Systematic review on the prevalence of lack of capacity in medical and psychiatric settings

Transforming Communication on Serious Illness and Frailty: A Comprehensive Approach to Empowering Informed Decision-Making

Health care professionals can enhance conversations about serious illness and medical decision-making by adopting a transparent, standardized approach. This article critiques established communication strategies, which often emphasize patient values and goals without providing the necessary medical information to align these goals with a shared understanding of prognosis. We propose an alternate strategy that (1) provides detailed explanations of medical conditions at the beginning of the conversation, (2) includes support persons in discussions, (3) considers capacity, and (4) offers tailored advice by clinicians. The proposed framework aims to provide patients (or their delegates) with the information they need to integrate their values in pursuit of well-informed medical decisions. This strategy builds trust by providing honest information about medical conditions and their trajectories. It empowers decision makers to consider realistic outcomes, allowing them to accept or reject treatments in accordance with their preferences. This article presents a thorough step-by-step guide on how to conduct a serious illness conversation and facilitate medical decision-making, including a supplement that provides example phrases for use in clinical practice.

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.

Improving the systematic screening and documentation of mental capacity for patients with severe brain injury: The Mental Capacity Screening assessment tool (MCScreen)

For patients who may lack capacity, the Mental Capacity Act 2005 requires capacity to be assessed for each decision at the time that treatment is offered, but this is not practical for every element of basic care and intervention delivered to patients undergoing rehabilitation following acquired brain injury, especially if their needs are changing. In this quality improvement project, we introduced a system for screening Mental Capacity and documentation to identify patients with a) largely intact cognition for whom capacity may be reasonably be presumed, and b) those in prolonged disorders of consciousness who clearly lacked capacity for all decisions. This enabled the multidisciplinary team to concentrate on evaluation of capacity in the third group who had more nuanced ability and required detailed assessment or support for decision-making. Two rounds of audit demonstrated that implementation improved the consistency of assessment and documentation. Multicentre roll-out of this approach is now required.

Assessment of Decision-Making Capacity in 97 Hospitalized Patients With Cancer: A Call for Standardization

Hospitalized patients with cancer face pivotal decisions that will affect their cancer care trajectory and quality of life, but frequently lack decision making capacity (DMC). Standardization is conspicuously missing for inpatient oncology teams and for consultation-liaison psychiatrists performing DMC assessments for patients with cancer. This study sought to characterize a single institutional experience of psychiatric consultations to assess DMC. We conducted a retrospective chart review of 97 consecutive psychiatric consultations for DMC from 2017 to 2019. Demographic, hospital-based, and psychiatry consult differences were assessed based on the reasons for DMC evaluation (uncertainty, patient refusal, and emergency) and whether patients had decisional capacity. Out of 97 consultations, 56 (59%) hospitalized patients with cancer were unable to demonstrate capacity. Consultations came from medical services almost exclusively. Only 5% of primary teams documented their own DMC evaluation. Only 22% of DMC evaluation by consultation-liaison psychiatrists documented four determinates of DMC. Few commented on reversibility or tenuousness of DMC, and the identification of agents/surrogates; however, psychiatry consultants were more likely to follow up on patients without DMC. One-third of patients died in the hospital and two-thirds of patients were deceased 3 months after the consult. Given the substantial heterogeneity in the documentation of DMC evaluations in this retrospective chart review, we call for more rigor and standardization in documentation of DMC evaluations.

Capacity to Consent in Healthcare: A Systematic Review and Meta-Analysis Comparing Patients with Bipolar Disorders and Schizophrenia Spectrum Disorders

Background: Mental capacity is a fundamental aspect that enables patients to fully participate in various healthcare procedures. To assist healthcare professionals (HCPs) in assessing patients' capacity, especially in the mental health field, several standardized tools have been developed. These tools include the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), and the Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD). The core dimensions explored by these tools include Understanding, Appreciation, Reasoning, and Expression of a choice. Objective: This meta-analysis aimed to investigate potential differences in decision-making capacity within the healthcare context among groups of patients with bipolar disorders (BD) and schizophrenia spectrum disorders (SSD). Methods: A systematic search was conducted on Medline/Pubmed, and Scopus. Additionally, Google Scholar was manually inspected, and a manual search of emerging reviews and reference lists of the retrieved papers was performed. Eligible studies were specifically cross-sectional, utilizing standardized assessment tools, and involving patients diagnosed with BD and SSD. Data from the studies were independently extracted and pooled using random-effect models. Hedges' g was used as a measure for outcomes. Results: Six studies were identified, with three studies using the MacCAT-CR, two studies the MacCAT-T, and one the CAT-PAD. The participants included 189 individuals with BD and 324 individuals with SSD. The meta-analysis revealed that patients with BD performed slightly better compared to patients with SSD, with the difference being statistically significant in the domain of Appreciation (ES = 0.23, 95% CI: 0.01 to 0.04, p = 0.037). There was no statistically significant difference between the two groups for Understanding (ES = 0.09, 95% CI:-0.10 to 0.27, p = 0.352), Reasoning (ES = 0.18, 95% CI: -0.12 to 0.47, p = 0.074), and Expression of a choice (ES = 0.23, 95% CI: -0.01 to 0.48, p = 0.60). In the sensitivity analysis, furthermore, when considering only studies involving patients in symptomatic remission, the difference for Appreciation also resulted in non-significant (ES = 0.21, 95% CI: -0.04 to 0.46, p = 0.102). Conclusions: These findings indicate that there are no significant differences between patients with BD and SSD during remission phases, while differences are minimal during acute phases. The usefulness of standardized assessment of capacity at any stage of the illness should be considered, both for diagnostic-therapeutic phases and for research and advance directives. Further studies are necessary to understand the reasons for the overlap in capacity between the two diagnostic categories compared in this study.

Attitudes of patients with schizophrenia spectrum or bipolar disorders towards medication self-management during hospitalisation

BACKGROUND

Medication self-management (MSM) is defined as a person's ability to cope with medication treatment for a chronic condition, along with the associated physical and psychosocial effects that the medication causes in their daily lives. For many patients, it is important to be able to self-manage their medication successfully, as they will often be expected to do after discharge.

AIM

The aim of this study was to describe the willingness and attitudes of patients with schizophrenia spectrum or bipolar disorders regarding MSM during hospital admission. A secondary aim was to identify various factors associated with patient willingness to participate in MSM and to describe their assumptions concerning needs and necessary conditions, as well as their attitudes towards their medication.

METHODS

A multicentre, quantitative cross-sectional observational design was used to study the willingness and attitudes of psychiatric patients regarding MSM during hospitalisation. The study adhered to guidelines for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

RESULTS

In this study, 84 patients, of which 43 were patients with schizophrenia spectrum disorders and 41 were patients with bipolar disorders, participated. A majority of the patients (81%) were willing to participate in MSM during their hospitalisation. Analysis revealed patients are more willing to MSM if they are younger (r = -.417, p < .001) and a decreasing number of medicines (r = -.373, p = .003). Patients' willingness was positively associated with the extent of support by significant others during and after hospitalisation (Pearson's r = .298, p = .011). Patients were convinced that they would take their medication more correctly if MSM were to be allowed during hospitalisation (65%).

CONCLUSION

Most of the patients were willing to self-manage their medication during hospitalisation, however, under specific conditions such as being motivated to take their medication correctly and to understand the benefits of their medication.

RELEVANCE TO CLINICAL PRACTICE

From a policy point of view, our study provided useful insights into how patients look at MSM to enable the development of future strategies. Since patients are willing to self-manage their medication during hospitalisation, this may facilitate its implementation.

PATIENT CONTRIBUTION

Patients were recruited for this study. Participation was voluntary, and signed informed consent was obtained from all participants prior to the questionnaire.

Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis

Decision-making capacity (DMC) among psychiatric inpatients is a pivotal clinical concern. A review by Okai et al. (2007) suggested that most psychiatric inpatients have DMC for treatment, and its assessment is reliable. Nevertheless, the high heterogeneity and mixed results from other studies mean there is considerable uncertainty around this topic. This study aimed to update Okai's research by conducting a systematic review with meta-analysis to address heterogeneity. We performed a systematic search across four databases, yielding 5351 results. We extracted data from 20 eligible studies on adult psychiatric inpatients, covering DMC assessments from 2006 to May 2022. A meta-analysis was conducted on 11 papers, and a quality assessment was performed. The study protocol was registered on PROSPERO (ID: CRD42022330074). The proportion of patients with DMC for treatment varied widely based on treatment setting, the specific decision and assessment methods. Reliable capacity assessment was feasible. The Mini-Mental State Examination (MMSE), Global Assessment of Function (GAF), and Brief Psychiatric Rating Scale (BPRS) predicted clinical judgments of capacity. Schizophrenia and bipolar mania were linked to the highest incapacity rates, while depression and anxiety symptoms were associated with better capacity and insight. Unemployment was the only sociodemographic factor correlated with incapacity. Assessing mental capacity is replicable, with most psychiatric inpatients able to make treatment decisions. However, this capacity varies with admission stage, formal status (involuntary or voluntary), and information provided. The severity of psychopathology is linked to mental capacity, though detailed psychopathological data are limited.

Reliability of clinical judgment for evaluation of informed consent in mental health settings and the validation of the Evaluation of Informed Consent to Treatment (EICT) scale

Introduction

The competence assessment to give informed consent in the legal and healthcare settings is often performed merely through clinical judgment. Given the acknowledged limited reliability of clinician-based evaluation in the mental health sector, particularly for the assessment of competence to consent, our objective was to ascertain the dependability of clinical judgment when evaluating the ability of schizophrenia patients to make choices about their health.

Methods

The potential convergence between clinical evaluation and scores from a new standardized assessment (the "Evaluation of Informed Consent to Treatment" - "EICT" scale) was therefore tested. The scale assesses four dimensions of competence, specifically how patients normally understand information relating to care (Understanding); how they evaluate the choice of treatment in terms of risk/benefit ratio (Evaluating); how they reason coherently in the decision-making process (Reasoning); and, finally, their ability to make a choice between treatment alternatives (Expressing a choice). Thirty-four outpatients with schizophrenia were evaluated for their competence to consent by five referring clinicians with different backgrounds (psychiatrist, forensic psychiatrist, geriatrician, anesthetist, and medico-legal doctor). Inter-raters variability was tested through correlation analyses between the scores obtained by the clinicians on a modified version of the Global Assessment of Functioning scale (GAF) designed specifically to subjectively assess functioning in each of the four competence dimensions. Two validated competence scales (Mac-CAT-T, SICIATRI-R), and a neuropsychological battery were also administered along with scales for evaluating neuropsychiatric symptoms severity and side effects of medication.

Results

Clinical judgments of the individual specialists showed great inter-rater variability. Likewise, only weak/non-significant correlations were found between the EICT subscales and the respective clinicians-rated GAF scales. Conversely, solid correlations were found between the EICT and MacCAT-T subscales. As expected, healthy controls performed better in the ability to give informed consent to treatment, as measured by the three scales (i.e., EICT, MacCAT-T, and SICIATRI-R), and neuropsychological test performance. In the comparisons between patients who, according to the administered EICT, were able or not able to give informed consent to treatment, significant differences emerged for the Phonemic verbal fluency task (p = 0.038), Verbal judgments (p = 0.048), MacCAT-T subscales, and SICIATRI-R total score. Moreover, EICT exhibited excellent internal consistency (Cronbach's alphas ranging from 0.96 to 0.98 for the four subscales) while the Item Analysis, by measuring the correlation between each item of the EICT and the total score, was excellent for all items of all subscales (alphas ranging from 0.86 to 0.98).

Discussion

In conclusion, our findings highlighted that the assessment of competence exclusively through clinical judgment is not fully reliable and needs the support of standardized tools. The EICT scale could therefore be useful in assessing general competence to consent both in healthcare and legal contexts, where it might be necessary to evaluate the effective competence of patients with psychiatric disorders. Finally, this scale could serve as a valuable tool for decisions regarding whether and to what extent a patient needs support.

Restraint in somatic healthcare: how should it be regulated?

Restraint is regularly used in somatic healthcare settings, and countries have chosen different paths to regulate restraint in somatic healthcare. One overarching problem when regulating restraint is to ensure that patients with reduced decision-making capacity receive the care they need and at the same time ensure that patients with a sufficient degree of decision-making capacity are not forced into care that they do not want. Here, arguments of justice, trust in the healthcare system, minimising harm and respecting autonomy are contrasted with different national regulations. We conclude that a regulation that incorporates an assessment of patients' decision-making capacity and considers the patient's best interests is preferable, in contrast to regulations based on psychiatric diagnoses or regulations where there are no legal possibilities to exercise restraint at all in somatic care.

Implications for Electronic Surveys in Inpatient Settings Based on Patient Survey Response Patterns: Cross-Sectional Study

BACKGROUND

Surveys of hospitalized patients are important for research and learning about unobservable medical issues (eg, mental health, quality of life, and symptoms), but there has been little work examining survey data quality in this population whose capacity to respond to survey items may differ from the general population.

OBJECTIVE

The aim of this study is to determine what factors drive response rates, survey drop-offs, and missing data in surveys of hospitalized patients.

METHODS

Cross-sectional surveys were distributed on an inpatient tablet to patients in a large, midwestern US hospital. Three versions were tested: 1 with 174 items and 2 with 111 items; one 111-item version had missing item reminders that prompted participants when they did not answer items. Response rate, drop-off rate (abandoning survey before completion), and item missingness (skipping items) were examined to investigate data quality. Chi-square tests, Kaplan-Meyer survival curves, and distribution charts were used to compare data quality among survey versions. Response duration was computed for each version.

RESULTS

Overall, 2981 patients responded. Response rate did not differ between the 174- and 111-item versions (81.7% vs 83%, P=.53). Drop-off was significantly reduced when the survey was shortened (65.7% vs 20.2% of participants dropped off, P<.001). Approximately one-quarter of participants dropped off by item 120, with over half dropping off by item 158. The percentage of participants with missing data decreased substantially when missing item reminders were added (77.2% vs 31.7% of participants, P<.001). The mean percentage of items with missing data was reduced in the shorter survey (40.7% vs 20.3% of items missing); with missing item reminders, the percentage of items with missing data was further reduced (20.3% vs 11.7% of items missing). Across versions, for the median participant, each item added 24.6 seconds to a survey's duration.

CONCLUSIONS

Hospitalized patients may have a higher tolerance for longer surveys than the general population, but surveys given to hospitalized patients should have a maximum of 120 items to ensure high rates of completion. Missing item prompts should be used to reduce missing data. Future research should examine generalizability to nonhospitalized individuals.

Decision-making capacity in older medical in-patients: frequency of assessment and rates of incapacity by decision-type and underlying brain/mind impairment

BACKGROUND

Hospital clinicians find mental capacity assessment challenging and may lack the necessary skills. Given high rates of cognitive impairment, data on mental capacity assessment in real-world hospital cohorts are required to inform the need for staff training and workforce planning.

OBJECTIVES

In unselected medical inpatients, we determined the rate and outcome of mental capacity assessment by decision type and underlying brain/mind disorder, and recorded the discipline of the assessor.

METHODS

We included consecutive patients (October-November 2018; November-December 2019) admitted to the complex medicine unit providing acute multidisciplinary care for multi-morbid patients (age ≥ 16 years, average age > 80 years). Audit data were collected at ward multidisciplinary meetings and extracted from electronic patient records.

RESULTS

Among 892 patients (mean/SD age = 82.8/8.6, 465 male), 140 (16%) required mental capacity assessment (40/140 (29%) had ≥2 assessments) with 203 assessments in total of which 162 (80%) were done by doctors. Capacity was deemed lacking in 124 (61%) assessments, most commonly in delirium with/without other co-morbid conditions (94/114, 82%) or dementia (9/12, 75%) with lower rates in other disorders (15/27, 56%), and no formal diagnosis of brain/mind disorder (6/50, 12%). Cognitive test scores were overall lower in those lacking capacity (mean/SD abbreviated-mental-test-score = 5.2/2.6, range = 0-10 versus 6.8/2.8, P = 0.001, range = 1-10). Decisions involving discharge planning were most often assessed (48%) followed by treatment (29%), discharge against medical advice (12%) and others (11%).

CONCLUSION

Mental capacity assessments were performed frequently and often repeated, justifying the need for robust training in the practical application of the principles of capacity assessment for staff managing complex older patients.

Decisional-Regret Trajectories From End-of-Life Decision Making Through Bereavement

CONTEXT

Regret plays a central role in surrogate decision making. Research on decisional regret in family surrogates is scarce and lacks longitudinal studies to illustrate the heterogenous, dynamic evolution of decisional regret.

OBJECTIVES

To identify distinct decisional-regret trajectories from end-of-life (EOL) decision making through the first two bereavement years among surrogates of cancer patients.

METHODS

A prospective, longitudinal, observational study was conducted on a convenience sample of 377 surrogates of terminally ill cancer patients. Decisional regret was measured by the five-item Decision Regret Scale monthly during the patient's last six months and 1, 3, 6, 13, 18, and 24 months post loss. Decisional-regret trajectories were identified using latent-class growth analysis.

RESULTS

Surrogates reported substantially high decisional regret (pre- and postloss mean [SD] as 32.20 [11.47] and 29.90 [12.47], respectively). Four decisional-regret trajectories were identified. The resilient trajectory (prevalence: 25.6%) showed a general low decisional-regret level with mild and transient perturbations around the time of patient death only. Decisional regret for the delayed-recovery trajectory (56.3%) accelerated before the patient's death and decreased slowly throughout bereavement. Surrogates in the late-emerging (10.2%) trajectory reported a low decisional-regret level before loss but their decisional regret increased gradually thereafter. The increasing-prolonged trajectory (6.9%) rapidly increased in decisional-regret levels during EOL decision making, peaked one-month post loss, then declined steadily but without a complete resolution.

CONCLUSION

Surrogates heterogeneously suffered decisional regret from EOL decision making through bereavement as evident by four identified distinct decisional-regret trajectories. Early identification and prevention of increasing/prolonged decisional-regret trajectories is warranted.

Preferred Place of End-of-Life Care Based on Clinical Scenario: A Cross-Sectional Study of a General Japanese Population

In Japan, which has an aging society with many deaths, it is important that people discuss preferred place for end-of-life care in advance. This study aims to investigate whether the preferred place of end-of-life care differs by the assumed clinical scenario. This clinical scenario-based survey used data from a nationwide survey conducted in Japan in December 2017. Participants aged 20 years and older were randomly selected from the general population. The survey contained questions based on three scenarios: cancer, end-stage heart disease, and dementia. For each scenario, respondents were asked to choose the preferred place of end-of-life care among three options: home, nursing home, and medical facility. Eight hundred eighty-nine individuals participated in this study (effective response rate: 14.8%). The proportions of respondents choosing home, nursing home, and medical facility for the cancer scenario were 49.6%, 10.9%, and 39.5%, respectively; for the end-stage heart disease scenario, 30.5%, 18.9%, and 50.6%; and for the dementia scenario, 15.2%, 54.5%, and 30.3% (p < 0.0001, chi-square test). The preferred place of end-of-life care differed by the assumed clinical scenario. In clinical practice, concrete information about diseases and their status should be provided during discussions about preferred place for end-of-life care to reveal people's preferences more accurately.

Optimized Informed Consent for Psychotherapy: Protocol for a Randomized Controlled Trial

Background

Informed consent is a legal and ethical prerequisite for psychotherapy. However, in clinical practice, consistent strategies to obtain informed consent are scarce. Inconsistencies exist regarding the overall validity of informed consent for psychotherapy as well as the disclosure of potential mechanisms and negative effects, the latter posing a moral dilemma between patient autonomy and nonmaleficence.

Objective

This protocol describes a randomized controlled web-based trial aiming to investigate the efficacy of a one-session optimized informed consent consultation.

Methods

The optimized informed consent consultation was developed to provide information on the setting, efficacy, mechanisms, and negative effects via expectation management and shared decision-making techniques. A total of 122 participants with an indication for psychotherapy will be recruited. Participants will take part in a baseline assessment, including a structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) disorders. Eligible participants will be randomly assigned either to a control group receiving an information brochure about psychotherapy as treatment as usual (n=61) or to an intervention group receiving treatment as usual and the optimized informed consent consultation (n=61). Potential treatment effects will be measured after the treatment via interview and patient self-report and at 2 weeks and 3 months follow-up via web-based questionnaires. Treatment expectation is the primary outcome. Secondary outcomes include the capacity to consent, decisional conflict, autonomous treatment motivation, adherence intention, and side-effect expectations.

Results

This trial received a positive ethics vote by the local ethics committee of the Center for Psychosocial Medicine, University-Medical Center Hamburg-Eppendorf, Hamburg, Germany on April 1, 2021, and was prospectively registered on June 17, 2021. The first participant was enrolled in the study on August 5, 2021. We expect to complete data collection in December 2022. After data analysis within the first quarter of 2023, the results will be submitted for publication in peer-reviewed journals in summer 2023.

Conclusions

If effective, the optimized informed consent consultation might not only constitute an innovative clinical tool to meet the ethical and legal obligations of informed consent but also strengthen the contributing factors of psychotherapy outcome, while minimizing nocebo effects and fostering shared decision-making.

Trial Registration

PsychArchives; http://dx.doi.org/10.23668/psycharchives.4929

International Registered Report Identifier (IRRID)

DERR1-10.2196/39843

Recruitment interventions for trials involving adults lacking capacity to consent: methodological and ethical considerations for designing Studies Within a Trial (SWATs)

BACKGROUND

The number of interventions to improve recruitment and retention of participants in trials is rising, with a corresponding growth in randomised Studies Within Trials (SWATs) to evaluate their (cost-)effectiveness. Despite recognised challenges in conducting trials involving adults who lack capacity to consent, until now, no individual-level recruitment interventions have focused on this population. Following the development of a decision aid for family members making non-emergency trial participation decisions on behalf of people with impaired capacity, we have designed a SWAT to evaluate the decision aid in a number of host trials (CONSULT). Unlike in recruitment SWATs to date, the CONSULT intervention is aimed at a 'proxy' decision-maker (a family member) who is not a participant in the host trial and does not receive the trial intervention. This commentary explores the methodological and ethical considerations encountered when designing such SWATs, using the CONSULT SWAT as a case example. Potential solutions to address these issues are also presented.

DISCUSSION

We encountered practical issues around informed consent, data collection, and follow-up which involves linking the intervention receiver (the proxy) with recruitment and retention data from the host trial, as well as issues around randomisation level, resource use, and maintaining the integrity of the host trial. Unless addressed, methodological uncertainty about differential recruitment and heterogeneity between trial populations could potentially limit the scope for drawing robust inferences and harmonising data from different SWAT host trials. Proxy consent is itself ethically complex, and so when conducting a SWAT which aims to disrupt and enhance proxy consent decisions, there are additional ethical issues to be considered.

CONCLUSIONS

Designing a SWAT to evaluate a recruitment intervention for non-emergency trials with adults lacking capacity to consent has raised a number of methodological and ethical considerations. Explicating these challenges, and some potential ways to address them, creates a starting point for discussions about conducting these potentially more challenging SWATs. Increasing the evidence base for the conduct of trials involving adults lacking capacity to consent is intended to improve both the ability to conduct these trials and their quality, and so help build research capacity for this under-served population.

Capacity to consent to treatment in psychiatry inpatients - a systematic review

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.

Smartphone App to Promote Patient Activation and Support Shared Decision Making in People With a Diagnosis of Schizophrenia in Outpatient Treatment Settings (Momentum Trial): Randomized Controlled Assessor-blinded Trial (Preprint)

Background

Shared decision-making (SDM) is a process aimed at facilitating patient-centered care by ensuring that the patient and provider are actively involved in treatment decisions. In mental health care, SDM has been advocated as a means for the patient to gain or regain control and responsibility over their life and recovery process. To support the process of patient-centered care and SDM, digital tools may have advantages in terms of accessibility, structure, and reminders.

Objective

In this randomized controlled trial, we aimed to investigate the effect of a digital tool to support patient activation and SDM.

Methods

The trial was designed as a randomized, assessor-blinded, 2-armed, parallel-group multicenter trial investigating the use of a digital SDM intervention for 6 months compared with treatment as usual. Participants with a diagnosis of schizophrenia, schizotypal or delusional disorder were recruited from 9 outpatient treatment sites in the Capital Region of Denmark. The primary outcome was the self-reported level of activation at the postintervention time point. The secondary outcomes included self-efficacy, hope, working alliance, satisfaction, preparedness for treatment consultation, symptom severity, and level of functioning. Explorative outcomes on the effect of the intervention at the midintervention time point along with objective data on the use of the digital tool were collected.

Results

In total, 194 participants were included. The intention-to-treat analysis revealed a statistically significant effect favoring the intervention group on patient activation (mean difference 4.39, 95% CI 0.99-7.79; Cohen d=0.33; P=.01), confidence in communicating with one’s provider (mean difference 1.85, 95% CI 0.01-3.69; Cohen d=0.24; P=.05), and feeling prepared for decision-making (mean difference 5.12, 95% CI 0.16-10.08; Cohen d=0.27; P=.04). We found no effect of the digital SDM tool on treatment satisfaction, hope, self-efficacy, working alliance, severity of symptoms, level of functioning, use of antipsychotic medicine, and number or length of psychiatric hospital admissions.

Conclusions

This trial showed a significant effect of a digital SDM tool on the subjective level of patient activation, confidence in communicating with one’s provider, and feeling prepared for decision-making at the postintervention time point. The effect size was smaller than the 0.42 effect size that we had anticipated and sampled for. The trial contributes to the evidence on how digital tools may support patient-centered care and SDM in mental health care.

Trial Registration

ClinicalTrials.gov NCT03554655; https://clinicaltrials.gov/ct2/show/NCT03554655

International Registered Report Identifier (IRRID)

RR2-doi: 10.1186/s12888-019-2143-2

Unpacking the 'black box of horrendousness': a qualitative exploration of the barriers and facilitators to conducting trials involving adults lacking capacity to consent

Background

Trials involving adults who lack capacity to consent encounter a range of ethical and methodological challenges, resulting in these populations frequently being excluded from research. Currently, there is little evidence regarding the nature and extent of these challenges, nor strategies to improve the design and conduct of such trials. This qualitative study explored researchers’ and healthcare professionals’ experiences of the barriers and facilitators to conducting trials involving adults lacking capacity to consent.

Methods

Semi-structured interviews were conducted remotely with 26 researchers and healthcare professionals with experience in a range of roles, trial populations and settings across the UK. Data were analysed using thematic analysis.

Results

A number of inter-related barriers and facilitators were identified and mapped against key trial processes including during trial design decisions, navigating ethical approval, assessing capacity, identifying and involving alternative decision-makers and when revisiting consent. Three themes were identified: (1) the perceived and actual complexity of trials involving adults lacking capacity, (2) importance of having access to appropriate support and resources and (3) need for building greater knowledge and expertise to support future trials. Barriers to trials included the complexity of the legal frameworks, the role of gatekeepers, a lack of access to expertise and training, and the resource-intensive nature of these trials. The ability to conduct trials was facilitated by having prior experience with these populations, effective communication between research teams, public involvement contributions, and the availability of additional data to inform the trial. Participants also identified a range of context-specific recruitment issues and highlighted the importance of ‘designing in’ flexibility and the use of adaptive strategies which were especially important for trials during the COVID-19 pandemic. Participants identified a need for better training and support.

Conclusions

Researchers encountered a number of barriers, including both generic and context or population-specific challenges, which may be reinforced by wider factors such as resource limitations and knowledge deficits. Greater access to expertise and training, and the development of supportive interventions and tailored guidance, is urgently needed in order to build research capacity in this area and facilitate the successful delivery of trials involving this under-served population.

Autonomy-based criticisms of the patient preference predictor

The patient preference predictor (PPP) is a proposed computer-based algorithm that would predict the treatment preferences of decisionally incapacitated patients. Incorporation of a PPP into the decision-making process has the potential to improve implementation of the substituted judgement standard by providing more accurate predictions of patients' treatment preferences than reliance on surrogates alone. Yet, critics argue that methods for making treatment decisions for incapacitated patients should be judged on a number of factors beyond simply providing them with the treatments they would have chosen for themselves. These factors include the extent to which the decision-making process recognises patients' freedom to choose and relies on evidence the patient themselves would take into account when making treatment decisions. These critics conclude that use of a PPP should be rejected on the grounds that it is inconsistent with these factors, especially as they relate to proper respect for patient autonomy. In this paper, we review and evaluate these criticisms. We argue that they do not provide reason to reject use of a PPP, thus supporting efforts to develop a full-scale PPP and to evaluate it in practice.

Examining the Dimensionality of Trust in the Inpatient Setting: Exploratory and Confirmatory Factor Analysis

BACKGROUND

Trust in healthcare providers is associated with important outcomes, but has primarily been assessed in the outpatient setting. It is largely unknown how hospitalized patients conceptualize trust in their providers.

OBJECTIVE

To examine the dimensionality of a measure of trust in the inpatient setting.

DESIGN

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

PARTICIPANTS

Hospitalized patients (N = 1756; 76% response rate) across six hospitals in the midwestern USA. The sample was randomly split such that approximately one half was used in the EFA, and the other half in the CFA.

MAIN MEASURES

The Trust in Physician Scale, adapted for inpatient care.

KEY RESULTS

Based on the Kaiser-Guttman criterion and parallel analysis, EFAs were inconclusive, indicating that trust may be comprised of either one or two factors in this sample. In follow-up CFAs, a 2-factor model fit best based on a chi-squared difference test (Δχ² = 151.48(1), p < .001) and a Comparative Fit Index (CFI) difference test (CFI difference = .03). The overall fit for the 2-factor CFA model was good (χ² = 293.56, df = 43, p < .01; CFI = .95; RMSEA = .081 [90% confidence interval = .072-.090]; TLI = .93; SRMR = .04). Items loaded onto two factors related to cognitive (i.e., whether patients view providers as competent) and affective (i.e., whether patients view that providers care for them) dimensions of trust.

CONCLUSIONS

While measures of trust in the outpatient setting have been validated as unidimensional, in the inpatient setting, trust appears to be composed of two factors: cognitive and affective trust. This provides initial evidence that inpatient providers may need to work to ensure patients see them as both competent and caring in order to gain their trust.

Ethical considerations in the surgical and neuromodulatory treatment of epilepsy

Surgical resection and neuromodulation are well-established treatments for those with medically refractory epilepsy. These treatments entail important ethical considerations beyond those which extend to the treatment of epilepsy generally. In this paper, the authors explore these unique considerations through a framework that relates foundational principles of bioethics to features of resective epilepsy surgery and neuromodulation. The authors conducted a literature review to identify ethical considerations for a variety of epilepsy surgery procedures and to examine how foundational principles in bioethics may inform treatment decisions. Healthcare providers should be cognizant of how an increased prevalence of somatic and psychiatric comorbidities, the dynamic nature of symptom burden over time, the individual and systemic barriers to treatment, and variable sociocultural contexts constitute important ethical considerations regarding the use of surgery or neuromodulation for the treatment of epilepsy. Moreover, careful attention should be paid to how resective epilepsy surgery and neuromodulation relate to notions of patient autonomy, safety and privacy, and the shared responsibility for device management and maintenance. A three-tiered approach-(1) gathering information and assessing the risks and benefits of different treatment options, (2) clear communication with patient or proxy with awareness of patient values and barriers to treatment, and (3) long-term decision maintenance through continued identification of gaps in understanding and provision of information-allows for optimal treatment of the individual person with epilepsy while minimizing disparities in epilepsy care.

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.

Development of a core outcome set for the evaluation of interventions to enhance trial participation decisions on behalf of adults who lack capacity to consent: a mixed methods study (COnSiDER Study)

BACKGROUND

Trials involving adults who lack capacity to provide consent rely on proxy or surrogate decision-makers, usually a family member, to make decisions about participation. Interventions to enhance proxy decisions about trial participation are now being developed. However, a lack of standardised outcome measures limits evaluation of these interventions. The aim of this study was to establish an agreed standardised core outcome set (COS) for use when evaluating interventions to improve proxy decisions about trial participation.

METHODS

We used established methods to develop the COS including a consensus study with key stakeholder groups comprising those who will use the COS in research (researchers and healthcare professionals) and patients or their representatives. Following a scoping review to identify candidate items, we used a modified two-round Delphi survey to achieve consensus on core outcomes, with equivocal items taken to a consensus meeting for discussion. The COS was finalised following an online consensus meeting in October 2020.

RESULTS

A total of 28 UK stakeholders (5 researchers, 10 trialists, 3 patient/family representatives, 7 recruiters and 3 advisors/approvers) participated in the online Delphi survey to rank candidate items from the scoping review (n = 36) and additional items proposed by participants (n = 1). Items were broadly grouped into three categories: how family members make decisions, their experiences of making decisions, and the personal aspects that influence the decision. Following the Delphi survey, 27 items were included and ten items exhibited no consensus which required discussion at the consensus meeting. Sixteen participants attended the meeting, including additional patient/family representatives invited to increase representation from this key group (n = 2). We reached consensus for the inclusion of 28 outcome items, including one selected at the consensus meeting.

CONCLUSIONS

The study identified outcomes that should be measured as a minimum in all evaluations of interventions to enhance proxy decisions about trials. These relate to the process of decision-making, proxies' experience of decision-making, and factors that influence decision-making such as understanding. Further work with people with impairing conditions and their families is needed to explore their views about the COS and to identify appropriate outcome measures and timing of measurement.

TRIAL REGISTRATION

The study is registered on the COMET database ( https://www.comet-initiative.org/Studies/Details/1409 ).

Can depressed patients make a decision to request voluntary assisted dying?

Depressive symptoms, including those as part of a major depressive disorder, are common at the end of life. A number of psychiatrists consider that a diagnosis of major depression precludes the capacity to make a decision to request voluntary assisted dying (VAD), although this is not a unanimous view. This paper uses a case of a patient in which two different psychiatric opinions were formed regarding her capacity to make the decision to request VAD. The difference of view can be related to whether major depression was diagnosed and the association made between depression and the capacity to request VAD. The view that an absence of major depression is required in order to establish the capacity to request VAD is potentially at odds with the legal definition and not necessarily in keeping with the patient's experience at the end of life.

Patients' Priorities for Surrogate Decision-Making: Possible Influence of Misinformed Beliefs

BACKGROUND

Many patients have three primary goals for how treatment decisions are made for them in the event of decisional incapacity. They want to be treated consistent with their preferences and values, they want their family to be involved in making decisions, and they want to minimize the stress on their family. The present paper investigates how patients' beliefs about surrogate decision-making influence which of these three goals they prioritize. Methods: Quantitative survey of 1,169 U.S. patients to assess their beliefs about surrogate decision-making, and how these beliefs influence patients' priorities for surrogate decision-making. Results: Most patients believed that families in general (68.8%) and their own family in particular (83.4%) frequently, almost always, or always know which treatments the patient would want in the event of incapacity. Patients with these beliefs were more likely to prioritize the goal of involving their family in treatment decision-making over the goal of minimizing family stress. Most patients (77.4%) also believed their family would experience significant stress from helping to make treatment decisions. However, patients' priorities were largely unchanged by this belief. Conclusions: Prior reports suggest that patients overestimate the extent to which their family knows which treatments they want in the event of decisional incapacity. The present analysis adds that these patients might be more likely to prioritize the goal of involving their family in treatment decision-making, even when this results in the family experiencing significant distress. This finding highlights that patients' misinformed beliefs about their family's knowledge might influence patients' priorities for surrogate decision-making, raising important questions for clinical practice, policy, and future research.

Supplemental data for this article is available online at https://doi.org/10.1080/23294515.2021.1983665.

In schizophrenia, are lack of capacity and lack of insight more usefully understood as anosognosia?

OBJECTIVE

To argue that lack of capacity, lack of insight and anosognosia represent different facets of an interconnected, underlying process.

METHODS

Electronic and manual literature search.

RESULTS

There is demographic, clinical, neurocognitive and possible neuroanatomical overlap between lack of capacity, lack of insight and anosognosia.

CONCLUSION

The use of different terms may reflect the background of the authors and their investigative methodologies rather than unrelated phenomena. Anosognosia is preferred as it progresses research and usefully informs clinical and legal practice.

Deprivation of patient liberty: a qualitative study of current practice among geriatricians in a tertiary setting

BACKGROUND

The Assisted Decision Making (Capacity) Act 2015 in Ireland is designed to support and maximise a person's capacity to make decisions, although it has not yet commenced. Amendments to the legislation propose to deal with deprivation of liberty of persons lacking capacity. Health care professionals such as geriatricians will need to focus on enabling patient autonomy in response to legislative changes.

AIMS

This study aimed to explore geriatricians' experience in a tertiary hospital setting when dealing with deprivation of liberty scenarios.

METHODS

A generic qualitative study was undertaken in 2019 via 10 separate, semi-structured, in-person interviews with consultant geriatricians. The interview covered patient decision-making and deprivation of patient liberty in the acute setting, thoughts on proposed legislation and elements learned from experience. A thematic analysis was conducted.

RESULTS

Regarding the potential deprivation of patient liberty, five themes emerged: (a) patient capacity, including assessment and opinions; (b) interaction of geriatricians with other professionals and dynamics amongst those that influence decision-making; (c) the environment of factors and frameworks shaping current practice; (d) medico-legal education and geriatricians recognising relevant, challenging cases; (e) the awareness of geriatricians of their attitudes and approaches, including reflecting on one's own practice.

CONCLUSIONS

Results highlight a need for collaborative communication between doctors and legal professionals to achieve a structured and supportive framework to inform practice when working under any proposed legislation relating to deprivation of liberty.

Internet of things issues related to psychiatry

Background

Internet of Things (IoT) devices for remote monitoring, diagnosis, and treatment are widely viewed as an important future direction for medicine, including for bipolar disorder and other mental illness. The number of smart, connected devices is expanding rapidly. IoT devices are being introduced in all aspects of everyday life, including devices in the home and wearables on the body. IoT devices are increasingly used in psychiatric research, and in the future may help to detect emotional reactions, mood states, stress, and cognitive abilities. This narrative review discusses some of the important fundamental issues related to the rapid growth of IoT devices.

Main body

Articles were searched between December 2019 and February 2020. Topics discussed include background on the growth of IoT, the security, safety and privacy issues related to IoT devices, and the new roles in the IoT economy for manufacturers, patients, and healthcare organizations.

Conclusions

The use of IoT devices will increase throughout psychiatry. The scale, complexity and passive nature of data collection with IoT devices presents unique challenges related to security, privacy and personal safety. While the IoT offers many potential benefits, there are risks associated with IoT devices, and from the connectivity between patients, healthcare providers, and device makers. Security, privacy and personal safety issues related to IoT devices are changing the roles of manufacturers, patients, physicians and healthcare IT organizations. Effective and safe use of IoT devices in psychiatry requires an understanding of these changes.

Incapacity in childbirth - Rare or common?

•

Women in obstetric emergency situations lack capacity more commonly than we thought (probably in the region of 14 %).

•

Retrospective capacity assessments are feasible.

•

Pain, younger age, and no previous theatre deliveries are risk factors for incapacity.

•

Capacity assessment results vary widely between assessors.

•

Introducing a Likert scale for capacity does not improve the result variability between capacity assessors.

Objective

Impaired decision making ability is common on general medical wards. Audit evidence suggests that the prevalence of incapacity may be higher than previously assumed in Obstetric Emergency Procedures (OEP) during childbirth. We investigated the prevalence of incapacity in OEP and factors associated with this.

Design

Capacity to consent to treatment was assessed retrospectively in 93 women undergoing OEP. All women were interviewed using a semi-structured questionnaire aided interview within 24 h of the emergency. Five assessors (3 obstetricians and 2 psychiatrists) were asked to determine capacity to consent from audio recordings of the interviews.

Results

All 5 assessors determined 59 % of women to have capacity to consent to treatment and 2 % of women to lack capacity. In 39 % of women there was some disagreement between assessors. Using a majority decision (3 assessors in agreement), 14 % of women lacked capacity. High pain scores, young age and no previous history of theatre deliveries were associated with more incapacity judgments, whilst parity and history of mental illness were not. Using a 7point Likert scale only marginally improved agreement between assessors, compared to their binary decision.

Conclusion

It is often assumed that it is rare to lack capacity in an obstetric emergency procedure during childbirth, but these data suggest that incapacity may be relatively common. In particular, severe pain is a demonstrable risk factor for impaired capacity. Wide variation between assessors questions the validity of current commonly employed (informal) methods used in clinical practice to assess capacity to consent during OEP.

Exploring patterns in psychiatric outpatients' preferences for involvement in decision-making: a latent class analysis approach

BACKGROUND

Shared decision-making (SDM), a collaborative approach that includes and respects patients' preferences for involvement in decision-making about their treatment, is increasingly advocated. However, in the practice of clinical psychiatry, implementing SDM seems difficult to accomplish. Although the number of studies related to psychiatric patients' preferences for involvement is increasing, studies have largely focused on understanding patients in public mental healthcare settings. Thus, investigating patient preferences for involvement in both public and private settings is of particular importance in psychiatric research. The objectives of this study were to identify different latent class typologies of patient preferences for involvement in the decision-making process, and to investigate how patient characteristics predict these typologies in mental healthcare settings.

METHODS

We conducted latent class analysis (LCA) to identify groups of psychiatric outpatients with similar preferences for involvement in decision-making to estimate the probability that each patient belonged to a certain class based on sociodemographic, clinical and health belief variables.

RESULTS

The LCA included 224 consecutive psychiatric outpatients' preferences for involvement in treatment decisions in public and private psychiatric settings. The LCA identified three distinct preference typologies, two collaborative and one passive, accounting for 78% of the variance. Class 1 (26%) included collaborative men aged 34-44 years with an average level of education who were treated by public services for a depressive disorder, had high psychological reactance, believed they controlled their disease and had a pharmacophobic attitude. Class 2 (29%) included collaborative women younger than 33 years with an average level of education, who were treated by public services for an anxiety disorder, had low psychological reactance or health control belief and had an unconcerned attitude toward medication. Class 3 (45%) included passive women older than 55 years with lower education levels who had a depressive disorder, had low psychological reactance, attributed the control of their disease to their psychiatrists and had a pharmacophilic attitude.

CONCLUSIONS

Our findings highlight how psychiatric patients vary in pattern of preferences for treatment involvement regarding demographic variables and health status, providing insight into understanding the pattern of preferences and comprising a significant advance in mental healthcare research.

Caregiving Experience and Other Factors Associated With Having End-Of-Life Discussions: A Cross-Sectional Study of a General Japanese Population

CONTEXT

The factors associated with end-of-life discussion (EOLD) are not well elucidated; an understanding of these factors may help facilitate EOLD.

OBJECTIVES

To investigate the associations between EOLD and experiences of the death of and/or care for a loved one and other factors.

METHODS

Data from a nationwide anonymous questionnaire survey of public attitudes toward end-of-life medical care, conducted in December 2017 in Japan, were used. Participants were randomly selected from the general population (age ≥ 20 years), and respondents who completed the questionnaire were analyzed (respondents: n = 836; effective response rate: 13.9%). Respondents were divided into two groups based on their experience of EOLD: those who had engaged in EOLD and those who had not. The main predictors were the experiences of the death of and care for a loved one. Multivariable logistic regression analyses were performed.

RESULTS

Of the 836 respondents (male: 55.6%, aged 65 and over: 43.5%), 43.7% reported their engagement in EOLD. In the analyses, "having experience of caring for a loved one" was associated with EOLD compared with never having experience (odds ratio 1.88, 95% confidence interval 1.35-2.64). However, having experience of the death of a loved one had no association.

CONCLUSION

For health-care providers, it may be worth recognizing that the care experience of their patient's caregiver might affect the caregiver's own EOLD in the future.

Statutes Governing Default Surrogate Decision Making for Mental Health Treatment

OBJECTIVE

The authors sought to describe state-to-state variations in the scope of statutory authority granted to default surrogates who decide on mental health treatment for incapacitated patients.

METHODS

The authors investigated state statutes delineating the powers of default surrogates to make decisions about mental health treatment. Statutes in all 50 U.S. states and the District of Columbia were identified and analyzed independently by three reviewers. Research was conducted from August 2017 to November 2018 and updated in January 2020.

RESULTS

State statutes varied in approaches to default surrogate decision making for mental health treatment. Eight states' statutes delegate broad authority to surrogates, whereas 25 states prohibit surrogates from giving consent for specific therapies. Thirteen states are silent on whether surrogates may make decisions.

CONCLUSIONS

Heterogeneity among state statutory laws contributes to complexity of treating patients without decisional capacity. This variability encumbers efforts to support surrogates and clinicians and may contribute to health disparities.

Psychiatric Illness and Medical Decision-Making Capacity: A Retrospective Study in Medical Settings

Determination of medical decision-making capacity (DMC) is one of the common encounters in Consultation-Liaison Psychiatry (CLP) services. It is a common misbelief that patients with “psych history” lack capacity more often than patients without mental illness. The study aims to examine the relationship between mental illness and DMC in patients presented to acute medical settings. The study is a retrospective chart review, where data were collected from the patients admitted to the medical units and assessed for capacity by a psychiatrist. Clinical and demographic characteristics were compared between two groups (patients having capacity and lacking capacity) using t-tests or chi-square tests, as appropriate. The commonest reason for DMC evaluation requests was for the patients who wanted to leave the hospital against medical advice. Overall, 53% (52/98) of the patients evaluated for DMC were found to lack capacity. Group of patients lacking DMC had a significantly higher percentage of males (58% vs. 35%) but were significantly less employed (8% vs. 10%). No significant difference was observed in other demographic characteristics and primary psychiatric diagnoses (past and current) among the two groups. However, patients lacking capacity were found to have a significantly more occurrence of current (48% vs. 11%) and past (23% vs. 4%) history of neurocognitive disorder, and larger trend significance (31% vs. 15%) of active psychiatric symptoms. We conclude that patients with neurocognitive disorders and active psychiatric symptoms might have poor DMC but not all patients who have psychiatric diagnoses lack medical DMC. Larger studies especially in outpatient psychiatric settings are suggested to derive more conclusive results.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.

Advances and challenges in conducting ethical trials involving populations lacking capacity to consent: A decade in review

Informed consent is an essential requirement prior to clinical trial participation, however some 'vulnerable' groups, such as people with cognitive impairments and those in medical emergency situations, may lack decisional capacity to consent. This raises ethical and practical challenges when designing and conducting clinical trials involving these populations, who are frequently excluded as a result. Despite recent advances in improving informed consent processes, there has been far less attention paid to the enrolment of adults lacking capacity. Exclusion criteria are an important determinant of the external validity of clinical trial results. The exclusion of these populations, and consent-based recruitment biases which arise from the challenges of identifying and involving surrogate decision-makers, leads to trials which are not representative of the clinical population. This article discusses the involvement of adults who lack decisional capacity to consent in clinical trials and presents the advances over the previous decade and the remaining ethical challenges for the inclusion of this under-represented population in research.

A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare

BACKGROUND

Determining the mental capacity of psychiatric patients for making healthcare related decisions is crucial in clinical practice. This meta-review of review articles comprehensively examines the current evidence on the capacity of patients with a mental illness to make medical care decisions.

METHODS

Systematic review of review articles following PRISMA recommendations. PubMed, Scopus, CINAHL and PsycInfo were electronically searched up to 31 January 2020. Free text searches and medical subject headings were combined to identify literature reviews and meta-analyses published in English, and summarising studies on the capacity of patients with serious mental illnesses to make healthcare and treatment related decisions, conducted in any clinical setting and with a quantitative synthesis of results. Publications were selected as per inclusion and exclusion criteria. The AMSTAR II tool was used to assess the quality of reviews.

RESULTS

Eleven publications were reviewed. Variability on methods across studies makes it difficult to precisely estimate the prevalence of decision-making capacity in patients with mental disorders. Nonetheless, up to three-quarters of psychiatric patients, including individuals with serious illnesses such as schizophrenia or bipolar disorder may have capacity to make medical decisions in the context of their illness. Most evidence comes from studies conducted in the hospital setting; much less information exists on the healthcare decision making capacity of mental disorder patients while in the community. Stable psychiatric and non-psychiatric patients may have a similar capacity to make healthcare related decisions. Patients with a mental illness have capacity to judge risk-reward situations and to adequately decide about the important treatment outcomes. Different symptoms may impair different domains of the decisional capacity of psychotic patients. Decisional capacity impairments in psychotic patients are temporal, identifiable, and responsive to interventions directed towards simplifying information, encouraging training and shared decision making. The publications complied satisfactorily with the AMSTAR II critical domains.

CONCLUSIONS

Whilst impairments in decision-making capacity may exist, most patients with a severe mental disorder, such as schizophrenia or bipolar disorder are able to make rational decisions about their healthcare. Best practice strategies should incorporate interventions to help mentally ill patients grow into the voluntary and safe use of medications.

'Delusional' consent in somatic treatment: the emblematic case of electroconvulsive therapy

Even more than for other treatments, great importance must be given to informed consent in the case of electroconvulsive therapy (ECT). In a percentage of cases, the symbolic connotation of the treatment, even if mostly and intrinsically negative, may actually be a determining factor in the patient's motives for giving consent. On an ethical and medicolegal level, the most critical point is that concerning consent to the treatment by a psychotic subject with a severely compromised ability to comprehend the nature and objective of the proposed therapy, but who nonetheless expresses his consent, for reasons derived from delusional thoughts. In fact, this situation necessarily brings to light the contradiction between an explicit expression of consent, a necessary formality for the commencement of therapy, and the validity of this consent, which may be severely compromised due to the patient's inability to comprehend reality and therefore to accept the proposal of treatment, which is intrinsic to this reality. With the use of an electric current, the symbolic experience associated with anaesthesia, and the connection to convulsions, ECT enters the collective consciousness. In relation to this, ECT is symbolic of these three factors and hooks on to the thoughts, fears, feelings and expectations of delusional patients. These are often exemplified in the violent intervention of the persecutor in the patient with schizophrenia, the expected punishment for the 'error' committed for which the depressed patient blames himself and the social repression of the maniacal patient's affirmation of his inflated self-esteem.

[Critical evaluation of the new legal regulation of pharmaceutical trials with adults who lack decision-making capacity: a survey of human research ethics committees in Germany]

BACKGROUND

In Germany, the drug law was revised in 2016 to include new regulations on clinical drug trials with adults who lack decision-making capacity. For the first time, trials with a merely indirect benefit (benefit for other patients with similar characteristics) will be possible if several safeguards are respected. The ethical justification and practicality of this regulation are controversially discussed.

OBJECTIVES

(1) Eliciting the current pertinent practice of research ethics committees in Germany regarding research with indirect benefit on adults without decision-making capacity; (2) exploring the possibilities and difficulties of implementing the new law.

METHODS

Semiquantitative, anonymous questionnaire among 249 members of all 53 human research ethics committees in Germany.

RESULTS

Eighty-four questionnaires were analyzed (response rate 34%). The participants disagreed on assigning research projects to the categories of research with direct benefit to the subject, with an indirect benefit, and without any benefit. Moreover, the criteria of minimum risk and minimum burden were interpreted heterogeneously. More than half of the participants judged the newly introduced research advance directive to be unnecessary, given the legal safeguards in place. The applicability of these directives was doubted because of the strict requirements for anticipatory informed consent and the restricted predictability of future research.

CONCLUSION

In spite of the new legal regulation, significant ethical uncertainties remain concerning research with indirect benefit on adults without decision-making capacity. It remains an open question whether we need a better explanation of the law, additional legal regulation, practice evaluation, or a completely new law.

Decisional capacity to consent to treatment and anaesthesia in patients over the age of 60 undergoing major orthopaedic surgery

Despite growing attention to the ability of patients to provide informed consent to treatment in different medical settings, few studies have dealt with the issue of informed consent to major orthopaedic surgery in those over the age of 60. This population is at risk of impaired decision-making capacity (DMC) because older age is often associated with a decline in cognitive function, and they often present with anxiety and depressive symptoms, which could also affect their capacity to consent to treatment. Consent to major orthopaedic surgery requires the patient to understand, retain and reason about complex procedures. This study was undertaken to extend the literature on decisional capacity to consent to surgery and anaesthesia of patients over the age of 60 undergoing major orthopaedic surgery. Recruited patients ( N=83) were evaluated using the Aid to Capacity Evaluation, the Beck Depression Inventory, the State–Trait Anxiety Inventory Y, the Mini-Mental State Examination and a visual analogue scale for measuring pain symptomatology. Impairment of medical DMC was common in the overall sample, with about 50% of the recruited patients showing a doubtful ability, or overt inability, to provide informed consent. Poor cognitive functioning was associated with reduced medical DMC, although no association was found between decisional capacity and depressive, anxiety and pain symptoms. These findings underline the need of an in-depth assessment of capacity in older patients undergoing major orthopaedic surgery.

Insight and capacity to consent to electroconvulsive therapy

OBJECTIVE

To critically examine a recent decision of the Victorian Supreme Court that found that the Mental Health Tribunal and the Victorian Civil and Administrative Tribunal erred in the application of the capacity test in the Mental Health Act 2014 (Vic) and that compulsory electroconvulsive therapy would infringe upon the human rights of two patients who had no insight into their chronic schizophrenia.

CONCLUSIONS

After considering the concepts of insight and capacity to consent to treatment, the paper concludes that the decision in NJE and PBU v Mental Health Tribunal [2018] VSC 564 is problematic clinically.

Capacity issues at the front door

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.

Age, psychiatry admission status and linear mental capacity for treatment decisions

The relationship between age and mental capacity among psychiatry inpatients is not fully understood. We aimed to assess mental capacity for treatment decisions in voluntary and involuntary psychiatry inpatients in Ireland and, in this analysis of our data-set, to elucidate the linear relationship, if any, between linear (as opposed to categorical) mental capacity and age. We used the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to assess mental capacity for treatment decisions in 215 psychiatry inpatients (176 voluntary and 39 involuntary) in four psychiatry admission units in Ireland. Mean age was 46.2 years and majorities were male (58.1%), never married (74.0%), unemployed (64.2%) and of Irish ethnicity (87.0%). The most common primary diagnoses were schizophrenia and related disorders (42.8%) followed by affective disorders (36.7%). On multi-variable linear regression analysis, linear mental capacity was significantly associated with voluntary admission status, being employed, having a primary diagnosis other than schizophrenia or a related disorder, and younger age. Together, these factors accounted for 44.4% of the variance in mental capacity between participants. Overall, while increased age is associated with diminished mental capacity, other factors appear more significant, including involuntary admission status which is likely an indicator of symptom severity. There is a need for further research to (a) elucidate the relationships between the significant factors identified in this study and the cognitive status of patients (which impacts on assessments of mental capacity); (b) identify and elucidate other factors of likely relevance to mental capacity (e.g. medical illness, medication use); and (c) translate these findings into targeted interventions to support decision-making in clinical practice among psychiatry inpatients, especially those with involuntary status.

Protection by exclusion? The (lack of) inclusion of adults who lack capacity to consent to research in clinical trials in the UK

BACKGROUND

Around two million adults in the UK have significantly impaired decision-making capacity. However, there are concerns that this population is under-represented in research, due in part to the challenges around obtaining consent. Under-representation of populations denies those who would have wanted to participate the opportunity to make a contribution to society, but also fails to generate results that are applicable to them. Consequently, the evidence base for their care is poorer than for other populations. We recently published in this journal an analysis of Participant Information Sheets provided to consultees and legal representatives of adults who lack capacity and noted the small number of trials designed to include adults who lack capacity. In order to understand how many adults who lack capacity to consent are actually enrolled in clinical trials, we further explored how many of the participants lacked capacity, and who acted as a consultee or legal representative on their behalf.

MAIN TEXT

The ISRCTN registry was searched for UK clinical trials in conditions commonly associated with cognitive impairment that were designed to include (or not exclude) adults who lack capacity to consent. Details about participants and capacity status were obtained from published data or directly from the trial teams. Of the 80 retrieved clinical trials that had completed in the previous 3 years, we identified 15 which included adults who lack capacity to consent. Data regarding participants' capacity status were not available for five trials. Where capacity was reported, 5-100% participants lacked capacity to consent. Trials predominantly utilised personal consultees/legal representatives; however, 39% (634/1631) of participants required a professional to act as consultee/legal representative.

CONCLUSIONS

Only a small number of trials including adults who lacked capacity were identified. The majority of participants were represented by a personal consultee/legal representative; however, between 21 and 100% of participants across five trials required the involvement of a professional, suggesting it is not uncommon. Data relating to capacity status were rarely reported, potentially masking the under-representation of adults who lack capacity. The findings may help researchers and funders target resources towards studies involving under-represented populations to increase the much-needed evidence base for their care and treatment.

Concordance of mental capacity assessments based on legal and clinical criteria: A cross-sectional study of psychiatry inpatients

This study aimed to compare assessments of mental capacity based on legal criteria with assessments based on clinical criteria among psychiatry inpatients to establish the concordance, if any, between these two approaches to assessing mental capacity. We assessed mental capacity for treatment decisions in 215 psychiatry inpatients (176 voluntary and 39 involuntary) in four psychiatry admission units in Ireland using both legal criteria (Ireland's Assisted Decision-Making (Capacity) Act 2015) and clinical criteria (the MacArthur Competence Assessment Tool for Treatment; MacCAT-T). Over one third of participants (34.9%) lacked mental capacity for treatment decisions according to the legal criteria. Mental incapacity was associated with involuntary admission status, being unemployed, a primary diagnosis of schizophrenia or a related disorder, and older age. Patients who lacked mental capacity according to the legislation scored significantly lower on all subscales of the MacCAT-T than patients who had mental capacity. We conclude that mental capacity assessments based on legal criteria correlate closely with those based on clinical criteria. These findings support current legal definitions of mental incapacity in Ireland and other jurisdictions with similar legislation (e.g. England and Wales).

Categorical mental capacity for treatment decisions among psychiatry inpatients in Ireland

This study aimed to assess mental capacity for treatment decisions among psychiatry inpatients in Ireland and explore the relationship, if any, between mental capacity and various demographics and clinical variables. We assessed mental capacity for treatment decisions in 215 psychiatry inpatients in four psychiatry admission units. Almost half of the participants were female and the most common diagnoses were schizophrenia or a related disorder and affective disorders. Overall, 1.9% of participants lacked mental capacity for treatment decisions; 50.7% had partial mental capacity; and 47.4% had full mental capacity. These proportions did not differ between female and male patients. On multi-variable regression analysis, greater mental capacity was significantly associated with, in order of strength of association, voluntary admission status, Irish ethnicity, being employed and younger age. However, while these relationships were statistically significant (i.e. were unlikely to have occurred by chance), together they accounted for just 27.6% of the variance in mental capacity between participants (i.e. they were not very strong). The relatively high rate of "partial mental capacity" identified in our work suggests that decision-making supports are likely to be of substantial importance in assisting psychiatry inpatients making decisions about treatment, especially involuntary inpatients whose mental capacity is especially likely to be impaired. Future research could usefully clarify and quantify the role of cognitive and other factors in relation to the unexplained variance (72.4%) in mental capacity identified in this study; and explore which models of supported decision-making are most likely to assist the substantial proportion (50.7%) of psychiatry inpatients who have partial mental capacity for treatment decisions, as well as the minority lacking such mental capacity (1.9%).

How do health and social care professionals in England and Wales assess mental capacity? A literature review

Purpose: To review evidence describing how health and social care professionals in England and Wales assess mental capacity, in order to identify ways to improve practice.Methods: A systematised literature review was completed. Electronic databases of published medical, health and social care research and gray literature were searched. Journal articles and research reports published between 2007 and 2018 were included if they met predefined eligibility criteria. Evidence from included studies was synthesized using thematic analysis.Results: 20 studies of variable methodological quality were included. The studies described assessments carried out by a range of multidisciplinary professionals working with different groups of service users in diverse care contexts. Four main themes were identified: preparation for assessment; capacity assessment processes; supported decision-making; interventions to facilitate or improve practice. There was a lack of detailed information describing how professionals provided information to service users and tested their decision-making abilities. Practice reported in studies varied in terms of its conformity to legal requirements.Conclusions: This review synthesized evidence about mental capacity assessment methods and quality in England and Wales and analyzed it to suggest ways in which practice might be improved.Implications for rehabilitationMental capacity assessment practice in England and Wales varies and is not always consistent with legal requirements, risking inconsistent and inaccurate judgements about capacity and exposure to legal action.Interventions have been developed to help professionals to engage in supported decision-making, and improve their mental capacity assessments and documentation in line with legal standards.These interventions include training and practical resources, such as assessment flowcharts, checklists and documentation aids. Such interventions would benefit from robust evaluation before they are implemented more widely.

The hidden health care costs of power of attorney legislation in Scotland: what needs to be done?

Current power of attorney legislation in many European countries seeks to protect the rights of adult patients who lack capacity by ensuring that discharge from hospital to an alternative care setting only occurs when there is legal authority to do so, via a named guardian or power of attorney. In Scotland, a clause introduced in 2007 allows some patients who lack capacity to be transferred from hospital to a community care service provided all relevant parties are agreed that this is in keeping with the legislation (the ‘least restrictive option’) and the patient does not resist the move. However, there is variation in the understanding and use of this clause by local authorities across Scotland, often resulting in avoidable hospital delays, which are costly and cause ‘bed blocking’. This essay illustrates the costs of hospital delays due to current power of attorney legislation in Scotland and highlights the need for the systematic monitoring of power of attorney data and related hospital delays, and for alternative legislation to be considered in the future.