The nature and consequences of forensic psychiatric decision-making

Consistency of physician judgments of capacity to consent in mild Alzheimer's disease

OBJECTIVE

To investigate the agreement of physician judgments of capacity to consent to treatment for normal and demented older adults.

DESIGN

Subjects were individually administered a standardized consent capacity interview. Physicians viewed videotapes of these interviews and made judgments of capacity to consent to treatment.

SETTING

University medical center.

PARTICIPANTS

Subjects assessed for competency (N = 45) were 16 normal older controls and 29 patients with mild Alzheimer's disease (AD). Five medical center physicians with experience assessing the competency of dementia patients were recruited from the specialties of geriatric psychiatry, geriatric medicine, and neurology.

MEASUREMENTS

Subjects were videotaped responding to a standardized consent capacity interview (SCCI) designed to evaluate capacity to consent to treatment. Study physicians blinded to subject diagnosis individually viewed each SCCI videotape and made a judgment of competent or incompetent to consent. Agreement of physician judgments was evaluated using percentage agreement, kappa, and logistic regression.

RESULTS

Competency judgements of physicians showed high agreement for controls but low agreement for AD patients. Physicians as a group achieved 98% judgment agreement for the controls but only 56% judgment agreement for the mild AD patients. The physician group kappa for controls was 1.00 (P < .0001) and differed significantly (P < .0001) from the physician group kappa of .14 (P = .44) for AD patients, indicative of a real difference in the ability of the study physicians to judge consistently competency across the two groups. Similarly, logistic regression analysis showed significant variability in physician judgements for the AD group (chi 2 = 63.8, P < .0001) but not for the control group (chi 2 = 4.1, P = 1.00). Within the Ad group, pairwise analyses revealed significant judgment disagreement (P < .01) for seven of the 10 physician pairs.

Clinical and demographic variables related to "fitness to stand trial" assessments in Manitoba

OBJECTIVE

To assess the extent to which clinical and nonclinical variables have been used by mental health professionals in Manitoba to determine fitness to stand trial. Researchers at a forensic setting in another province have suggested that demographic variables account for as much of the variance in predicting the outcome of these assessments as clinical variables.

METHOD

These variables were assessed by the examination of 100 fitness assessments conducted at Winnipeg's Forensic Services unit during a 2-year period.

RESULTS

Contrary to findings reported in Ontario, the variance in fitness evaluations in Manitoba was primarily accounted for by clinical rather than demographic variables.

CONCLUSION

Since Manitoba's forensic clinicians were using standardized criteria that were very similar to 1992 Criminal Code revisions of fitness, the findings attest to the usefulness of these criteria.