL REGISTRATION DRKS00030799 .
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Affiliation(s)
- Janina Florack
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany.
- Klinikum Siegen, Siegen, Germany.
| | - Christina Abele
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stefanie Baisch
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | - Simon Forstmeier
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | - Daniel Garmann
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- Klinikum Siegen, Siegen, Germany
| | | | | | - Tarik Karakaya
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Jonas Karneboge
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | | | - Gregor Lindl
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Tanja Müller
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | - Frank Oswald
- Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Nathalie Pfeiffer
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | | | - Aoife Poth
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Andreas Reif
- University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Irene Schmidtmann
- University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Anna Theile-Schürholz
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
| | | | - Julia Haberstroh
- Faculty V: School of Life Sciences, Department of Psychology, Psychological Aging Research (PAR), University of Siegen, Adolf-Reichwein-Str. 2a, 57068, Siegen, Germany
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Curley A, Watson C, Kelly BD. Capacity to consent to treatment in psychiatry inpatients - a systematic review. Int J Psychiatry Clin Pract 2022; 26:303-315. [PMID: 34941467 DOI: 10.1080/13651501.2021.2017461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Mental capacity for treatment decisions in psychiatry inpatients is an important ethical and legal concern, especially in light of changes in mental capacity legislation in many jurisdictions. AIMS To conduct a systematic review of literature examining the prevalence of mental capacity for treatment decisions among voluntary and involuntary psychiatry inpatients, and to assess any correlations between research tools used to measure mental capacity and binary judgements using criteria such as those in capacity legislation. METHOD We searched PsycINFO, Ovid MEDLINE and EMBASE for studies assessing mental capacity for treatment decisions in people admitted voluntarily and involuntarily to psychiatric hospitals. RESULTS Forty-five papers emanating from 33 studies were identified. There was huge variability in study methods and often selective populations, but the prevalence of decision-making capacity varied between 5% and 83.7%. These figures resulted from studies using cut-off scores or categorical criteria only. The prevalence of decision-making capacity among involuntary patients ranged from 7.7% to 42%, and among voluntary patients ranged from 29% to 97.9%. Two papers showed positive correlations between clinicians' judgement of decision-making capacity and scores on the MacArthur Competence Assessment Tool for Treatment; two papers showed no such correlation. CONCLUSIONS Not all voluntary psychiatry inpatients possess mental capacity and many involuntary patients do. This paradox needs to be clarified and resolved in mental health legislation; supported decision-making can help with this task.Key PointsLegislative changes for mental capacity are taking place in many jurisdictions.This is an important human rights issue for many people, including psychiatry inpatients.In our review, we found the prevalence of decision-making capacity varies between 5% and 83.7% in psychiatry inpatients.Not all voluntary inpatients have decision-making capacity.Many involuntary inpatients have mental capacity to make decisions.Supported decision-making can help those with impairments in their mental capacity.
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Affiliation(s)
- Aoife Curley
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Tallaght, Dublin, Ireland.,Cavan Monaghan Mental Health Service, Monaghan, Ireland
| | - Carol Watson
- Cavan Monaghan Mental Health Service, Monaghan, Ireland
| | - Brendan D Kelly
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Sciences, Tallaght University Hospital, Tallaght, Dublin, Ireland
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Hariri E, Al Hammoud M, Donovan E, Shah K, Kittleson MM. The Role of Informed Consent in Clinical and Research Settings. Med Clin North Am 2022; 106:663-674. [PMID: 35725232 DOI: 10.1016/j.mcna.2022.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Informed consent plays an integral role in governing the patient-physician relationship with origins traced back to ancient Greek philosophy. The main pillars of informed consent are autonomy, integrity, respect, and care. In the last century, these notions have been codified into legislation to promote healthy patient-physician relationships. Understanding the process of informed consent is critical for patients, researchers, and medical practitioners. In this article, the authors provide a brief historical narrative of informed consent, elaborate on the process of obtaining an ethically and legally valid informed consent, and present some of the future challenges in the field.
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Affiliation(s)
- Essa Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, G10 Clinic, Cleveland OH 44195, USA
| | - Mazen Al Hammoud
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Erin Donovan
- Department of Communication Studies, The University of Texas at Austin, 2504A Whitis Ave, Austin, TX 78712, USA
| | - Kevin Shah
- Department of Medicine, Division of Cardiology, University of Utah Hospital, 30 North 1900 East, Rm 4A100, Salt Lake City, UT 84132, USA
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Medical Center, 8670 Wilshire Blvd, 2nd floor, Beverly Hills, CA 90211, USA.
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Killey CM, Allott K, Whitson S, Francey SM, Bryant C, Simmons MB. Decisional capacity in young people with first episode psychosis, major depressive disorder and no mental disorder. Schizophr Res Cogn 2022; 28:100228. [PMID: 35242603 PMCID: PMC8861421 DOI: 10.1016/j.scog.2021.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/20/2021] [Accepted: 11/21/2021] [Indexed: 11/26/2022] Open
Abstract
We aimed to (1) examine decisional capacity for treatment in young people (aged 15 to 25 years) with first-episode psychosis (FEP), Major Depressive Disorder (MDD) and no mental disorder, and (2) determine which theoretically relevant factors are associated with, and predict decisional capacity. We assessed decisional capacity (using MacArthur Competence Assessment Tool-Treatment; MacCAT-T), cognitive abilities, insight and symptom severity in young people with no mental disorder (n = 38), MDD (n = 38) and FEP (n = 18) from inpatient and outpatient services. Most young people with MDD (84.2%) or no mental disorder (86.8%) had adequate decisional capacity to consent to treatment based on recommended cut-off scores, compared with fewer than half of the those with FEP (44.4%). Levels of capacity were not significantly different between young people with MDD and those with no mental disorder (p = .861). However, young people with FEP demonstrated significantly poorer decisional capacity than those with no mental disorder (p = .006) and MDD (p = .009). A hierarchical regression analysis suggested that differences may be better explained by variation in cognitive ability, especially thematic verbal recall. Greater symptom severity and poorer insight were associated with poorer decisional capacity for FEP (p = .008 and p < .001, respectively), but not MDD (p = .050 and p = .805, respectively). Cognitive performance (i.e., predicted IQ, processing speed, mental flexibility and thematic verbal memory) collectively explained 36.6% of the variance in decisional capacity (p < .001). Thematic verbal memory was the strongest predictor of decisional capacity (p < .001). Supports for memory should be implemented to facilitate involvement in treatment decisions during the early course of illness. We tested decisional capacity in young people with first episode psychosis, major depressive disorder and no mental disorder. Most with major depressive disorder or no mental disorder had adequate capacity, compared to fewer than half with first episode psychosis. In first episode psychosis, greater symptom severity and poorer insight were related to poorer decisional capacity. Cognitive performance significantly explained variance in decisional capacity. A subgroup of young people will need support to be involved in making decisions, even in early stages of illness.
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Psychopharmakologische Zwangsbehandlung im Maßregelvollzug. FORENSISCHE PSYCHIATRIE PSYCHOLOGIE KRIMINOLOGIE 2022. [DOI: 10.1007/s11757-022-00716-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDas nordrhein-westfälische Maßregelvollzugsgesetz regelte in § 17a Abs. 2 bis vor Kurzem die Zwangsbehandlung einwilligungsunfähiger Patienten zur „Erreichung der Entlassfähigkeit“. Bislang ist wenig über die Effekte derartiger Zwangsbehandlungen auf dieses vorgegebene Ziel bekannt. Ziel der Arbeit stellt daher die Evaluation antipsychotischer Zwangsmedikationen bei gem. § 63 StGB Untergebrachten mit einer Erkrankung aus dem schizophrenen Formenkreis dar.Für alle n = 16 in 2019 entsprechend erfolgten Zwangsmedikationen zur Erreichung der Entlassfähigkeit in 3 Maßregelvollzugsklinken des Landschaftsverbands Westfalen-Lippe wurden direkt vor Erstapplikation sowie 4 Wochen und 6 Monate danach mittels Positive and Negative Syndrome Scale (PANSS) bzw. Global Assessment of Functioning (GAF) die psychotische Symptomatik und das Funktionsniveau der Patienten durch die Behandelnden bewertet. Die Erreichung weiterer Behandlungsziele sowie Einschätzungen zur Entlassfähigkeit und eine Gesamtbewertung der Zwangsbehandlung wurden ebenfalls erfragt.Zum ersten Katamnesezeitpunkt ergaben sich eine signifikante Reduktion der PANSS-Faktoren „Positivsymptomatik“ und „erregbar/feindselig“ sowie eine Steigerung des Funktionsniveaus, die sich je leicht abgeschwächt fortsetzten. Auf individueller Ebene zeigte sich nur bei 2 Patienten kein oder ein negativer Effekt. Obwohl die Auswirkungen auf die Behandlungsziele hinter den Erwartungen zurückblieben, bewerteten die Behandler die Maßnahme überwiegend positiv.Zwangsweise verabreichte Antipsychotika können sich günstig auf das Ziel der „Erreichung der Entlassfähigkeit“ auswirken. Insbesondere eingeschränkte Effekte auf Krankheitseinsicht und die Einsicht in die Notwendigkeit der Medikamenteneinnahme zeigen Limitationen auf, die deutlich machen, dass diese Maßnahme allein nicht ausreicht, um die Entlassfähigkeit herzustellen.
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Kane NB, Keene AR, Owen GS, Kim SYH. Applying decision-making capacity criteria in practice: A content analysis of court judgments. PLoS One 2021; 16:e0246521. [PMID: 33544766 PMCID: PMC7864395 DOI: 10.1371/journal.pone.0246521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/20/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/OBJECTIVES Many jurisdictions use a functional model of capacity with similar legal criteria, but there is a lack of agreed understanding as to how to apply these criteria in practice. We aimed to develop a typology of capacity rationales to describe court practice in making capacity determinations and to guide professionals approaching capacity assessments. METHODS We analysed all published cases from courts in England and Wales [Court of Protection (CoP) judgments, or Court of Appeal cases from the CoP] containing rationales for incapacity or intact capacity(n = 131). Qualitative content analysis was used to develop a typology of capacity rationales or abilities. Relationships between the typology and legal criteria for capacity [Mental Capacity Act (MCA)] and diagnoses were analysed. RESULTS The typology had nine categories (reliability: kappa = 0.63): 1) to grasp information or concepts, 2) to imagine/ abstract, 3) to remember, 4) to appreciate, 5) to value/ care, 6) to think through the decision non-impulsively, 7) to reason, 8) to give coherent reasons, and 9) to express a stable preference. Rationales most frequently linked to MCA criterion 'understand' were ability to grasp information or concepts (43%) or to appreciate (42%), and to MCA criterion 'use or weigh' were abilities to appreciate (45%) or to reason (32%). Appreciation was the most frequently cited rationale across all diagnoses. Judges often used rationales without linking them specifically to any MCA criteria (42%). CONCLUSIONS A new typology of rationales could bridge the gap between legal criteria for decision-making capacity and phenomena encountered in practice, increase reliability and transparency of assessments, and provide targets for decision-making support.
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Affiliation(s)
- Nuala B. Kane
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Alex Ruck Keene
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Gareth S. Owen
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Scott Y. H. Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
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Scholten M, Gather J, Vollmann J. Equality in the Informed Consent Process: Competence to Consent, Substitute Decision-Making, and Discrimination of Persons with Mental Disorders. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2021; 46:108-136. [PMID: 33491736 PMCID: PMC7829547 DOI: 10.1093/jmp/jhaa030] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
According to what we propose to call “the competence model,” competence is a necessary condition for valid informed consent. If a person is not competent to make a treatment decision, the decision must be made by a substitute decision-maker on her behalf. Recent reports of various United Nations human rights bodies claim that article 12 of the Convention on the Rights of Persons with Disabilities involves a wholesale rejection of this model, regardless of whether the model is based on a status, outcome, or functional approach to competence. The alleged rationale of this rejection is that denying persons the right to make their own treatment decisions based on an assessment of competence necessarily discriminates against persons with mental disorders. Based on a philosophical account of the nature of discrimination, we argue that a version of the competence model that combines supported decision-making with a functional approach to competence does not discriminate against persons with mental disorders. Furthermore, we argue that status- and outcome-based versions of the competence model are discriminatory.
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Affiliation(s)
- Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany.,Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jochen Vollmann
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
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Kotzé C, Roos JL, Ehlers R. End-of-Life Decision-Making Capacity in Older People With Serious Mental Illness. Front Psychiatry 2021; 12:752897. [PMID: 34630189 PMCID: PMC8492912 DOI: 10.3389/fpsyt.2021.752897] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The study's main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness. Methods: A cross-sectional, observational study, was done at Weskoppies Psychiatric Hospital, Gauteng Province, South Africa that included 100 adults older than 60 years of age and diagnosed with serious mental illness. The Mini-Cog and a semi-structured clinical assessment of end-of-life decision-making capacity was done before a standardized interview, Assessment of Capacity to Consent to Treatment, was administered. This standardized instrument uses a hypothetical vignette to assess decision-making capacity and explores healthcare-related values. Results: The Assessment of Capacity to Consent to Treatment scores correlated (p < 0.001) with the outcomes of the semi-structured decision-making capacity evaluation. Significant correlations with impaired decision-making capacity included: lower scores on the Mini-Cog (p < 0.001); a duration of serious mental illness of 30-39 years (p = 0025); having a diagnosis of schizophrenia spectrum disorders (p = 0.0007); and being admitted involuntarily (p < 0.0001). A main finding was that 65% of participants had decision-making capacity for end-of-life decisions, were able to express their values and engage in advance care discussions. Discussion and Conclusion: Healthcare providers have a duty to initiate advance care discussions, optimize decision-making capacity, and protect autonomous decision-making. Many older patients with serious mental illness can engage in end-of-life discussions and can make autonomous decisions about preferred end-of-life care. Chronological age or diagnostic categories should never be used as reasons for discrimination, and older people with serious mental illness should receive end-of-life care in keeping with their preferences and values.
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Affiliation(s)
- Carla Kotzé
- Department of Psychiatry, Faculty of Health Sciences, School of Medicine, Weskoppies Psychiatric Hospital, University of Pretoria, Pretoria, South Africa
| | - Johannes Lodewikus Roos
- Department of Psychiatry, Faculty of Health Sciences, School of Medicine, Weskoppies Psychiatric Hospital, University of Pretoria, Pretoria, South Africa
| | - René Ehlers
- Department of Statistics, Faculty of Natural and Agricultural Sciences, University of Pretoria, Pretoria, South Africa
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Pons EV, Salvador‐Carulla L, Calcedo‐Barba A, Paz S, Messer T, Paccardi B, Zeller SL. The capacity of schizophrenia and bipolar disorder individuals to make autonomous decisions about pharmacological treatments for their illness in real life: A scoping review. Health Sci Rep 2020; 3:e179. [PMID: 32782974 PMCID: PMC7415958 DOI: 10.1002/hsr2.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND AIM Having decision making capacity is central to the exercise of autonomy in mental health care. The objective of this scoping review is to summarize the evidence on the capacity of people with schizophrenia or bipolar disorder to make decisions about their treatment in real life to support medical practice. METHODS Systematic search of observational studies on the assessment of capacity of patients with schizophrenia, psychosis, or bipolar disorder to make healthcare and treatment-related decisions, conducted in any clinical setting published up to January 31, 2020 was performed. Free text searches and medical subject headings in English were combined in PubMed, Scopus, CINAHL, and PsycInfo. Publications were selected as per inclusion and exclusion criteria. The Newcastle-Ottawa Scale for observational studies was used to assess the quality of publications. RESULTS Thirty publications were reviewed. According to the Newcastle-Ottawa Scale criteria, the publications reviewed were good quality. Findings showed that more than 70% of schizophrenia and schizoaffective disorder outpatients understood treatment options at the point of making decisions about their illness and healthcare. Patients treated voluntarily had considerably better scores for decisional capacity than those treated involuntarily. The burden of psychiatric symptoms could compromise decisional capacity temporarily. Decision-making capacity improved over time from admission to discharge from hospital, and with treatment among psychiatry inpatients. Schizophrenia and bipolar disorder patients could be as competent as nonpsychiatric individuals in making decisions about their treatments in everyday life. CONCLUSIONS This scoping review provides a body of evidence for healthcare professionals in need of assessing the capacity of schizophrenia and bipolar disorder patients for autonomously decide about their treatments. Decisional capacity judgements should consider variations in capacity over time and be based on the type of decision to be made, the severity of symptoms, and the specific phase of the mental disorder.
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Affiliation(s)
- Enric Vincens Pons
- Department of PsychiatryParc Sanitari Sant Joan de Déu, Sant Boi de LlobregatBarcelonaSpain
| | - Luis Salvador‐Carulla
- Centre for Mental Health ResearchResearch School of Population Health, College of Health and Medicine, Australian National UniversityCanberraAustralia
| | - Alfredo Calcedo‐Barba
- Department of Psychiatry, Hospital Gregorio MarañónMedical School at the Universidad Complutense de MadridMadridSpain
| | | | - Thomas Messer
- Department of PsychiatryDanuviusklinikPfaffenhofenGermany
| | - Bruno Paccardi
- Psychiatric UnitSanta Chiara University Hospital, University of PisaPisaItaly
| | - Scott L. Zeller
- Department of PsychiatryUniversity of CaliforniaCaliforniaUSA
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12
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Kotze C, Roos JL. End-of-life decision-making capacity in an elderly patient with schizophrenia and terminal cancer. S Afr Fam Pract (2004) 2020; 62:e1-e4. [PMID: 32787389 PMCID: PMC8378126 DOI: 10.4102/safp.v62i1.5111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 12/22/2022] Open
Abstract
Medical practitioners are confronted daily with decisions about patients’ capacity to consent to interventions. To address some of the pertinent issues with these assessments, the end-of-life decision-making capacity of a 72-year-old female with treatment-resistant schizophrenia and terminal cancer is discussed, as are the role of the treating clinician and the importance of health-related values. There is a recommendation that the focus of these assessments can rather be on practical outcomes, especially when capacity issues arise. This implies that the decision-making capacity of the patient is only practically important when the treatment team is willing to proceed against the patient’s wishes. This shifts the focus from a potentially difficult assessment to the simpler question of whether the patient’s capacity will change the treatment approach. Clinicians should attend to any possible underlying issues, instead of focusing strictly on capacity. Compared to the general populations people with serious mental illness (SMI) have higher rates of physical illness and die at a younger age, but they do not commonly access palliative care services. Conversations about end-of-life care can occur without fear that a person’s psychiatric symptoms or related vulnerabilities will undermine the process. More research about palliative care and advance care planning for people with SMI is needed. This is even more urgent in light of the coronavirus disease-2019 (COVID-19) pandemic, and South African health services should consider recommendations that advanced care planning should be routinely implemented. These recommendations should not only focus on the general population and should include patients with SMI.
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Affiliation(s)
- Carla Kotze
- Department of Psychiatry, Weskoppies Psychiatric Hospital, University of Pretoria, Pretoria.
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13
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Pace A, Koekkoek JAF, van den Bent MJ, Bulbeck HJ, Fleming J, Grant R, Golla H, Henriksson R, Kerrigan S, Marosi C, Oberg I, Oberndorfer S, Oliver K, Pasman HRW, Le Rhun E, Rooney AG, Rudà R, Veronese S, Walbert T, Weller M, Wick W, Taphoorn MJB, Dirven L. Determining medical decision-making capacity in brain tumor patients: why and how? Neurooncol Pract 2020; 7:599-612. [PMID: 33312674 DOI: 10.1093/nop/npaa040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Brain tumor patients are at high risk of impaired medical decision-making capacity (MDC), which can be ethically challenging because it limits their ability to give informed consent to medical treatments or participation in research. The European Association of Neuro-Oncology Palliative Care Multidisciplinary Task Force performed a systematic review to identify relevant evidence with respect to MDC that could be used to give recommendations on how to cope with reduced MDC in brain tumor patients. Methods A literature search in several electronic databases was conducted up to September 2019, including studies with brain tumor and other neurological patients. Information related to the following topics was extracted: tools to measure MDC, consent to treatment or research, predictive patient- and treatment-related factors, surrogate decision making, and interventions to improve MDC. Results A total of 138 articles were deemed eligible. Several structured capacity-assessment instruments are available to aid clinical decision making. These instruments revealed a high incidence of impaired MDC both in brain tumors and other neurological diseases for treatment- and research-related decisions. Incapacity appeared to be mostly determined by the level of cognitive impairment. Surrogate decision making should be considered in case a patient lacks capacity, ensuring that the patient's "best interests" and wishes are guaranteed. Several methods are available that may help to enhance patients' consent capacity. Conclusions Clinical recommendations on how to detect and manage reduced MDC in brain tumor patients were formulated, reflecting among others the timing of MDC assessments, methods to enhance patients' consent capacity, and alternative procedures, including surrogate consent.
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Affiliation(s)
- Andrea Pace
- Neuro-Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Martin J van den Bent
- Department of Neurology, The Brain Tumor Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Helen J Bulbeck
- Brainstrust (The Brain Cancer People), Cowes, Isle of Wight, UK
| | - Jane Fleming
- Department of Palliative Medicine, University Hospital Waterford, Waterford, Ireland
| | - Robin Grant
- Edinburgh Centre for Neuro-Oncology, Western General Hospital, Edinburgh, Scotland, UK
| | - Heidrun Golla
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
| | - Roger Henriksson
- Department of Radiation Sciences and Oncology, Umeå University, Umeå, Sweden
| | | | - Christine Marosi
- Department of Internal Medicine I, Clinical Division of Medical Oncology, Medical University of Vienna, Vienna, Austria
| | - Ingela Oberg
- Department of Neuroscience, Cambridge University Hospitals, Cambridge, UK
| | - Stefan Oberndorfer
- Department Neurology, University Clinic St Pölten, KLPU and KLI-Neurology and Neuropsychology, St Pölten, Austria
| | - Kathy Oliver
- International Brain Tumour Alliance, Tadworth, UK
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Emilie Le Rhun
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Alasdair G Rooney
- Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Edinburgh, Scotland, UK
| | - Roberta Rudà
- Department of Neuro-Oncology, University and City of Health and Science Hospital, Turin, Italy
| | - Simone Veronese
- Department of Palliative Care, Fondazione FARO, Turin, Italy
| | - Tobias Walbert
- Department of Neurology and Neurosurgery, Henry Ford Health System, Detroit, Michigan, US
| | - Michael Weller
- Department of Neurology & Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Wolfgang Wick
- Neurology Clinic and National Centre for Tumour Diseases, University Hospital Heidelberg, Heidelberg, Germany.,German Consortium of Translational Cancer Research (DKTK), Clinical Cooperation Unit Neurooncology, German Cancer Research Center, Heidelberg, Germany
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
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14
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Scholten M, Gather J, Vollmann J. The Narrative Coherence Standard Adds Either Too Much, or Nothing at All. AJOB Neurosci 2020; 11:38-40. [PMID: 32043929 DOI: 10.1080/21507740.2019.1704923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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15
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Lepping P. Capacity issues at the front door. Br J Hosp Med (Lond) 2019; 80:513-516. [PMID: 31498667 DOI: 10.12968/hmed.2019.80.9.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Decision-making capacity is often overestimated by clinicians. An average of one third of patients lack capacity to make complex decisions and clinicians should be alert to such a possibility. Cognitive impairment, acute infection, intoxication and other common medical and psychiatric problems can impair patients' capacity. The Mental Capacity Act 2005 has to be applied when treating patients who lack capacity. The main decision maker for a proposed treatment or investigation is responsible for assessing capacity. However, all clinicians have to consider and assess capacity, and act in a patient's best interests if he/she lacks capacity.
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Affiliation(s)
- Peter Lepping
- Consultant Psychiatrist, Wrexham Maelor Hospital Psychiatric Liaison Team, Betsi Cadwaladr University Health Board, Heddfan Psychiatric Unit, Wrexham LL13 7TD
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16
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Mertz M, Schildmann J. Beyond integrating social sciences: Reflecting on the place of life sciences in empirical bioethics methodologies. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2018; 21:207-214. [PMID: 28733796 DOI: 10.1007/s11019-017-9792-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Empirical bioethics is commonly understood as integrating empirical research with normative-ethical research in order to address an ethical issue. Methodological analyses in empirical bioethics mainly focus on the integration of socio-empirical sciences (e.g. sociology or psychology) and normative ethics. But while there are numerous multidisciplinary research projects combining life sciences and normative ethics, there is few explicit methodological reflection on how to integrate both fields, or about the goals and rationales of such interdisciplinary cooperation. In this paper we will review some drivers for the tendency of empirical bioethics methodologies to focus on the collaboration of normative ethics with particularly social sciences. Subsequently, we argue that the ends of empirical bioethics, not the empirical methods, are decisive for the question of which empirical disciplines can contribute to empirical bioethics in a meaningful way. Using already existing types of research integration as a springboard, five possible types of research which encompass life sciences and normative analysis will illustrate how such cooperation can be conceptualized from a methodological perspective within empirical bioethics. We will conclude with a reflection on the limitations and challenges of empirical bioethics research that integrates life sciences.
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Affiliation(s)
- Marcel Mertz
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany.
| | - Jan Schildmann
- Institute for Ethics, Wilhelm Löhe University of Applied Science, Fürth Merkurstraße 41/Südstadtpark, 90763, Fürth, Germany
- Department of Medicine III, Klinikum der Universität München, Campus Großhadern, Munich, Germany
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17
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Elzakkers IFFM, Danner UN, Grisso T, Hoek HW, van Elburg AA. Assessment of mental capacity to consent to treatment in anorexia nervosa: A comparison of clinical judgment and MacCAT-T and consequences for clinical practice. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2018; 58:27-35. [PMID: 29853010 DOI: 10.1016/j.ijlp.2018.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 01/22/2018] [Accepted: 02/13/2018] [Indexed: 06/08/2023]
Abstract
Informed consent requires adequate mental capacity to consent to treatment. Mental capacity (MC) to consent to treatment refers to the ability to make medical decisions. MC is assessed in a general psychiatric interview, but this clinical assessment is known to overestimate mental capacity in patients and the inter rater reliability is low. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) has emerged as the gold standard to assess mental capacity to consent to treatment. The MacCAT-T is a semi-structured interview designed to aid clinicians in this assessment and has shown good inter rater reliability in patients with schizophrenia and other mental disorders, but has hardly been studied in patients with anorexia nervosa. Patients with anorexia nervosa (AN) regularly avoid treatment, even when severely ill and discussion includes assessing MC to consent to treatment. The aim of this study is to compare clinical judgment and the MacCAT-T in evaluating MC in patients with AN which in turn may influence use of the MacCAT-T in daily practice. In a sample of 70 consecutively referred severely ill patients with AN with a mean BMI of 15.5 kg/m2 and a mean duration of illness of 8.6 years, clinical assessment of MC by experienced psychiatrists and the outcome of the MacCAT-T interview were compared. Agreement (κ-value) was calculated. Agreement between clinical assessment and outcome of the MacCAT-T was questionable (κ 0.23). Unlike in other psychiatric populations, clinicians judged a high proportion of patients with AN as having diminished MC. The MacCAT-T can be useful in assessing MC in AN when used in addition to clinical judgment to aid clinicians in complex cases. Why clinicians judge a relatively high proportion of patients with AN as having diminished MC, in contrast to lower proportions in other psychiatric disorders, is an area in need of further research.
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Affiliation(s)
- Isis F F M Elzakkers
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands
| | - Unna N Danner
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands; Utrecht University, Department of Psychology, The Netherlands
| | - Thomas Grisso
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hans W Hoek
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands; Parnassia Psychiatric Institute, The Hague, The Netherlands; Department of Psychiatry, University Medical Center Groningen, The Netherlands; Department of Epidemiology, Mailman School of Public Health, Columbia University New York, USA
| | - Annemarie A van Elburg
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands; Utrecht University, Department of Psychology, The Netherlands.
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18
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Wang YY, Wang SB, Ungvari GS, Yu X, Ng CH, Xiang YT. The assessment of decision-making competence in patients with depression using the MacArthur competence assessment tools: A systematic review. Perspect Psychiatr Care 2018; 54:206-211. [PMID: 28543187 DOI: 10.1111/ppc.12224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/19/2017] [Accepted: 04/22/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE This is a systematic review of the usefulness of the MacArthur Competence Assessment Tools (MacCAT) in assessing the decision-making competence in patients with depression. DESIGN AND METHODS A systematic literature search was performed. FINDINGS Eleven studies met the search criteria. The decision-making capacity was impaired in 9-31% of the patients with depression. There was inconsistency regarding the differences of MacCAT scores between patients with depression and controls, while relatively large effect sizes were found on the Appreciation and Reasoning MacCAT subscales. PRACTICE IMPLICATIONS The MacCAT appears to be a useful tool for measuring decision-making capacity in patients with depression, but the association between depression and competence is not consistent. The mechanisms mediating such association are likely to be complex and multifactorial.
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Affiliation(s)
- Yuan-Yuan Wang
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macau, SAR, China
| | - Shi-Bin Wang
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macau, SAR, China
| | - Gabor S Ungvari
- University of Notre Dame Australia/Marian Centre, Perth, Australia.,School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia
| | - Xin Yu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Chee H Ng
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
| | - Yu-Tao Xiang
- Unit of Psychiatry, Faculty of Health Sciences, University of Macau, Macau, SAR, China
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19
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Bentwich ME, Dickman N, Oberman A, Bokek-Cohen Y. "I Treat Him as a Normal Patient": Unveiling the Normalization Coping Strategy Among Formal Caregivers of Persons With Dementia and Its Implications for Person-Centered Care. J Transcult Nurs 2018; 29:420-428. [PMID: 29308708 DOI: 10.1177/1043659617745137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Currently, 47 million people have dementia, worldwide, often requiring paid care by formal caregivers. Research regarding family caregivers suggests normalization as a model for coping with negative emotional outcomes in caring for a person with dementia (PWD). The study aims to explore whether normalization coping mechanism exists among formal caregivers, reveal differences in its application among cross-cultural caregivers, and examine how this coping mechanism may be related to implementing person-centered care for PWDs. METHOD Content analysis of interviews with 20 formal caregivers from three cultural groups (Jews born in Israel [JI], Arabs born in Israel [AI], Russian immigrants [RI]), attending to PWDs. RESULTS We extracted five normalization modes, revealing AI caregivers had substantially more utterances of normalization expressions than their colleagues. DISCUSSION The normalization modes most commonly expressed by AI caregivers relate to the personhood of PWDs. These normalization modes may enhance formal caregivers' ability to employ person-centered care.
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Affiliation(s)
| | - Nomy Dickman
- 1 Faculty of Medicine, Bar-Ilan University, Tzfat, Israel
| | - Amitai Oberman
- 1 Faculty of Medicine, Bar-Ilan University, Tzfat, Israel
| | - Ya'arit Bokek-Cohen
- 1 Faculty of Medicine, Bar-Ilan University, Tzfat, Israel.,2 Mofet Institute, Tel Aviv-Yafo, Israel
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20
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Huang J, Chiovenda A, Shao Y, Ma H, Li H, Good MJD. Low level of knowledge regarding diagnosis and treatment among inpatients with schizophrenia in Shanghai. Neuropsychiatr Dis Treat 2018; 14:185-191. [PMID: 29379291 PMCID: PMC5757975 DOI: 10.2147/ndt.s152917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The study was designed to measure the level of knowledge of the diagnosis of illness and its treatment among patients with schizophrenia in China, and to examine the association between the capacity to provide informed consent and participation in treatment. PARTICIPANTS AND METHODS A cross-sectional study was conducted at three clinical inpatient sites in Shanghai, China, during 2015. Patients' knowledge of the illness, as well as the knowledge of the patients' families and psychiatrists, was determined. Logistic regression was used to determine the factors associated with patients' knowledge of schizophrenia. RESULTS Out of 109 enrolled schizophrenic inpatients (mean age 42.46±1.29 years), 60.6% were aware of their diagnosis and 67.0% knew details of their treatment plan. The group with unimpaired capacity for giving informed consent had a greater knowledge of their diagnosis (χ2=5.002, p=0.038) and of their treatment plan (χ2=11.196, p<0.01) in comparison with patients who were regarded to be impaired. Using logistic regression analysis, it was found that patients' capacity to give informed consent to treatment was associated with the level of knowledge surrounding the diagnosis (odds ratio =3.230, p<0.05) and the level of knowledge of treatment (odds ratio =4.962, p<0.01). CONCLUSION The level of knowledge reported by inpatients with schizophrenia was low with respect to the diagnosis of schizophrenia and of the treatment associated with this illness. An association between patients' capacities for giving informed consent and knowledge of their illness was confirmed in the present study. The results suggest that, in clinical practice, the informed consent process should be strengthened to protect the interests of patients with schizophrenia.
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Affiliation(s)
- Jingjing Huang
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Andrea Chiovenda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Yang Shao
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huajian Ma
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huafang Li
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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21
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Elie D, Marino A, Torres-Platas SG, Noohi S, Semeniuk T, Segal M, Looper KJ, Rej S. End-of-Life Care Preferences in Patients with Severe and Persistent Mental Illness and Chronic Medical Conditions: A Comparative Cross-Sectional Study. Am J Geriatr Psychiatry 2018; 26:89-97. [PMID: 29066037 DOI: 10.1016/j.jagp.2017.09.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/29/2017] [Accepted: 09/11/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Physicians rarely engage severe and persistent mental illness (SPMI) patients in end-of-life care discussion despite an increased risk of debilitating medical illnesses and mortality. Access to quality palliative care and medical assistance in dying (MAID) has become a priority in Canada and many jurisdictions. In this study, we compared SPMI and chronic medically ill (CMI) patients' end-of-life care preferences and comfort level with end-of-life care discussion, and identified potential predictors of interest in MAID. DESIGN Comparative cross-sectional study. SETTING Hospital-based. PARTICIPANTS We recruited 106 SPMI and 95 CMI patients at the Jewish General Hospital, Canada. Patients aged ≥40 years, without severe cognitive impairment, able to communicate in English or French and provide written informed consent were included. MEASUREMENTS Attitudes towards pain management, palliative sedation, MAID, and artificial life support were collected with the Health Care Preferences Questionnaire. Adjusted odd ratios (aOR) were calculated for each end-of-life care intervention. Comfort with discussion was rated on a Likert scale. A stepwise regression analysis was performed to identify predictors of interest in MAID. RESULTS SPMI was not correlated to any end-of-life care intervention, except for MAID where SPMI patients were less likely to support its use (aOR: 0.48, 95% CI: 0.25-0.94, p = 0.03). Religiosity was also correlated with interest in MAID (aOR: 0.14, 95% CI: 0.06-0.31, p < 0.001). Patients in both groups were comfortable talking about end-of-life care. CONCLUSIONS SPMI patients are able to voice their end-of-life care preferences, and contrary to some fears, do not want MAID more than CMI patients.
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Affiliation(s)
- Dominique Elie
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada.
| | - Amanda Marino
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Susana G Torres-Platas
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Saeid Noohi
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Trent Semeniuk
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Marilyn Segal
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Karl J Looper
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
| | - Soham Rej
- Geri-PARTy Research Group, Department of Psychiatry, Jewish General Hospital, McGill University, Montreal, Canada
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22
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Spencer BWJ, Shields G, Gergel T, Hotopf M, Owen GS. Diversity or disarray? A systematic review of decision-making capacity for treatment and research in schizophrenia and other non-affective psychoses. Psychol Med 2017; 47:1906-1922. [PMID: 28441976 DOI: 10.1017/s0033291717000502] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Valid consent for treatment or research participation requires that an individual has decision-making capacity (DMC), which is the ability to make a specific decision. There is evidence that the psychopathology of schizophrenia can compromise DMC. The objective of this review was to examine the presence or absence of DMC in schizophrenia and the socio-demographic/psychopathological factors associated. METHODS We searched three databases Embase, Ovid MEDLINE(R), and PsycINFO for studies reporting data on the proportion of DMC for treatment and research (DMC-T and DMC-R), and/or socio-demographic/psychopathological associations with ability to make such decisions, in people with schizophrenia and related illnesses. RESULTS A total of 40 studies were identified. While high levels of heterogeneity limited direct comparison, meta-analysis of inpatient data showed that DMC-T was present in 48% of people. Insight was strongly associated with DMC-T. Neurocognitive deficits were strongly associated with lack of DMC-R and to a lesser extent DMC-T. With the exception of years of education, there was no evidence for an association with socio-demographic factors. CONCLUSIONS Insight and neurocognitive deficits are most closely associated with DMC in schizophrenia. The lack of an association with socio-demographic factors dispels common misperceptions regarding DMC and characteristics such as age. Although our results reveal a wide spectrum of DMC-T and DMC-R in schizophrenia, this could be partly due to the complexity of the DMC construct and the heterogeneity of existing studies. To facilitate systematic review research, there is a need for improvement within research study design and increased consistency of concepts and tools.
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Affiliation(s)
- B W J Spencer
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - G Shields
- South London and Maudsley NHS Foundation Trust,Maudsley Hospital,Denmark Hill,London, SE5 8AZ,UK
| | - T Gergel
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - M Hotopf
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - G S Owen
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
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Fernandez C, Kennedy HG, Kennedy M. The recovery of factors associated with decision-making capacity in individuals with psychosis. BJPsych Open 2017; 3:113-119. [PMID: 28507770 PMCID: PMC5415675 DOI: 10.1192/bjpo.bp.116.004226] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There is limited data on the recovery of factors associated with decisional capacity in patients with psychosis. AIMS To study the relationship between changes in mental capacity, symptoms and global functioning using structured measures during treatment for psychosis. METHOD Fifty-six patients with psychosis were assessed for capacity to consent to treatment on admission and at 6 and 12 weeks following treatment. The MacArthur Competence Assessment Tool - Treatment, the Positive and Negative Symptom Scale and the Global Assessment of Functioning Scale were used to measure mental capacities, symptom severity and global functioning respectively. Treating consultants rated capacity to consent, masked to these measures. RESULTS Greater impairments on all measures were found in patients assessed as lacking capacity. These improved with treatment over 12 weeks with significant effect sizes (0.5 to 0.6). Stronger correlations between mental capacities, positive symptoms (-0.47) and global functioning (0.56) were noted in the first 6 weeks. CONCLUSIONS Impairments in capacity in acute stages of psychosis are related to symptom severity and functional impairment. They improve during treatment, particularly in the first 6 weeks. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Affiliation(s)
- Colin Fernandez
- , MSc, MRCPsych, St Patrick's University Hospital, Dublin, Ireland
| | - Harry G Kennedy
- , MD, FRCPsych, Academic Department of Psychiatry, University of Dublin, Trinity College, Dublin, Ireland; National Forensic Mental Health Service, Central Mental Hospital, Dublin, Ireland
| | - Miriam Kennedy
- , PhD, MRCPsych, St Patrick's University Hospital, Dublin, Ireland; Academic Department of Psychiatry, University of Dublin, Trinity College, Dublin, Ireland
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Assessing capacity to consent to treatment with cholinesterase inhibitors in dementia using a specific and standardized version of the MacArthur Competence Assessment Tool (MacCAT-T). Int Psychogeriatr 2017; 29:333-343. [PMID: 27825402 DOI: 10.1017/s104161021600154x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The use of assessment tools has been shown to improve the inter-rater reliability of capacity assessments. However, instrument-based capacity assessments of people with dementia face challenges. In dementia research, measuring capacity with instruments like the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) mostly employ hypothetical treatment vignettes that can overwhelm the abstraction capabilities of people with dementia and are thus not always suitable for this target group. The primary aim of this study was to provide a standardized real informed consent paradigm that enables the dementia-specific properties of capacity to consent to treatment in people with dementia to be identified in a real informed consent process that is both externally valid and ethically justifiable. METHODS The sample consisted of 53 people with mild to moderate dementia and a group of 133 people without cognitive impairment. Rather than using a hypothetical treatment vignette, we used a standardized version of the MacCAT-T to assess capacity to consent to treatment with cholinesterase inhibitors in people with dementia. Inter-rater reliability, item statistics, and psychometric properties were also investigated. RESULTS Intraclass correlations (ICCs) (0.951-0.990) indicated high inter-rater reliability of the standardized real informed consent paradigm. In the dementia group, performance on different items of the MacCAT-T varied. Most people with dementia were able to express a treatment choice, and were aware of the need to take a tablet. Further information on the course of the disorder and the benefits and risks of the treatment were less understood, as was comparative reasoning regarding treatment alternatives. CONCLUSION The standardized real informed consent paradigm enabled us to detect dementia-specific characteristics of patients' capacity to consent to treatment with cholinesterase inhibitors. In order to determine suitable enhanced consent procedures for this treatment, we recommend the consideration of MacCAT-T results on an item level. People with dementia seem to understand only basic information. Our data indicate that one useful strategy to enhance capacity to consent is to reduce attention and memory demands as far as possible.
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Siegel AM, Barrett MS, Bhati MT. Deep Brain Stimulation for Alzheimer’s Disease: Ethical Challenges for Clinical Research. J Alzheimers Dis 2017; 56:429-439. [DOI: 10.3233/jad-160356] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Andrew M. Siegel
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marna S. Barrett
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mahendra T. Bhati
- Departments of Psychiatry and Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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Boettger S, Bergman M, Jenewein J, Boettger S. Advanced age and decisional capacity: The effect of age on the ability to make health care decisions. Arch Gerontol Geriatr 2016; 66:211-7. [DOI: 10.1016/j.archger.2016.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 05/10/2016] [Accepted: 06/13/2016] [Indexed: 10/21/2022]
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Gather J, Henking T, Juckel G, Vollmann J. Vorausverfügte Therapieablehnungen in Situationen von Eigen- oder Fremdgefährdung. Ethische und rechtliche Überlegungen zur Umsetzung von Patientenverfügungen in der Psychiatrie. Ethik Med 2016. [DOI: 10.1007/s00481-016-0409-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Swiatek KM, Jordan K, Coffman J. New use for an old drug: oral ketamine for treatment-resistant depression. BMJ Case Rep 2016; 2016:bcr-2016-216088. [PMID: 27489070 DOI: 10.1136/bcr-2016-216088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Treatment-resistant depression (TRD) is a disabling disorder that can interfere with a patient's capacity to understand and participate in medical care and thus negatively impact individual morbidity and mortality. Hospitalised patients with TRD may require rapid alleviation of severe symptomatology, particularly when suicidal or if unable to participate in care decisions. Ketamine is well known for its anaesthetic effects and its use as a 'street' drug; however, its action as an N-methyl-D-aspartate receptor antagonist makes ketamine a potential therapy for TRD. The majority of studies investigating ketamine for TRD have used intravenous drug delivery, demonstrating benefit for rapid alleviation and sustained response of depression symptoms. Oral ketamine for urgent alleviation of TRD symptoms is less reported. We describe rapid alleviation of severe TRD with oral ketamine in a severely ill postoperative hospitalised patient, and review the current literature on 'off-label' use of ketamine for treatment of refractory depression.
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Affiliation(s)
| | - Kim Jordan
- Department of Internal Medicine and Geriatrics, Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Julie Coffman
- Department of Internal Medicine, Hospice & Palliative Medicine, Riverside Methodist Hospital, Columbus, Ohio, USA
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Morán-Sánchez I, Luna A, Pérez-Cárceles MD. Assessment of Capacity to Consent to Research Among Psychiatric Outpatients: Prevalence and Associated Factors. Psychiatr Q 2016; 87:89-105. [PMID: 25952945 DOI: 10.1007/s11126-015-9365-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Mental capacity is an emerging ethical legal concept in psychiatric settings but its relation to clinical parameters remains yet uncertain. The aim of this study is to evaluate the association between capacity to consent research and different psychiatric disorders and to characterize predictors of impairments in research decision-making capacity across diagnostic groups in a cross-sectional study. 139 consecutively referred outpatients with DSM-IV TR diagnoses of psychotic, mood and anxiety disorders were interviewed and a binary judgment of incapacity was made guided by the MacArthur competence assessment tool for consent research (MacCAT-CR). Demographics and clinical information were assessed by cases notes. Patients with anxiety disorders performed the best on the MacCAT-CR, and patients with psychotic disorders had the worst performance, however, there was considerable heterogeneity within each group. Cognitive impairment and global functioning were strongly correlated with MacCAT-CR subscales scores. 30.6% participants lacked research-related decisional capacity. Low Understanding score OR 0.07 (IC 95% 0.01-0.32) and Low Reasoning score OR 0.30 (IC 95% 0.11-0.82) were the factors most closely associated with lack of capacity. No absolute statements about decisional capacity can be driven merely due to the diagnosis. We found several risk factors which may be considered to decide which populations may require more thorough capacity assessments. The issues under consideration in the present study are by no means unique to people with psychiatric conditions. Ignoring this caveat, risks further inappropriate stigmatization of those with serious mental illness.
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Affiliation(s)
- Inés Morán-Sánchez
- Mental Health Centre, Health Service of Murcia, 30201, Cartagena, Murcia, Spain.
| | - Aurelio Luna
- Department of Legal and Forensic Medicine, Biomedical Research Institute (IMIB), Regional Campus of International Excellence "Campus Mare Nostrum", Faculty of Medicine, University of Murcia, Murcia, Spain
| | - Maria D Pérez-Cárceles
- Department of Legal and Forensic Medicine, Biomedical Research Institute (IMIB), Regional Campus of International Excellence "Campus Mare Nostrum", Faculty of Medicine, University of Murcia, Murcia, Spain
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Zlodre J, Yiend J, Burns T, Fazel S. Coercion, competence, and consent in offenders with personality disorder. PSYCHOLOGY, CRIME & LAW : PC & L 2015; 22:315-330. [PMID: 27284235 PMCID: PMC4896379 DOI: 10.1080/1068316x.2015.1109086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Competence to consent to treatment has not previously been examined in a personality disorder cohort without comorbid mental disorder. We examined competence and coercion in 174 individuals diagnosed with severe personality disorder using two validated tools (the MacArthur Competence Assessment Tool for Treatment and the MacArthur Coercion Assessment Scale - Short Form). Competence was not categorically impaired, but there were variations within the sample on dimensional competence measures. Further, there were significant negative correlations between experienced coercion and competence. Higher coercion scores were associated with two components of competence: lower understanding and reasoning. Patients who consented to treatment had higher scores on competence measures and experienced less coercion. These findings suggest that therapeutic approaches that decrease experienced coercion and increase competence may increase the engagement of individuals diagnosed with severe personality disorders in treatment.
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Affiliation(s)
- J Zlodre
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - J Yiend
- Institute of Psychiatry, King's College London, London, UK
| | - T Burns
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - S Fazel
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
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Lepping P, Stanly T, Turner J. Systematic review on the prevalence of lack of capacity in medical and psychiatric settings. Clin Med (Lond) 2015; 15:337-43. [PMID: 26407382 PMCID: PMC4952795 DOI: 10.7861/clinmedicine.15-4-337] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Recent court cases in England and Wales have refocused attention on patients' decision-making capacity to consent. Little is known about the prevalence of incapacity across specialities but decision-making capacity is likely to be overestimated by clinicians. The aim of this systematic review is to estimate the prevalence of incapacity to consent to treatment or admission in different medical and psychiatric settings, and compare the two. We conducted an electronic search following PRISMA principles and included 35 studies in psychiatric and 23 studies in medical settings. The 58 included studies revealed 70 data sets across all settings. For psychiatric settings the weighted average proportion of patients with incapacity was 45% (95% confidence interval (CI) 39-51%). For medical settings, the weighted average proportion of patients with incapacity was 34% (95% CI 25-44%). The two groups are not significantly different from each other in terms of the proportion of incapacity (p=0.92). A considerable number of medical and psychiatric patients lack capacity to make treatment and assessment decisions. Clinicians should be more alert to the possibility that their patients may lack decision-making capacity. Assessment of capacity should be frequent using the appropriate legal frameworks to act in the best interest of patients.
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Affiliation(s)
- Peter Lepping
- Betsi Cadwaladr University Local Health Board, and Centre for Mental Health and Society, Wrexham, UK, and Mysore Medical College and Research Institute, Mysore, India
| | | | - Jim Turner
- Betsi Cadwaladr University Local Health Board and Bangor University, UK
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Hein IM, Daams J, Troost P, Lindeboom R, Lindauer RJL. Accuracy of assessment instruments for patients' competence to consent to medical treatment or research. Hippokratia 2015. [DOI: 10.1002/14651858.cd011099.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Irma M Hein
- De Bascule and Academic Medical Center; Department of Child and Adolescent Psychiatry; Meibergdreef 5 Amsterdam Netherlands 1105 AZ
| | - Joost Daams
- Academic Medical Center; Amsterdam Netherlands
| | - Pieter Troost
- De Bascule and Academic Medical Center; Department of Child and Adolescent Psychiatry; Meibergdreef 5 Amsterdam Netherlands 1105 AZ
| | | | - Ramón JL Lindauer
- De Bascule and Academic Medical Center; Department of Child and Adolescent Psychiatry; Meibergdreef 5 Amsterdam Netherlands 1105 AZ
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Informierte Einwilligung in der Demenzforschung. Eine qualitative Studie zum Informationsverständnis von Probanden. Ethik Med 2015. [DOI: 10.1007/s00481-015-0359-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Elzakkers IFFM, Danner UN, Hoek HW, Schmidt U, van Elburg AA. Compulsory treatment in anorexia nervosa: a review. Int J Eat Disord 2014; 47:845-52. [PMID: 24990434 DOI: 10.1002/eat.22330] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Compulsory in-patient refeeding of patients with severe anorexia nervosa (AN) has caused considerable controversy. The effects of such treatment on longer-term outcome are not well known. The objective of this article is to review the evidence on the outcome of compulsory treatment for AN. METHOD Three large databases were searched for studies regarding compulsory treatment in AN. RESULTS Detained patients have more severe symptoms and comorbidity and a longer duration of inpatient stay. In the short term compulsory refeeding in AN appears to be beneficial, but the longer term effects remain uncertain. Clinicians report no worsening of the therapeutic relationship after compulsory treatment. DISCUSSION In severe cases of AN where the patient refuses life-saving treatment compulsory treatment needs to be considered. Future research should focus on the longer term effects of compulsory treatment and also on questions related to mental capacity in AN.
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Affiliation(s)
- Isis F F M Elzakkers
- Altrecht Eating Disorders Rintveld, Altrecht Mental Health Institute, The Netherlands
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Kepple AL, Azzam PN, Gopalan P, Arnold RM. Decision-making capacity at the end of life. PROGRESS IN PALLIATIVE CARE 2014. [DOI: 10.1179/1743291x14y.0000000109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Aydin Er R, Sehiralti M. Comparing assessments of the decision-making competencies of psychiatric inpatients as provided by physicians, nurses, relatives and an assessment tool. JOURNAL OF MEDICAL ETHICS 2014; 40:453-457. [PMID: 23824965 DOI: 10.1136/medethics-2012-100928] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To compare assessments of the decision-making competencies of psychiatric inpatients as provided by physicians, nurses, relatives and an assessment tool. METHODS This study was carried out at the psychiatry clinic of Kocaeli University Hospital from June 2007 to February 2008. The decision-making competence of the 83 patients who participated in the study was assessed by physicians, nurses, relatives and MacCAT-T. RESULTS Of the 83 patients, the relatives of 73.8% of them, including the parents of 47.7%, were interviewed during the study. A moderately good consistency between the competency assessments of the nurses versus those of the physicians, but a poor consistency between the assessments of the physicians and nurses versus those of the patients' relatives, was determined. The differences in the competency assessment obtained with the MacCAT-T versus the evaluations of the physicians, nurses and patients' relatives were statistically significant. CONCLUSIONS Our findings demonstrate those physicians, nurses and the patients' relatives have difficulty in identifying patients lacking decision-making competence. Therefore, an objective competence assessment tool should be used along with the assessments of physicians and nurses, both of whom can provide clinical data, as well as those of relatives, who can offer insights into the patient's moral values and expectations.
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Affiliation(s)
- Rahime Aydin Er
- Vocational School of Health, Kocaeli University, Kocaeli, Turkey
| | - Mine Sehiralti
- Department of History of Medicine and Ethics, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
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Assessing decision-making capacity at end of life. Gen Hosp Psychiatry 2014; 36:392-7. [PMID: 24698057 DOI: 10.1016/j.genhosppsych.2014.02.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 02/21/2014] [Accepted: 02/25/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Patients with terminal illness often face important medical decisions that may carry ethical and legal implications, yet they may be at increased risk for impaired decisional capacity. This study examined the prevalence of impairment on the four domains of decisional capacity relevant to existing legal standards. METHOD Twenty-four adults diagnosed with a terminal illness completed the MacArthur Competence Assessment Tool for Treatment, a semi-structured measure of decision-making capacity and measures of cognitive functioning and psychological distress. RESULTS Approximately one third of the sample demonstrated serious impairment on at least one domain of decisional capacity. The greatest proportion of impairment was found on subscales that rely heavily on verbal abilities. Decisional capacity was significantly associated with cognitive functioning and education, but not with symptoms of anxiety or depression. CONCLUSIONS This study is the first to examine decisional capacity in patients with terminal illness relative to legal standards of competence. Although not universal, decisional impairment was common. Clinicians working with terminally ill patients should frequently assess capacity as these individuals are called on to make important medical decisions. Comprehensive assessment will aid clinicians in their responsibility to balance respect for patient autonomy with their responsibility to protect patients from harm resulting from impaired decisional capacity.
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Abstract
Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder (OCD), and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient's autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient's and the therapist's perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist's approach, who used motivational interventions with a view to appealing to the patient's responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions.
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La décision d’hospitalisation sans consentement aux urgences : approche dimensionnelle ou catégorielle ? Encephale 2014; 40:247-54. [DOI: 10.1016/j.encep.2013.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 03/21/2013] [Indexed: 11/18/2022]
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Hein IM, Daams J, Troost P, Lindeboom R, Lindauer RJL. Accuracy of assessment instruments for patients' competence to consent to medical treatment or research. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [DOI: 10.1002/14651858.cd011099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Hubbeling D. Decision-making capacity should not be decisive in emergencies. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2014; 17:229-238. [PMID: 24370815 DOI: 10.1007/s11019-013-9534-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Examples of patients with anorexia nervosa, depression or borderline personality disorder who have decision-making capacity as currently operationalized, but refuse treatment, are discussed. It appears counterintuitive to respect their treatment refusal because their wish seems to be fuelled by their illness and the consequences of their refusal of treatment are severe. Some proposed solutions have focused on broadening the criteria for decision-making capacity, either in general or for specific patient groups, but these adjustments might discriminate against particular groups of patients and render the process less transparent. Other solutions focus on preferences expressed when patients are not ill, but this information is often not available. The reason for such difficulties with assessing decision-making capacity is that the underlying psychological processes of normal decision-making are not well known and one cannot differentiate between unwise decisions caused by an illness or other factors. The proposed alternative, set out in this paper, is to allow compulsory treatment of patients with decision-making capacity in cases of an emergency, if the refusal is potentially life threatening, but only for a time-limited period. The argument is also made for investigating hindsight agreement, in particular after compulsory measures.
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Affiliation(s)
- Dieneke Hubbeling
- Wandsworth Crisis and Home Treatment Team, South West London and St. George's Mental Health NHS Trust, 61 Glenburnie Road, London, SW17 7DJ, UK,
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Hindmarch T, Hotopf M, Owen GS. Depression and decision-making capacity for treatment or research: a systematic review. BMC Med Ethics 2013; 14:54. [PMID: 24330745 PMCID: PMC4029430 DOI: 10.1186/1472-6939-14-54] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 11/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychiatric disorders can pose problems in the assessment of decision-making capacity (DMC). This is so particularly where psychopathology is seen as the extreme end of a dimension that includes normality. Depression is an example of such a psychiatric disorder. Four abilities (understanding, appreciating, reasoning and ability to express a choice) are commonly assessed when determining DMC in psychiatry and uncertainty exists about the extent to which depression impacts capacity to make treatment or research participation decisions. METHODS A systematic review of the medical ethical and empirical literature concerning depression and DMC was conducted. Medline, EMBASE and PsycInfo databases were searched for studies of depression and consent and DMC. Empirical studies and papers containing ethical analysis were extracted and analysed. RESULTS 17 publications were identified. The clinical ethics studies highlighted appreciation of information as the ability that can be impaired in depression, indicating that emotional factors can impact on DMC. The empirical studies reporting decision-making ability scores also highlighted impairment of appreciation but without evidence of strong impact. Measurement problems, however, looked likely. The frequency of clinical judgements of lack of DMC in people with depression varied greatly according to acuity of illness and whether judgements are structured or unstructured. CONCLUSIONS Depression can impair DMC especially if severe. Most evidence indicates appreciation as the ability primarily impaired by depressive illness. Understanding and measuring the appreciation ability in depression remains a problem in need of further research.
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Owen GS, Szmukler G, Richardson G, David AS, Raymont V, Freyenhagen F, Martin W, Hotopf M. Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study. Br J Psychiatry 2013; 203:461-7. [PMID: 23969482 PMCID: PMC3844898 DOI: 10.1192/bjp.bp.112.123976] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 03/25/2013] [Accepted: 05/08/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients? AIMS To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice. METHOD A secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool - Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability. RESULTS Most people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P = 0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better 'test' of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P = 0.02). CONCLUSIONS Among those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting.
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Affiliation(s)
- Gareth S Owen
- Gareth S. Owen, PhD, MRCPsych, Department of Psychological Medicine, King's College London, Institute of Psychiatry, London, UK; George Szmukler, FRCPsych, Department of Health Service and Population Research, King's College London, Institute of Psychiatry, London, UK; Genevra Richardson, LLM FBA, School of Law, King's College London, UK; Anthony S. David, FRCPsych, Department of Psychological Medicine, King's College London, Institute of Psychiatry, London, UK; Vanessa Raymont, MRCPsych, Centre for Mental Health, Department of Medicine, Imperial College, London, UK, and Department of Radiology, Johns Hopkins University, USA; Fabian Freyenhagen, PhD, Wayne Martin, PhD, School of Philosophy and Art History, University of Essex, Wivenhoe Park, Essex, UK; Matthew Hotopf, PhD, MRCPsych, Department of Psychological Medicine, King's College London, Institute of Psychiatry, London, UK
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Hutton P, Morrison AP. Collaborative Empiricism in Cognitive Therapy for Psychosis: A Practice Guide. COGNITIVE AND BEHAVIORAL PRACTICE 2013. [DOI: 10.1016/j.cbpra.2012.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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End-of-life (care) perspectives and expectations of patients with schizophrenia. Arch Psychiatr Nurs 2013; 27:246-52. [PMID: 24070994 DOI: 10.1016/j.apnu.2013.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 04/23/2013] [Accepted: 05/05/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Schizophrenia is a disabling and life-shortening psychiatric disorder due to disease, medication, and lifestyle-related factors. It is therefore not unreasonable to assume that existential themes are important for these patients. METHODS Transcripts of 20 patients were coded and analyzed thematically, using a modified grounded theory approach in the exploration of perspectives and expectations of end-of-life (care). RESULTS No fear of death, skilled companionship and preserving quality of life were major themes in the interviews. CONCLUSION This study showed that patients, despite emotional flattening and cognitive deficits, find the possibility to discuss end-of-life topics reassuring and some even therapeutic.
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Gather J, Vollmann J. Physician-assisted suicide of patients with dementia. A medical ethical analysis with a special focus on patient autonomy. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:444-453. [PMID: 23850340 DOI: 10.1016/j.ijlp.2013.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
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.
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Affiliation(s)
- Jakov Gather
- Department of Psychiatry, LWL University Hospital, Ruhr-University Bochum, Germany.
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Vollmann J. [Compulsory treatment in psychiatry: an ethical analysis of the new legal regulations for clinical practice]. DER NERVENARZT 2013; 85:614-20. [PMID: 23979362 DOI: 10.1007/s00115-013-3866-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The new legal regulations of compulsory treatment in Germany require a change in clinical psychiatric practice as well as an ethical analysis of the consequences for those involved. MATERIALS AND METHODS The new legal regulations are reported and via ethical analysis new problematic fields, such as consequences of the new law are identified and discussed in the context of psychiatry and law. RESULTS The main ethical identified problems are care of mentally ill with mental competence who refuse medical treatment, the different normative assessment of compulsory treatment and mechanical fixation, the ambivalent role of the conversation between psychiatrist and patient in order to change the natural will of the patient to avoid compulsory measures, the ethical consequences of questionable financial incentives in the context of compulsory treatment and the contradictive legal regulations in the field. CONCLUSIONS The ethical analysis of the new law on compulsory treatment in Germany shows chances for improvement of clinical psychiatric practice as well as normative problematic regulations and fields of conflicts.
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Affiliation(s)
- J Vollmann
- Institut für Medizinische Ethik und Geschichte der Medizin, Ruhr-Universität Bochum, Markstr. 258a, 44799, Bochum, Deutschland,
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Abstract
The use of community treatment orders (CTOs) remains controversial despite their widespread use in a number of different countries. The focus of a CTO should be on individuals with severe and enduring mental disorders, typically requiring adherence with recommended outpatient treatment in the community and requiring that they allow access to members of the clinical team for the purpose of assessment. There is no current provision for CTOs under Irish mental health legislation, although patients who are involuntarily detained under the MHA 2001 (Ireland) can be granted approved leave from hospital. This provision allows for the patient to be managed in the community setting, though, while technically on leave, they remain as inpatients detained under the MHA 2001 (Ireland). This article describes the use of CTOs and considerations relating to their implementation. There is discussion of the ethical grounds and evidence base for their use. Ethical considerations such as balancing autonomy against health needs and the utilisation of capacity principles need to be weighed by clinicians considering the use of CTOs. Though qualitative research provides some support for the use of CTOs, there remains a clear lack of robust evidence based findings to support their use in terms of hospitalisation rates, duration of illness remission and improved social functioning.
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Use of a computerized medication shared decision making tool in community mental health settings: impact on psychotropic medication adherence. Community Ment Health J 2013; 49:185-92. [PMID: 22837104 DOI: 10.1007/s10597-012-9528-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 07/02/2012] [Indexed: 10/28/2022]
Abstract
Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes.
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