Assessment of Healthcare Decision-making Capacity

Neuropsychology's Role in Assessment of Medical Decision-Making Capacity, Home Safety, and Driving Ability

Individuals with neurologic illness/injury often experience changes in their daily functioning. Clinical providers caring for these individuals are frequently called upon for input as patients and their families navigate challenging decisions to ensure safety. This article reviews 3 areas in which recommendations from clinicians are often requested: medical decision-making, home safety, and driving. Strategies for making recommendations in these areas is offered including discussion of how neuropsychology evaluations can provide useful information to aid in making recommendations.

Capacity to consent: a scoping review of youth decision-making capacity for gender-affirming care

BACKGROUND

Transgender and gender expansive (TGE) youth often seek a variety of gender-affirming healthcare services, including pubertal suppression and hormone therapy requiring that TGE youth and their parents participate in informed consent and decision making. While youth must demonstrate the ability to understand and appreciate treatment options, risks, benefits, and alternatives as well as make and express a treatment choice, standardized approaches to assess the capacity of TGE youth to consent or assent in clinical practice are not routinely used. This scoping review identified the currently available data regarding adolescent capacity to consent to gender-affirming medical treatments.

METHODS

Articles relevant to assessing adolescent capacity for clinical decision-making were identified using OVID Medline, Web of Science, and PubMed. Articles were reviewed and thematically analyzed.

RESULTS

Eight relevant articles were identified using three tools for measuring adolescent clinical decision-making capacity: Measure of Understanding, Measure of Competence, and MacArthur Competence Assessment Tool (MacCAT). These studies explored hypothetical treatment decisions, mental health treatment decisions, HIV treatment decisions, genetic testing decisions, and gender-affirming medical decisions. Only one study specifically examines the capacity of TGE youth to consent to medical treatments. Age was correlated with capacity in most, but not all studies. Other studies found cognitive measures (IQ, literacy, numeracy) may impact important aspects of capacity (understanding and reasoning).

CONCLUSIONS

For clinicians caring for TGE youth, tools such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) may prove useful, in conjunction with consideration of youth developmental abilities and utilization of shared decision-making practices. A standardized, collaborative approach to assessing TGE youth capacity would benefit TGE youth and their parents, and allow clinicians to more easily resolve ethical concerns.

It's a spiral staircase, not just two steps: An iterative approach to assessing patient capacity for medical decision-making

The assessment of medical decision-making capacity as part of the process of clinical informed consent has been considered a bioethical housekeeping matter for decades. Yet in practice, the reality bears little resemblance to what is described in the medical literature and professed in medical education. Most literature on informed consent refers to medical decision-making capacity as a precondition to the consent process. That is, a clinician must first determine if a patient has capacity, and only then may the clinician engage with the patient for the rest of informed consent. The problem with this two-step approach is that it makes no sense in actual practice. We see the assessment of medical decision-making capacity within the process of informed consent as a spiral staircase, not just two steps, requiring clinicians to keep circling up and around, making progress, until they get to where they need to be: 1. Clinicians start with a general presumption of capacity for most adults, sometimes having a provisional appraisal of capacity based on prior patient contact. 2. Then, they begin performing informed consent for the current situation and intervention options. 3. Next, they must reassess capacity during this process. 4. After that, they continue with informed consent. 5. If capacity is not yet clear, they repeat 1-4.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

CONCLUSIONS

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

Critical Steps for Determining Capacity to Refuse Emergency Medical Services Transport: A Modified Delphi Study

OBJECTIVES

Emergency physicians without specialized Emergency Medical Services (EMS) training are often required to provide online medical oversight. One common ethical question faced by these physicians is the assessment for decision-making capacity in a patient who does not accept EMS transport to the hospital. We sought expert consensus for a standardized set of guiding questions and recommendations to ensure a rigorous and feasible capacity assessment.

METHODS

A modified Delphi method approach was used to achieve group consensus among expert individuals. Nineteen physician experts were recruited from across the country, representing populations totaling over 22 million and a variety of urban, suburban, and rural practice environments. Experts completed a Round 1 survey that included 19 questions surrounding best practices for capacity evaluation among patients refusing transport. The threshold for consensus was predefined as 80% agreement. Participants gathered virtually meeting where the results from the first round were shared with the group. Discussion generated new items and refined the language of existing items. Following the virtual meeting, a Round 2 survey was conducted, and voted on by the panel for the items that did not meet consensus in Round 1.

RESULTS

After the first round, 15 of 19 items reached consensus. Three of the items that met consensus were universally noted to require language modification for clarification. A large portion of the discussion involved the proper method of integrating patient concerns around ambulance transport (e.g., cost of transport, financial concerns, social barriers) into the capacity assessment and whether alternate care options should be discussed. After the second round of voting, one additional item was reversed to meet consensus, resulting in a total of 16 items.

CONCLUSIONS

A consensus expert panel was able to agree upon 16 standardized steps to guide best practices and assist emergency physicians in real-time evaluation of patients that refuse EMS transport.

Assessment of decision-making autonomy in chronic pain patients: a pilot study

BACKGROUND

Patient decision-making autonomy refers to the patients' ability to freely exert their own choices and make their own decisions, given sufficient resources and information to do so. In pain medicine, it is accepted that appropriate beneficial management aims to propose an individualized treatment plan shared with the patients, as agents, to help them live as autonomously as possible with their pain. However, are patients in chronic pain centers sufficiently autonomous to participate in the therapeutic decisions that concern them? As this question still remains unanswered, a pilot study was set up to that aim.

METHODS

Over a 2-month period, first-time patients within a tertiary multidisciplinary pain center underwent a systematic evaluation of their autonomy using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), considered the benchmark tool for measuring a patient's ability to consent to treatment. Demographic data and pain characteristics of the patients were collected and their respective attending pain physicians were asked to clinically assess their patients' degree of autonomy. Another physician, who had not participated in the initial patient evaluation, subsequently administered the MacCAT-T questionnaire to the same patients.

RESULTS

Twenty-seven patients were included during the study period (21 women and 6 men), with an average age of 50 years. The average duration of pain was 8 years. Based on their clinical experience, the 4 different pain physicians in charge of these patients considered that out of 25 assessed patients, 22 of them (89%) had full decision-making capacity, with no deficit in autonomy. According to the MacCAT-T results, only 13 of these 25 patients (48%) had no deficit, while 7 (26%) had a major deficit in autonomy. The only patient characteristic that appeared to be related to autonomy was pain type, specifically nociplastic pain. The average time taken to complete the test was 20 min, and patients were very satisfied with the interview.

CONCLUSION

Results from the present pilot study suggest that patients suffering from chronic pain do not appear to be entirely autonomous in their decision to consent to the proposed treatment plan according to the MacCAT-T questionnaire, and physicians seem to find it difficult to properly assess this competence in a clinical setting. Further studies with larger samples are needed to better evaluate this concept to improve the complex management of these patients.

Adolescents' healthcare decisional capacity in the clinical context: a theoretical study and model

OBJECTIVE

To provide a theoretical study and model for the bioethical foundations of the factors that influence adolescents' healthcare decisional capacity.

SOURCES

Materials from diverse sources, including indexed articles in recognized databases and official government documents, were examined for a purposefully selected sample. The research consisted of two stages: selection of documents and reflective thematic analysis, followed by the preparation of a report. The analysis adopted a phenomenological stance and a reflective view compatible with human rights. To reduce bias and ensure the robustness of the results, measures such as data triangulation were employed. Ethical measures were taken to ensure data integrity, including considerations of anonymity and conflicts of interest in the selected studies.

SUMMARY OF THE FINDINGS

It was possible to list intrinsic and extrinsic factors of the adolescent patient that influence their decisional capacity regarding health. A theoretical model was developed to discuss these factors for evaluation by means of an infographic.

CONCLUSIONS

It seems clear that the evaluation of healthcare decisional capacity of adolescents must position itself ethically regarding the tension between the moral duty to respect the self-determination of the able subject and the need to protect adolescents decidedly unable to make a specific health decision at a given time.

C-L Case Conference: Assessment of Dispositional Capacity in Medically Complex Patients

We present the case of a 76-year-old male with mild cognitive impairment and delirium who was referred to consultation-liaison psychiatry for an assessment of capacity to choose discharge. Cases involving "dispositional capacity" are complex and increasingly frequent, with momentous consequences for patients and their families, but are rarely discussed in the literature. In this article, experts in functional assessment, cognition, and ethics provide guidance for this commonly encountered clinical scenario based on their experience and available literature. We review the content and formulation of occupational and physical therapy assessments and their utility to the consultation-liaison psychiatrist. We also examine the relationship of cognitive impairment to decisional capacity and offer suggestions on a structured approach to evaluation. Finally, we discuss the ethical and systemic considerations of dispositional capacity and explore potential pitfalls that can lead to interprofessional conflict and missed opportunities in patient care.

Decisional Capacity After Dark: Is Autonomy Delayed Truly Autonomy Denied?

The model for capacity assessment in the United States and much of the Western world relies upon the demonstration of four skills including the ability to communicate a clear, consistent choice. Yet such assessments often occur at only one moment in time, which may result in the patient expressing a choice to the evaluator that is highly inconsistent with the patient's underlying values and goals, especially if a short-term factor (such as frustration with the hospital staff) distorts the patient's preferences momentarily. These challenges are particularly concerning in cases, which arise frequently in hospital settings, in which patients demand immediate self-discharge, often during off-hours, while faced with life-threatening risks. This paper examines the distinctive elements that shape such cases and explores their ethical implications, ultimately offering a model for such situations that can be operationalized.

Decision-Making Capacity in a Transgender Patient With Schizophrenia and Concerns for a Life-Threatening Skin Infection

Assessing patient decision-making capacity while adhering to the requests of patients with mental illness remains a great ethical challenge. In patients with severe mental illness, the assessment of decision-making capacity can be difficult, particularly when a care team is also trying to navigate cultural, educational, and linguistic barriers. It becomes especially complex in situations where the patient is not only diagnosed with a severe mental illness but also suffers from a comorbid medical illness that the patient refuses to have treated appropriately. Balancing patient wishes while respecting patient autonomy creates further issues when assessing decision-making capacity. As such, the following case presents a transgender man who suffers from schizophrenia with a persistent skin infection on the patient's torso secondary to wearing a brassiere for an extended period. This case report addresses the intricacies surrounding patient decision-making capacity, specifically in the psychiatric population.

Ethics rounds in the ambulance service: a qualitative evaluation

BACKGROUND

It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians' ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians' experiences of participating in ethics rounds.

METHODS

This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis.

RESULTS

Two themes describe the participants' experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue.

CONCLUSION

Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.

Hidden Fault Lines in the Bedrock: A Critical Examination of Surrogate Decision-Making Standards in Ethics Consultation

AbstractClinical ethicists are routinely consulted in cases that involve conflicts and uncertainties related to surrogate decision-making for incapacitated patients. To navigate these cases, we invoke a canonical ethical-legal hierarchy of decision-making standards: the patient's known wishes, substituted judgment, and best interest. Despite the routine application of this hierarchy, however, critical scholarly literature alleges that these standards fail to capture patients' preferences and surrogates' behaviors. Moreover, the extent to which these critiques are incorporated into consultant practices is unclear. In this article I thus explore whether, and how, existing critiques of the hierarchy affect the application of these standards during ethics consults. After discussing four critiques of the hierarchy, I examine how two prominent published ethics consultation methodologies-bioethics mediation and CASES-incorporate these critiques differently. I then argue that while both methodologies explicitly endorse the same hierarchy, the varying degrees to which these four criticisms are incorporated into the prescribed consultation process could produce different applications of the same standard. I demonstrate with a case study how an ethics consultant following either methodology might produce two substantively different recommendations despite using the same substituted judgment standard. I conclude that while this heterogeneity of application should not dismantle the hierarchy's status as field-wide canon, it complicates projects of professional ethics consultation consensus building.

Status Epilepticus and Low-Grade Glioma in the Pregnant State: Case Report and Ethical Considerations

Introduction

The pregnant state may cause or exacerbate existing neurological disease. Gliomas appear to be influenced by the physiological changes that occur during pregnancy. The pregnant state may also cause seizures, including status epilepticus. There are currently no defined treatment guidelines to direct clinical decision making, and many of the commonly employed therapies are contraindicated during pregnancy.

Case Presentation

The current article describes the case of a 40-year-old G3P1101 female at 10 weeks' gestation, who sought medical care for recurrent left hemifacial twitching, eventually leading to nonconvulsive status epilepticus. Intubation and sedation were required to achieve seizure cessation. Imaging revealed a lobulated cystic mass in the right parietal lobe, suspicious for low-grade glioma. Despite thorough explanation of the potential risks, the patient adamantly wished to pursue surgical intervention. An uneventful craniotomy was performed for resection of a low-grade glioma. No patient or fetal complications were encountered, and the patient has not had any reported seizures since surgery.

Discussion

Managing complex neurosurgical diseases in pregnant patients provides both clinical and ethical quandaries. We describe the successful management of a patient presenting with status epilepticus caused by an underlying glioma during pregnancy. Although challenging, favorable neurosurgical outcomes are possible during pregnancy.

Informed consent for image-guided procedures: a nationwide survey of perceptions and current practices

AIM

To characterise the current landscape of informed consent practices for image-guided procedures, including location of consent, guideline availability, and utility of decision-aid resources.

MATERIALS AND METHODS

A survey of 159 interventional radiologists was conducted from April through June 2022. The survey evaluated participant demographics (gender, practice type, and level of training) and consent practices. Fifteen questions investigated discussion of benefits, risks, and alternatives, who obtained consent, location of consent conversations, how decision-making capacity is assessed, availability of formal guidance on consent discussions, and if and how decision-aids are used.

RESULTS

Most respondents (93.7%) were "extremely" or "very" comfortable discussing the benefits and risks of image-guided procedures during informed consent. Most respondents were "very" comfortable discussing alternative treatments within radiology (86.8%) while fewer felt confident regarding alternatives outside radiology (46.5%). Most respondents indicated obtaining consent in a pre-procedure area (89.9%), while 12.7% of respondents obtained consent in the procedure room. Of the respondents, 66.7% did not have formal education or documented guidance on what providers should disclose during consent. Ninety-two respondents (57.9%) reported using decision aids. The type of decision aid varied, with most reporting using illustrations or drawings (46.6%). Decision aid utility was more prevalent in non-teaching/academic (71.4%) versus academic (61%) institutions (p=0.02).

CONCLUSION

Regardless of demographics, interventionalists are confident in discussing benefits, risks, and alternative image-guided therapies, but are less confident discussing alternative treatment options outside of radiology. Formal education on informed consent is less common, and the use of decision aids varies between teaching and non-teaching institutions.

Ethical considerations for the use of artificial intelligence in medical decision-making capacity assessments

The rapid advancement of artificial intelligence (AI) and machine learning are providing new tools to clinicians. AI tools have the potential to process vast amounts of data in a short amount of time, providing new insights and changing how we approach complicated healthcare problems. AI has the potential to assist clinicians in medical decision-making capacity assessments by providing additional insights to an evaluation process that currently lacks universal objective standards. However, despite the promise of AI in this setting, there remain significant concerns making it unlikely to replace human evaluators anytime soon. AI remains highly susceptible to biased inputs and thus biased decisions, raises questions about autonomy, and creates uncertainty for who is accountable for the ultimate decision of capacity. In this paper we explore these ethical considerations of using AI for capacity assessments. While we acknowledge AI may not be ready to replace physicians in determining patient medical-decision making capacity, these new technologies have significant near-term potential as a tool to screen patients, uncover physician biases, and guide next steps after a capacity determination has been made.

Adaptations of the balloon analog risk task for neuroimaging settings: a systematic review

Introduction

The Balloon Analog Risk Task (BART), a computerized behavioral paradigm, is one of the most common tools used to assess the risk-taking propensity of an individual. Since its initial behavioral version, the BART has been adapted to neuroimaging technique to explore brain networks of risk-taking behavior. However, while there are a variety of paradigms adapted to neuroimaging to date, no consensus has been reached on the best paradigm with the appropriate parameters to study the brain during risk-taking assessed by the BART. In this review of the literature, we aimed to identify the most appropriate BART parameters to adapt the initial paradigm to neuroimaging and increase the reliability of this tool.

Methods

A systematic review focused on the BART versions adapted to neuroimaging was performed in accordance with PRISMA guidelines.

Results

A total of 105 articles with 6,879 subjects identified from the PubMed database met the inclusion criteria. The BART was adapted in four neuroimaging techniques, mostly in functional magnetic resonance imaging or electroencephalography settings.

Discussion

First, to adapt the BART to neuroimaging, a delay was included between each trial, the total number of inflations was reduced between 12 and 30 pumps, and the number of trials was increased between 80 and 100 balloons, enabling us to respect the recording constraints of neuroimaging. Second, explicit feedback about the balloon burst limited the decisions under ambiguity associated with the first trials. Third, employing an outcome index that provides more informative measures than the standard average pump score, along with a model incorporating an exponential monotonic increase in explosion probability and a maximum explosion probability between 50 and 75%, can yield a reliable estimation of risk profile. Additionally, enhancing participant motivation can be achieved by increasing the reward in line with the risk level and implementing payment based on their performance in the BART. Although there is no universal adaptation of the BART to neuroimaging, and depending on the objectives of a study, an adjustment of parameters optimizes its evaluation and clinical utility in assessing risk-taking.

Tools for measuring individual self-care capability: a scoping review

BACKGROUND

Our ability to self-care can play a crucial role in the prevention, management and rehabilitation of diverse conditions, including chronic non-communicable diseases. Various tools have been developed to support the measurement of self-care capabilities of healthy individuals, those experiencing everyday self-limiting conditions, or one or more multiple long-term conditions. We sought to characterise the various non-mono-disease specific self-care measurement tools for adults as such a review was lacking.

OBJECTIVE

The aim of the review was to identify and characterise the various non-mono-disease specific self-care measurement tools for adults. Secondary objectives were to characterise these tools in terms of their content, structure and psychometric properties.

DESIGN

Scoping review with content assessment.

METHODS

The search was conducted in Embase, PubMed, PsycINFO and CINAHL databases using a variety of MeSH terms and keywords covering 1 January 1950 to 30 November 2022. Inclusion criteria included tools assessing health literacy, capability and/or performance of general health self-care practices and targeting adults. We excluded tools targeting self-care in the context of disease management only or indicated to a specific medical setting or theme. We used the Seven Pillars of Self-Care framework to inform the qualitative content assessment of each tool.

RESULTS

We screened 26,304 reports to identify 38 relevant tools which were described in 42 primary reference studies. Descriptive analysis highlighted a temporal shift in the overall emphasis from rehabilitation-focused to prevention-focused tools. The intended method of administration also transitioned from observe-and-interview style methods to the utilisation of self-reporting tools. Only five tools incorporated questions relevant to the seven pillars of self-care.

CONCLUSIONS

Various tools exist to measure individual self-care capability, but few consider assessing capability against all seven pillars of self-care. There is a need to develop a comprehensive, validated tool and easily accessible tool to measure individual self-care capability including the assessment of a wide range of self-care practices. Such a tool could be used to inform targeted health and social care interventions.

US clinicians' perspectives on advance care planning for persons with dementia: A qualitative study

BACKGROUND

Although advance care planning (ACP) for persons with dementia (PWD) can promote patient-centered care by aligning future healthcare with patient values, few PWD have documented ACPs for reasons incompletely understood. The objective of this paper is to characterize the perceived value of, barriers to, and successful strategies for completing ACP for PWD as reported by frontline clinicians.

METHODS

Qualitative study using semi-structured interviews (August 2018-December 2019) with clinicians (physicians, nurse practitioners, nurses, social workers) at 11 US health systems. Interviews asked clinicians about their approaches to ACP with PWDs, including how ACP was initiated, what was discussed, how carepartners were involved, how decision-making was approached, and how decision-making capacity was assessed.

RESULTS

Of 75 participating generalist and specialty clinicians from across the United States, 61% reported conducting ACP with PWD, of whom 19% conducted ACP as early as possible with PWD. Three themes emerged: value of early ACP preserves PWD's autonomy in cases of differing PWD carepartner values, acute medical crises, and clinician paternalism; barriers to ACP with PWD including the dynamic and subjective assessment of patient decision-making capacity, inconsistent awareness of cognitive impairment by clinicians, and the need to balance patient and family carepartner involvement; and strategies to support ACP include clarifying clinicians' roles in ACP, standardizing clinicians' approach to PWD and their carepartners, and making time for ACP and decision-making assessments that allow PWD and carepartner involvement regardless of the patients' capacity.

CONCLUSIONS

Clinicians found early ACP for PWD valuable in promoting patient-centered care among an at-risk population. In sharing their perspectives on conducting ACP for PWD, clinicians described challenges that are amenable to changes in training, workflow, and material support for clinician time. Clinical practices need sustainable scheduling and financial support models.

Persons with mental disorders and assisted dying practices in Spain: An overview

On 25 June 2021, the Law on Euthanasia in Spain came into force, providing for two modes of helping an individual end their life: euthanasia and/or medically assisted suicide. Among the requisites that a request for euthanasia has to fulfil are that the individual must be suffering a severe, chronic and debilitating condition or a severe and incurable disease, at the same time as that person shows the necessary competence to decide. The possibility exists that a patient suffering mental health problems submits such a request; however, the specific characteristics of a mental health disorder make such a request considerably more complex. In this article, based on a narrative review of the law itself and the related literature, the requisites established under the law are analysed from an ethical-legal perspective with the aim of defining when a request for euthanasia from a person with a mental health disorder may be deemed legitimate and in line with legal provisions. This should help clinicians make rational, reasoned decisions when dealing with a request of this type.

A Leg to Stand On: Working With Marginal Decision-making Capacity in a Patient With a Severe Leg Infection and Schizophrenia

Assessment of a patient's capacity to make treatment decisions and working with the wishes of a patient with mental illness against the best medically indicated plan is a complex and dynamic task. It is particularly challenging when the course of deterioration of the illness is meandering and slow, and the time horizon for recovery is uncertain, providing no clear point of entry for definitive crisis intervention. High-impact decisions concerning body integrity, such as the amputation of a leg, further complicate the task. To highlight these challenges and complexities, we present the case of a man who suffered from schizophrenia, with a worsening diabetic foot ulcer and suboptimal acceptance of proper wound care. The patient died as a result of his refusal of a proposed amputation to address his life-threatening infection. Medical system and cultural issues are also considered.

Nurse Managers' Involvement in Decision-Making and Associated Factors in Selected Government Hospitals, Addis Ababa, Ethiopia: A Cross-Sectional Study

Introduction

In the healthcare system, nurse managers' participation in decision-making was invaluable in preserving cost-effective service and safe patient care. Despite the fact that nurse managers have the power to ensure optimal health care service, their involvement in decision-making has not been well studied.

Objectives

To assess nurse managers' decision-making involvement and associated factors working in selected governmental hospitals in Addis Ababa, Ethiopia 2021.

Methods

A cross-sectional study was conducted among 176 nurse managers from government hospitals in Addis Ababa, with a response rate of 168 (95.5%). The total sample size is assigned in proportion. The technique of systematic random sampling was used. A structured, self-administered questionnaire was used to collect data, which was then checked, cleaned, entered into EPI Info version 7.2, and exported to SPSS software version 25 for analysis. In a binary logistic regression model analysis, a p-value < .25 was used as the cut-off point to consider variables as candidates for multivariable analysis. A p-value of .05 was used to determine the predictor variables with a 95% confidence interval.

Result

The mean age and standard deviation of the 168 respondents were 34.9 ± 4.1 years. More than half, 97 (57.7%), were excluded from general decision-making. Nurse managers in matron positions were 10 times more likely to participate in decision-making than head nurses (AOR = 10.00, 95% CI: 1.14-87.72, p = .038). Nurse managers who received managerial support were five times more likely to participate in good decision-making than nurse managers who did not receive managerial support (AOR = 5.29, 95% CI: 1.208-23.158, p = .027). Nurse managers who received feedback on their decision-making involvement had 7.7 times more good decision-making involvement than those who did not (AOR = 7.70, 95% CI: 2.482-23.911, p = .000).

Conclusion

According to the findings of the study, the majority of nurse managers were not involved in decision-making.

Consent in Interventional Radiology-How Can We Make It Better?

Informed consent is an important part of the clinician-patient relationship. However, studies suggest consent practices tend to be limited in consistency and completeness. This may be particularly challenging for interventional radiology given more limited public awareness and the often fast-paced, dynamic nature of our practices. This article reviews these challenges as well as ideal consent practices and potential approaches to improve consent in interventional radiology.

Anything You Do Not Say Can Be Used against You: Volitional Refusal to Engage in Decisional Capacity Assessment

AbstractThe most widely accepted model of decisional capacity assessment requires that a patient communicate a clear and consistent choice to the evaluator. This approach works effectively when patients prove unable to express a choice owing to physical, psychological, or cognitive limitations. In contrast, the approach raises ethics concerns when applied to patients who volitionally refuse to communicate a choice. This article examines the ethical issues that arise in such cases and offers a rubric for addressing decisional capacity under such circumstances.

Healthcare decision-making capacity in old age: A qualitative study

Objectives

Research about decision-making capacity has been growing in the last decades. That relates to more concerns regarding patients' autonomy, and an increase in diseases that can negatively impact capacity. This research aims to: explore perceptions, legal aspects, and assessment procedures related to healthcare decision-making capacity in older adults with cognitive impairment; and study the first version of a new assessment instrument of this capacity.

Method

Nine focus groups were conducted, including healthcare, law and justice, nursing home professionals, institutionalized older adults, and dwelling older adults. Focus group discussions followed semi-structured interview scripts, specifically developed for each group. After group discussions, the assessment instrument was presented, and participants were asked to evaluate each item relevance and comprehensibility. Qualitative coding of the transcriptions was performed with resource to MAXQDA, using direct content analysis.

Results

Six primary themes emerged from the qualitative analysis: Decision-making capacity features; Abilities implied in decision-making; Factors influencing decision-making; Obstacles to decision-making; Legal aspects; and Assessment procedures.

Discussion

Results corroborate previous theoretical formulations of capacity. Generally, research results have implications for clinical and assessment practices, as well as preventive strategies that can improve older adult's decision-making capacity. Assessment procedures of capacity should include a thorough protocol for the assessment of cognition, functionality, depressive symptoms, and decision-making abilities. In this respect, the need for an assessment tool that can provide valid information during evaluation processes is highlighted. Concerning the strategies to promote decision-making capacity, these rely on improving older adult's health literacy and healthcare providers communication skills, as well as conduct actions to reduce stigma toward people with dementia.

Patients' Choice, Consent, and Ethics in Patient Blood Management

The goal of patient blood management (PBM) is to optimize clinical outcomes for individual patients by managing their blood as a precious and unique resource to be safeguarded and managed judiciously. A corollary to successful PBM is the minimization or avoidance of blood transfusion and stewardship of donated blood. The first is achieved by a multidisciplinary approach with personalized management plans shared and decided on with the patient or their substitute. It follows that the physician-patient relationship is an integral component of medical practice and the fundamental link between patient and doctor based on trust and honest communication. Central to PBM is accurate and timely diagnosis based on sound physiology and pathophysiology as the bedrock on which scientifically based medicine is founded. PBM in all disease contexts starts with the questions, "What is the status of the patient's blood?" "If there are specific abnormalities in the blood, how should they be managed?" and "If allogeneic blood transfusion is considered, is there no reasonable alternative therapy?" There are compelling scientific reasons to implement a nontransfusion default position when there is clinical uncertainty and questionable evidence of clinical efficacy for allogeneic blood transfusion due to known potential hazards. Patients must be informed of their diagnosis, the nature, severity and prognosis of the disease, and treatment options along with risks and benefits. They should be involved in decision-making regarding their management. However, as part of this process, there are multifaceted medical, legal, ethical, and economic issues, encompassing shared decision-making, patient choice, and informed consent. Furthermore, variability in patient circumstances and preferences, the complexity of medical science, and the workings of health care systems in which consent takes place can be bewildering, not only for the patient but also for clinicians obtaining consent. Adding "patient" to the concept of blood management differentiates it from "donor" blood management to avoid confusion and the perception that PBM is a specific medical intervention. Personalized PBM is tailoring the PBM to the specific characteristics of each patient. With this approach, there should be no difficulty addressing the informed consent and ethical aspects of PBM. Patients can usually be reassured that there is nothing out of order with their blood, in which case the focus of PBM is to keep it that way. In some circumstances, a hematologist may be involved as a patient's blood advocate when abnormalities require expert involvement while the primary disease is being managed.

Ageism, human rights and ethical aspects of end-of-life care for older people with serious mental illness

There are many complex concepts to consider during end-of-life discussions and advance care planning, especially when vulnerable populations such as older individuals with serious mental illness are involved. This article aims to summarize some of these important concepts, such as the effects of ageism, preservation of human rights and dignity, supported or shared decision making and palliative approaches. It emerged from a study that found two thirds of 100 participants 60 years of age and older with serious mental illness had end-of-life decision-making capacity. This finding highlighted the individual and contextual nature of decision-making capacity, the importance of consideration of individual values and protection of human dignity during end-of-life care. Healthcare providers have a duty to initiate end-of-life and advance care discussions, to optimize decision-making capacity, and to protect autonomous decision-making. Chronological age or diagnostic categories should never be used as reasons for discrimination and all patients should receive end-of-life care in keeping with their preferences and values.

Decisional capacity to consent to treatment and research in patients affected by Mild Cognitive Impairment. A systematic review and meta-analysis

OBJECTIVES

To perform a meta-analysis of clinical studies on the differences in treatment or research decision-making capacity among patients with Mild Cognitive Impairment (MCI), Alzheimer's disease (AD), and healthy comparisons (HCs).

DESIGN

A systematic search was conducted on Medline/Pubmed, CINAHL, PsycINFO, Web of Science, and Scopus. Standardized mean differences and random-effects model were used in all cases.

SETTING

The United States, France, Japan, and China.

PARTICIPANTS

Four hundred and ten patients with MCI, 149 with AD, and 368 HCs were included.

MEASUREMENTS

The studies we included in the analysis assessed decisional capacity to consent by the MacArthur Competence Assessment Tool for Treatment (MAcCAT-T), MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), Capacity to Consent to Treatment Instrument (CCTI), and University of California Brief Assessment of Capacity to Consent (UBACC).

RESULTS

We identified 109 potentially eligible studies from 1672 records, and 7 papers were included in the meta-analysis. The meta-analysis showed that there was significant impairment in a decision-making capacity in MCI patients compared to the HCs group in terms of Understanding (SMD = -1.04, 95% CI: -1.31 to -0.77, P < 0.001; I² = 52%, P = 0.07), Appreciation (SMD = -0.51, 95% CI: -0.66 to -0.36, P < 0.001; I² = 0%, P = 0.97), and Reasoning (SMD = -0.62, 95% CI: -0.77, -0.47, P < 0.001; I²=0%, P =0.46). MCI patients scored significantly higher in Understanding (SMD = 1.50, 95% CI: 0.91, 2.09, P = 0.01, I² = 78%, P = 0.00001) compared to patients affected by AD.

CONCLUSIONS

Patients affected by MCI are at higher risk of impaired capacity to consent to treatment and research compared to HCs, despite being at lower risk compared to patients affected by AD. Clinicians and researchers need to carefully evaluate decisional capacity in MCI patients providing informed consent.

Psychometric properties of the end-of-life care decision inventory (EOL-CDI): a mixed-methods study

Background

End-of-life care decision-making has become important to support dignity and quality of life for patients who are facing death in Korea, along with the enactment of the Life-Sustaining Treatment Act in 2018. However, it seems that the concepts and policies related to the law are not yet familiar to health care providers or the general public. This unfamiliarity can hinder efficient end-of-life care discussions. Therefore, the purpose of this study was to propose a valid and reliable tool to explore the level of understanding of concepts and attributes related to end-of-life care decisions.

Methods

This is a mixed-methods study design. A relevant law and literature analysis, expert consultation, cognitive interviews of 10 adults, and cross-sectional survey for psychometric tests using data from 238 clinical nurses were performed to update a tool developed before the life-sustaining treatment Act was enacted in Korea.

Results

29 items of the draft version were polished in terms of literacy, total length, and scoring method via cognitive interviews and finalized into 21 items through psychometric tests and expert consultations. The 21 items conformed to the Rasch unidimensional paramenters.

Conclusion

A tool to identify the level of understanding of concepts related to end-of-life care decisions was proposed through a rather rigorous process to ensure feasibility and validity/reliability. We recommend the proposed tool to apply to the adult population and nurses for evaluation and educational purposes.

Decision-Making Capacity in Healthcare: Instruments Review and Reflections About its Assessment in the Elderly with Cognitive Impairment and Dementia

The prevalence of neurodegenerative diseases has been significantly increasing in the last decades, and it is expected to continue to grow. These health disorders can impair patients' decision-making capacity in healthcare. The capacity to make healthcare decisions is a fundamental pillar of informed consent, therefore, it should be carefully assessed. Clinicians' assessment, when not supported by a standardized tool, has revealed to be unreliable, so the recourse to an instrument of capacity assessment is crucial. The present paper aims to identify and summarize published instruments of healthcare decision-making capacity. To do so, a search of peer-reviewed articles in English, Portuguese and Spanish was conducted. A total of eighteen articles, detailing seventeen assessment instruments were selected. Instruments differ on format, structure, assessed abilities and psychometric properties. Likewise, instruments' targeted population also varies, with a few being specifically developed for patients with dementia. Although a high number of instruments were found, there is still no gold standard for healthcare decision-making capacity assessment. The lack of a gold standard highlights the need for more research in this field, as well as an effort to develop guidelines and normative data, in order to improve clinical practices.

Patterns of impairment in decision-making capacity in Alzheimer's disease and its relationship with cognitive and clinical variables

OBJECTIVES

To investigate the patterns of impairment in decision-making abilities and their relationship with cognitive and clinical symptoms in people with Alzheimer's disease. We hypothesized that decision-making abilities would not be impaired at the same level and would be related to impairment of global cognition and other clinical symptoms of the disease.

METHODS

Using a cross-sectional design, we included a consecutive sample of 102 people with Alzheimer's disease and their respective caregivers. We investigated the relationship between decision-making capacity and quality of life (QoL), disease awareness, mood, functionality, neuropsychiatric symptoms, and cognition.

RESULTS

Different levels of impairment were observed in the participants' decision-making abilities. Understanding, appreciation, and reasoning were correlated, but expressing a choice was only correlated with appreciation. Deficits in understanding were related to impaired disease awareness, lower self-reported QoL, and lower comprehension of spoken language. Better appreciation was related to better orientation and lower age. Better reasoning was related to better orientation and better self-reported QoL. Deficits in expressing a choice were related to lower self-reported QoL.

CONCLUSION

The pattern of impairment in decision-making abilities was not linear. Each decision-making ability was related to different cognitive and clinical deficits. Therefore, cognitive functioning is an insufficient criterion for judging an individual's decision-making ability.

Ethical considerations in the management of poststroke aphasia

From the onset of the first signs of stroke, patients are faced with a chain of events that requires quick decision-making to ensure that lifesaving care is administered. Considering that acute stroke is often associated with altered mental status and changes in cognitive-linguistic abilities, ethical dilemmas may arise when patients are unable to provide input in their own care and must rely on surrogate decision-makers to act on their behalf. Although the most critical, lifesaving decisions are made acutely, for the patients who go on to have residual chronic cognitive-linguistic deficits, loss of language, and/or impaired cognition may mean that a healthcare power of attorney or other proxy is needed to assist with medical decision-making. This chapter discusses ethical concerns surrounding the care of stroke survivors, with a focus on how poststroke cognitive-linguistic deficits can complicate this topic; clinical recommendations are provided.

Key concepts and opportunities

Neuropalliative care is an emerging field dedicated to applying palliative care approaches to meet the needs of persons living with neurologic illness and their families. The development of this field acknowledges the unique needs of this population, including in terms of neuropsychiatric symptoms, the impact of neurologic illness on personhood, and the logistics of managing neurologic disability. In defining the goals of this field, it is important to distinguish between neuropalliative care as an approach to care, as a skillset, as a medical subspecialty, and as a public health goal as each of these constructs offers their own contributions and opportunities. As a newly emerging field, there are nearly unlimited opportunities to improve care through research, clinical care, education, and advocacy.

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

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

Reconsidering research exclusion for serious mental illness: Ethical principles, current status, and recommendations

BACKGROUND

Historically, individuals managing serious mental illness (SMI) have often been excluded from research, typically because of concern that these individuals may not be able to understand and provide truly informed consent. As treatment has improved, the assumption that individuals managing SMI may not be capable of consent needs to be re-examined. Systematic exclusion from research may limit empirically tested treatments available for people managing SMI, and may contribute to the health care disparities seen in this population.

OBJECTIVES

This article examines this issue by documenting current rates of research exclusion for high disease burden conditions, based on empirical review of studies in ClinicalTrials.gov.

RESEARCH DESIGN

Current rates of exclusion from studies for psychiatric conditions were assessed through systematic review of relevant clinical trials on ClinicalTrials.gov.

SUBJECTS

Subjects in this inquiry are either articles accessed in the literature reviews, or descriptions of studies in public data on ClinicalTrials.gov.

MEASURES

The primary measure was a previously published coding system to document the extent and types of research exclusion related to psychiatric status.

RESULTS

Among studies of interventions for substance use disorders and chronic pain, individuals managing SMI were more likely to be excluded than those with other psychiatric disorders at statistically significant levels. This was not the case among studies of interventions for ischemic heart disease. In studies of substance use disorders, 9% explicitly excluded SMI and 83% could exclude people with SMI based on broader exclusion criteria. In studies of chronic pain these two categories of exclusion were 16% and 55%, and in studies of ischemic heart disease, these two categories of exclusion were 1% and 20%.

CONCLUSIONS

Evidence indicates that it is ethically and scientifically more appropriate to exclude based on capacity to consent than membership in the group of individuals managing SMI. The discussion outlines techniques researchers can use for more equitable and generalizable sampling.

Research Involving Participants With Impaired Consent Capacity: An Examination of Methods to Determine Capacity to Consent

OBJECTIVE

To examine methods of assessing consent capacity in research protocols involving participants with impaired consent capacity, and examine instruments used to evaluate research consent capacity.

METHODS

A retrospective review of 330 active research protocols involving participants lacking capacity to consent over a 10-year period (January 1, 2009, through March 1, 2019) was conducted to collect protocol characteristics (medical specialty, level of risk and type of study, consent and assent procedures, and type of vulnerable or protected population). Methods to assess consent capacity are described, and instruments to assess consent capacity are summarized.

RESULTS

The specialties most frequently involving participants with impaired consent capacity in research were Neurology (27.3%), Critical Care (16.7%), and Surgery (10%). Type of studies are observational (43.9%), clinical trials (33%), chart review (11.5%), biobank (6.1%), and biomarker (5.5%). Minimal risk (53.3%) outnumbered greater than minimal risk (46.7%) studies. Most obtained written informed consent (77%) and assent (40.9%). The most common method to assess consent capacity was direct assessment by investigators (32.7%). Only 86 (26%) studies used instruments to assess consent capacity. Of the 13 instruments used, the most common was the Evaluation of Decision-Making Capacity for Consent to Act as a Research Subject, and is the only instrument that assesses all four components of decisional capacity: understanding, appreciation, reasoning, and choice.

CONCLUSION

Generally, there was lack of uniformity in determining capacity to consent to research participation. Very few studies used instruments to assess consent capacity. Institutional review boards can provide greater guidance for research consent capacity determination.

Perceived barriers to assessing understanding and appreciation of informed consent in clinical trials: A mixed-method study

Introduction:

Participants and research professionals often overestimate how well participants understand and appreciate consent information for clinical trials, and experts often vary in their determinations of participant’s capacity to consent to research. Past research has developed and validated instruments designed to assess participant understanding and appreciation, but the frequency with which they are utilized is unknown.

Methods:

We administered a survey to clinical researchers working with older adults or those at risk of cognitive impairment (N = 1284), supplemented by qualitative interviews (N = 60).

Results:

We found that using a validated assessment of consent is relatively uncommon, being used by only 44% of researchers who had an opportunity. Factors that predicted adoption of validated assessments included not seeing the study sponsor as a barrier, positive attitudes toward assessments, and being confident that they had the resources needed to implement an assessment. The perceived barriers to adopting validated assessments of consent included lack of awareness, lack of knowledge, being unsure of how to administer such an assessment, and the burden associated with implementing this practice.

Conclusions:

Increasing the use of validated assessments of consent will require educating researchers on the practice and emphasizing very practical assessments, and may require Institutional Review Boards (IRBs) or study sponsors to champion the use of assessments.

Anxiety Impacts Consent Capacity to Treatment in Alzheimer's Disease

This study aimed to clarify how behavioral and psychological symptoms of dementia (BPSD) and cognitive function affect the decision-making capacity of persons with Alzheimer's disease (AD) in a real informed consent situation about anti-dementia drug prescriptions. The participants were 76 patients with AD. We used the MacArthur Competence Assessment Tool to assess the capacity for consent to treatment (MacCAT-T). We simultaneously used the Mini-Mental State Examination, Executive Interview, Executive Clock Drawing Task, Logical Memory I of the Wechsler Memory Scale-Revised (LM I), LM II, and Neuropsychiatric Inventory (NPI) to assess cognitive function and psychiatric symptoms. We calculated the correlations between the MacCAT-T scores and the demographic, neuropsychological, and psychiatric variables. Once the univariable correlations were determined, we performed simple linear regression analyses to examine if the regression equations were significant. In the final analyses, we incorporated significant variables into stepwise multiple linear regression analyses to determine the most significant predictors of mental capacity. Age (β = −0.34), anxiety (β = −0.27), and LM I (β = 0.26) were significant predictors of “understanding” (adjusted R² = 0.29). LM II (β = 0.39), anxiety (β = −0.29), and education (β = 0.21) were significant predictors of “understanding of alternative treatments” (adjusted R² = 0.30). Anxiety (β = −0.36) and age (β = −0.22) were significant predictors of “appreciation” (adjusted R² = 0.18). Age (β = −0.31) and anxiety (β = −0.28) were significant predictors of explained variance in “reasoning” (adjusted R² = 0.17). Patients with anxiety had lower scores on all five MacCAT-T subscales: “understanding,” without 3.8 [SD = 1.2] vs. with 2.6 [SD = 1.1]; “understanding of alternative treatments,” without 2.9 [SD = 2.2] vs. with 1.3 [SD = 1.8]; “appreciation,” without 2.9 [SD = 1.1] vs. with 1.9 [SD = 1.2]; “reasoning,” without 4.0 [SD = 2.0] vs. with 2.7 [SD = 1.7]; and “expressing a choice,” without 1.9 [SD = 0.4] vs. with 1.5 [SD = 0.6]. Considering the effects of BPSD, cognitive function, and age/education when assessing consent capacity in persons with AD is important. Reducing anxiety may contribute to improved capacity in persons with AD.

Thinking without speaking: Neuropsychological testing with individuals who have communication impairments

PURPOSE

Cognitive ability may be masked by communication impairments. This study aimed to assess cognitive functioning using binary choice (i.e., yes/no) neuropsychological tests in patients with communication impairments. Four participants underwent neuropsychological testing. Two participants were in the minimally conscious state (MCS), one participant had locked-in syndrome and was an alternative communication user, and one participant was an augmentative communication user. There was better performance in all cognitive domains for the augmentative and alternative communication (AAC) users (who performed like the non-communication impaired normative data) compared to the MCS participants. However, using established yes/no communication methods, MCS participants performed above chance on a measure of memory and performance on measures of auditory comprehension was variable. Auditory comprehension appeared to be more influenced by working memory demands for the MCS participants than for the AAC users. For emotional functioning, the AAC users endorsed lower mood compared to the MCS participants. The results support the need to assess cognition, communication, as well as capacity in individuals with communication impairments with the consultation of a neuropsychologist and a speech-language pathologist.

Limitations of Traditional Models for Medical Decision-Making Capacity and Ethical Clinical Practice in Light of the SARS-CoV-2 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has upended psychiatric practice and poses unprecedented challenges for maintaining access to quality care. We discuss the ethical challenges of treating a patient with schizophrenia in need of hospitalization but who declined severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) surveillance testing. The traditional framework of capacity assessment depends on the patient’s ability to weigh risks and benefits, but this framework is of limited utility in context of the COVID-19 pandemic; the personal benefits of testing for the patient are unclear and in fact may not outweigh the risk of being declined psychiatric care. Moreover, classic capacity assessment does not well account for physicians’ obligations to other patients and the public health. We conclude that physicians cannot coerce surveillance testing, and we consider the implications of requiring SARS-CoV-2 testing for accessing mental health treatment.

What Is the Capacity of Individuals with Schizophrenia and Bipolar Disorder to Make Healthcare Decisions? An Exploratory Study of the Views of Patients, Psychiatrists, and Family Caregivers—A Survey on Decisional Capacity in Mental Health

Background: Research on the decisional capacity of schizophrenia and bipolar disorder patients mostly reflects the hospital context. Aim: To describe the views of patients, psychiatrists, and caregivers on the capacity of individuals with schizophrenia and bipolar disorder to make everyday decisions on their care related to their illness. Methods: A survey was conducted among schizophrenia and bipolar disorder patients, psychiatrists, and caregivers (June 2019 to January 2020; seven countries). A questionnaire was emailed to members of the Global Alliance of Mental Illness of Advocacy Network—Europe (GAMIAN; patients) and the European Federation of Families of People with Mental Illness (EUFAMI; caregivers) and to psychiatrists who voluntarily agreed to participate. Questions referred to patients’ involvement and capacity for healthcare decision making, and to barriers to and opportunities for autonomous decision making. Frequency, agreement, and importance were rated on Likert scales. Descriptive statistics were conducted. Results: 21 schizophrenia or bipolar disorder patients (52.3% female; mean age (years) ± SD: 50.71 ± 12.02), 11 psychiatrists (18.2% female), and 15 caregivers (86.6% female; 100% family related) participated in the survey. In total, 86% of patients felt frequently involved in decisions about everyday care and medications, and 91% of psychiatrists and 40% of caregivers perceived the same; 38% of patients felt frequently involved in decisions about the use of acute symptom medications, and 57% on care planning, and 55% and 82% of psychiatrists, and 40% and 53% of caregivers, respectively, believed the same; and 86% of patients, 91% of psychiatrists, and 47% of caregivers agreed on the capacity of schizophrenia or bipolar disorder patients to value the implications of taking medicines to prevent acute psychotic crises. Poor understanding and training are barriers, while advocacy and increasing interest in patients’ needs are opportunities for increasing autonomous decision making. Conclusions: Stakeholders concur that schizophrenia and bipolar disorder patients have the capacity to make everyday decisions around their care related to their illness, including acute symptom management. Barriers and opportunities exist to foster autonomous decisions among mental illness individuals.

This Wasn't a Split-Second Decision": An Empirical Ethical Analysis of Transgender Youth Capacity, Rights, and Authority to Consent to Hormone Therapy

Inherent in providing healthcare for youth lie tensions among best interests, decision-making capacity, rights, and legal authority. Transgender (trans) youth experience barriers to needed gender-affirming care, often rooted in ethical and legal issues, such as healthcare provider concerns regarding youth capacity and rights to consent to hormone therapy. Even when decision-making capacity is present, youth may lack the legal authority to give consent. The aims of this paper are therefore to provide an empirical analysis of minor trans youth capacity to consent to hormone therapy and to address the normative question of whether there is ethical justification for granting trans youth the authority to consent to this care. Through qualitative content analysis of interviews with trans youth, parents, and healthcare providers, we found that trans youth demonstrated the understandings and abilities characteristic of the capacity to consent to hormone therapy and that they did consent to hormone therapy with positive outcomes. Employing deontological and consequentialist reasoning and drawing on a foundation of empirical evidence, human rights, and best interests we conclude that granting trans youth with decisional capacity both the right and the legal authority to consent to hormone therapy via the informed consent model of care is ethically justified.