1
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McFarland D, Alici Y, Kostelecky NT, Voigt L. Assessment of Decision-Making Capacity in Ninety-Seven Hospitalized Patients with Cancer: A Call for Standardization. J Acad Consult Liaison Psychiatry 2024:S2667-2960(24)00052-1. [PMID: 38797329 DOI: 10.1016/j.jaclp.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/08/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND 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. METHODS We conducted a retrospective chart review of ninety-seven consecutive psychiatric consultations for DMC from 2017-2019. Demographic, hospital-based, and psychiatry consult differences were assessed based on the reasons for DMC evaluation (uncertainty, patient refusal, emergency) and whether patients had decisional capacity. RESULTS 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 C-L 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 three months after the consult. CONCLUSIONS 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.
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Affiliation(s)
- Daniel McFarland
- Department of Psychiatry, University of Rochester, Rochester, NY; Wilmont Cancer Center, University of Rochester, Rochester, NY.
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY; Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Natalie T Kostelecky
- Department of Anesthesiology, Pain and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Louis Voigt
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Anesthesiology, Pain and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Anesthesiology, Weill Cornell Medical College; Department of Medicine, Weill Cornell Medical College
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2
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Riva L. The Physician-Assisted Suicide Pathway in Italy: Ethical Assessment and Safeguard Approaches. JOURNAL OF BIOETHICAL INQUIRY 2024; 21:185-192. [PMID: 37831290 PMCID: PMC11052828 DOI: 10.1007/s11673-023-10302-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/02/2023] [Indexed: 10/14/2023]
Abstract
Although in Italy there is currently no effective law on physician-assisted suicide or euthanasia, Decision No. 242 issued by the Italian Constitutional Court on September 25, 2019 established that an individual who, under specific circumstances, has facilitated the implementation of an independent and freely-formed resolve to commit suicide by another individual is exempt from criminal liability. Following this ruling, some citizens have submitted requests for assisted suicide to the public health system, generating a situation of great uncertainty in the application processes. As a matter of fact, shared and defined procedures are lacking as Decision 242/2019 merely added some principles on which the legislature will have to base its future intervention. This paper analyses the advisory role that the Decision attributes to territorial ethics committees with the aim of stimulating discussions on their role in oversight mechanisms. The proposed conclusion is that the envisaged role does not appear consistent with the functions of these bodies and is ultimately substantially undefined and unjustified.
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Affiliation(s)
- Luciana Riva
- Bioethics Unit, Istituto Superiore di Sanità, Via Giano della Bella 34, 00162, Roma, Italia.
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3
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Waler N, Daubenspeck D. Ethical Considerations Surrounding Patient Refusal of Emergent Aortic Surgery. J Cardiothorac Vasc Anesth 2024; 38:542-548. [PMID: 37880039 DOI: 10.1053/j.jvca.2023.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Nicholas Waler
- Department of Anesthesiology and Critical Care, University of Chicago, Chicago, IL.
| | - Danisa Daubenspeck
- Department of Anesthesiology and Critical Care, University of Chicago, Chicago, IL
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4
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Mirza OF, Appel JM. Capacity Reconceptualized: From Assessment Tool to Clinical Intervention. Camb Q Healthc Ethics 2024; 33:35-39. [PMID: 36825923 DOI: 10.1017/s0963180123000105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Capacity evaluation has become a widely used assessment device in clinical practice to determine whether patients have the cognitive ability to render their own medical decisions. Such evaluations, which might be better thought of as "capacity challenges," are generally thought of as benign tools used to facilitate care. This paper proposes that such challenges should be reconceptualized as significant medical interventions with their own set of risks, side effects, and potentially deleterious consequences. As a result, a cost-benefit analysis should be implemented prior to imposing such capacity challenges, and efforts should be made to minimize such challenges in situations where they are unlikely to alter the course of treatment.
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Affiliation(s)
- Omar F Mirza
- Department of Psychiatry, Harlem Hospital, New York, New York, USA
| | - Jacob M Appel
- Department of Psychiatry and Medical Education, Mount Sinai's Icahn School of Medicine, New York, New York, USA
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5
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Serdenes R, Arana F, Karasin J, Kontos N, Musselman M. Approaching differential diagnosis and decisional capacity assessment in the context of COVID-19 conspiracy beliefs: A narrative review and clinical discussion. Gen Hosp Psychiatry 2023; 83:75-80. [PMID: 37119781 PMCID: PMC10121076 DOI: 10.1016/j.genhosppsych.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/20/2023] [Accepted: 04/17/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE COVID-19 conspiracy theories have become widespread since the onset of the pandemic and compound the existing challenges of decisional capacity assessment. This paper aims to review the literature pertaining to decisional capacity assessment in the context of COVID-19 conspiracy beliefs and synthesize a practical approach with an emphasis on differential diagnosis and clinical pearls for the practicing physician. METHODS We reviewed papers on decisional capacity assessment and differential diagnosis in the context of COVID-19 conspiracy beliefs. A literature search was conducted using the US National Library of Medicine's PubMed.gov resource and Google Scholar. RESULTS The resulting article content was utilized to synthesize a practical approach to decisional capacity assessment in the context of COVID-19 conspiracy beliefs. Specifically, aspects related to the history, taxonomy, evaluation, and management are reviewed. CONCLUSIONS Appreciating the nuanced differences between delusions, overvalued ideas, and obsessions while with integrating the non-cognitive domains of capacity into the assessment are crucial to navigating the wide differential diagnosis of COVID-19 conspiracy beliefs. It is important to attempt to clarify and optimize patient decision-making abilities by addressing circumstances, attitudes, and cognitive styles specific to patients with seemingly irrational beliefs about COVID-19.
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Affiliation(s)
- Ryan Serdenes
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America.
| | - Francesca Arana
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Jamie Karasin
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Nicholas Kontos
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Meghan Musselman
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
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6
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Why the Capacity Consult? The Perspective of Medicine Hospitalists on their Reasons for Consulting Psychiatry for Decision-Making Capacity. Gen Hosp Psychiatry 2023; 80:40-42. [PMID: 36577191 DOI: 10.1016/j.genhosppsych.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/16/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
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7
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Geppert CMA, Brendel RW, Trachsel M. Editorial: Community series in ethics in psychiatry and psychotherapy - Volume II. Front Psychiatry 2023; 14:1199083. [PMID: 37205978 PMCID: PMC10191112 DOI: 10.3389/fpsyt.2023.1199083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 04/05/2023] [Indexed: 05/21/2023] Open
Affiliation(s)
- Cynthia M. A. Geppert
- School of Medicine, University of New Mexico, Albuquerque, NM, United States
- Alden March Bioethics Institute, Albany Medical College, Albany, NY, United States
| | - Rebecca Weintraub Brendel
- Center for Bioethics, Harvard Medical School, Boston, MA, United States
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Manuel Trachsel
- Medical Faculty, University of Basel, Basel, Switzerland
- Clinical Ethics Unit, University Hospital of Basel, Basel, Switzerland
- Clinical Ethics Unit, University Psychiatric Clinic Basel, Basel, Switzerland
- *Correspondence: Manuel Trachsel
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8
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Caravella RA, Skimming K, Bradley MV. Psychiatric Consultation When a Patient Refuses Medical Care. Psychiatr Ann 2023. [DOI: 10.3928/00485713-20230103-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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9
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Kim SYH, Kane NB, Ruck Keene A, Owen GS. Broad concepts and messy realities: optimising the application of mental capacity criteria. JOURNAL OF MEDICAL ETHICS 2022; 48:838-844. [PMID: 34341150 PMCID: PMC9626907 DOI: 10.1136/medethics-2021-107571] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/25/2021] [Indexed: 06/13/2023]
Abstract
Most jurisdictions require that a mental capacity assessment be conducted using a functional model whose definition includes several abilities. In England and Wales and in increasing number of countries, the law requires a person be able to understand, to retain, to use or weigh relevant information and to communicate one's decision. But interpreting and applying broad and vague criteria, such as the ability 'to use or weigh' to a diverse range of presentations is challenging. By examining actual court judgements of capacity, we previously developed a descriptive typology of justifications (rationales) used in the application of the Mental Capacity Act (MCA) criteria. We here critically optimise this typology by showing how clear definitions-and thus boundaries-between the criteria can be achieved if the 'understanding' criterion is used narrowly and the multiple rationales that fall under the ability to 'use or weigh' are specifically enumerated in practice. Such a typology-aided practice, in theory, could make functional capacity assessments more transparent, accountable, reliable and valid. It may also help to create targeted supports for decision making by the vulnerable. We also discuss how the typology could evolve legally and scientifically, and how it lays the groundwork for clinical research on the abilities enumerated by the MCA.
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Affiliation(s)
- Scott Y H Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Nuala B Kane
- Department of Psychological Medicine, IoPPN, London, UK
| | - Alexander Ruck Keene
- Dickson Poon School of Law, King's College London, London, UK
- 39 Essex Chambers, London, UK
| | - Gareth S Owen
- Department of Psychological Medicine, IoPPN, London, UK
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10
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Kane NB, Ruck Keene A, Owen GS, Kim SYH. Difficult Capacity Cases-The Experience of Liaison Psychiatrists. An Interview Study Across Three Jurisdictions. Front Psychiatry 2022; 13:946234. [PMID: 35898632 PMCID: PMC9309683 DOI: 10.3389/fpsyt.2022.946234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/20/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Assessment of capacity for treatment and discharge decisions is common in the general hospital. Liaison psychiatrists are often asked to support the treating medical or surgical team in difficult capacity assessments. However, empirical research on identification and resolution of difficult capacity cases is limited. Some studies have identified certain patient, decisional, and interpersonal factors which cause difficulty, but no study has explored how these issues are resolved in practice. Our study therefore aimed to describe how experienced liaison psychiatrists identify and resolve difficult capacity cases in a general hospital setting. METHODS We carried out semi-structured interviews with 26 liaison psychiatrists from England, Scotland, and New Zealand, on their most difficult capacity cases. Thematic analysis was used to examine types of difficulty and how these were resolved in practice. Summaries were prepared and example quotes extracted to illustrate phenomena described. RESULTS We identified four types of difficulty in capacity assessment, spanning both clinical and ethical domains: 1) Difficulty determining whether the decision is the patient's own or driven by illness, 2) Difficulty in applying ethical principles, 3) Difficulty in avoiding personal bias, and 4) Procedural difficulties. The liaison psychiatrists presented as self-reflective and aware of challenges and pitfalls in hard cases. We summarized their creative strategies to resolve difficulty in assessment. CONCLUSION Practitioners approaching difficult capacity cases require both clinical skills, e.g., to uncover subtle illness impairing decision-making and to consider interpersonal dynamics, and ethical skills, e.g., to negotiate the role of values and risks in capacity assessment. Education and training programmes should incorporate both aspects and could include the resolution strategies identified in our study. Practitioners, supported by health and social care systems, should work to develop self-aware and reflective capacity assessment practice.
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Affiliation(s)
- Nuala B Kane
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Alex Ruck Keene
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Gareth S Owen
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Scott Y H Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, United States
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11
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Hamm B. Psychiatric Facilitation of Care When Requested for Assessment of Decision-Making Capacity. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210215-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Kane NB, Keene AR, Owen GS, Kim SYH. Applying decision-making capacity criteria in practice: A content analysis of court judgments. PLoS One 2021; 16:e0246521. [PMID: 33544766 PMCID: PMC7864395 DOI: 10.1371/journal.pone.0246521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/20/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/OBJECTIVES Many jurisdictions use a functional model of capacity with similar legal criteria, but there is a lack of agreed understanding as to how to apply these criteria in practice. We aimed to develop a typology of capacity rationales to describe court practice in making capacity determinations and to guide professionals approaching capacity assessments. METHODS We analysed all published cases from courts in England and Wales [Court of Protection (CoP) judgments, or Court of Appeal cases from the CoP] containing rationales for incapacity or intact capacity(n = 131). Qualitative content analysis was used to develop a typology of capacity rationales or abilities. Relationships between the typology and legal criteria for capacity [Mental Capacity Act (MCA)] and diagnoses were analysed. RESULTS The typology had nine categories (reliability: kappa = 0.63): 1) to grasp information or concepts, 2) to imagine/ abstract, 3) to remember, 4) to appreciate, 5) to value/ care, 6) to think through the decision non-impulsively, 7) to reason, 8) to give coherent reasons, and 9) to express a stable preference. Rationales most frequently linked to MCA criterion 'understand' were ability to grasp information or concepts (43%) or to appreciate (42%), and to MCA criterion 'use or weigh' were abilities to appreciate (45%) or to reason (32%). Appreciation was the most frequently cited rationale across all diagnoses. Judges often used rationales without linking them specifically to any MCA criteria (42%). CONCLUSIONS A new typology of rationales could bridge the gap between legal criteria for decision-making capacity and phenomena encountered in practice, increase reliability and transparency of assessments, and provide targets for decision-making support.
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Affiliation(s)
- Nuala B. Kane
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Alex Ruck Keene
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Gareth S. Owen
- Department of Psychological Medicine, Mental Health, Ethics and Law Research Group, King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Scott Y. H. Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
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13
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Reddy R, Gerkin JS, Laughon SL, Nash RP, Sowa NA, Park EM, Gala GJ, Rosenstein DL. Implementation of a Psychiatry Consultation-Liaison Service "Conseminar". J Acad Consult Liaison Psychiatry 2020; 62:472-477. [PMID: 34219658 DOI: 10.1016/j.jaclp.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 12/20/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The field of consultation-liaison psychiatry has generated a relatively small number of rigorous clinical trials that guide clinical care. Consequently, there is a need for a consensus-building process to inform best practices for common clinical dilemmas in consultation-liaison psychiatry. OBJECTIVE We review several consensus-building approaches in academic medicine and describe a novel educational process called a "conseminar," which is intended to minimize the variability in teaching and practice on a service staffed by multiple faculty members. METHODS The conseminar is an iterative group exercise among faculty who attend on a consultation-liaison service. Faculty members generate a list of candidate topics and then prioritize those topics for a focused and critical literature review, aided by a librarian. In the absence of definitive clinical trial data or established practice guidelines, the faculty articulates a consensus "best-practice" approach and creates a brief document that summarizes specific recommendations for learners on the service. CONCLUSIONS The conseminar process can minimize variability among consultation-liaison faculty within a single institution with respect to the diagnostic and treatment recommendations conveyed to trainees. Furthermore, conseminar documents can be shared across institutions to promote more consistent teaching and practice within consultation-liaison psychiatry.
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Affiliation(s)
- Rishika Reddy
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan S Gerkin
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Sarah L Laughon
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Rebekah P Nash
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Nate A Sowa
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Gary J Gala
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC.
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Vara A, Young G, Douglass A, Sundram F, Henning M, Cheung G. General practitioners and decision-making capacity assessment: the experiences and educational needs of New Zealand general practitioners. Fam Pract 2020; 37:535-540. [PMID: 32206799 DOI: 10.1093/fampra/cmaa022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Assessing decision-making capacity to health care is within the scope of practice for all doctors, yet the experience of GPs in this area is unknown. OBJECTIVE To explore the experiences, perspectives, approaches and challenges for GPs in New Zealand when conducting decision-making capacity assessments. METHODS Qualitative study design comprising individual in-depth semi-structured interviews conducted with a convenience sample of GPs. Interview transcripts were transcribed verbatim and analysed using a thematic analysis approach. RESULTS Twelve participants were recruited. The following themes emerged: (i) GPs' roles and responsibilities in decision-making capacity assessments; (ii) GPs lack formal training, knowledge, and confidence in decision-making capacity assessments; (iii) the legal interface of decision-making capacity assessments; (iv) GPs' relationships with specialists and the resulting impact on their confidence in decision-making capacity assessments; and (v) opportunities to improve GPs' knowledge and confidence in decision-making capacity assessments. CONCLUSIONS GPs take responsibility for decision-making capacity assessments; however, assessments can be complex. There is a need to develop specific curriculum and training resources for GPs to improve their clinical skills and legal knowledge in decision-making capacity assessments.
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Affiliation(s)
- Alisha Vara
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Greg Young
- Capital and Coast District Health Board, Wellington, New Zealand.,Bioethics Centre, University of Otago, Dunedin, New Zealand
| | - Alison Douglass
- Bioethics Centre, University of Otago, Dunedin, New Zealand.,Barristers Chambers, Dunedin, New Zealand
| | - Frederick Sundram
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Marcus Henning
- Centre for Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Gary Cheung
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
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15
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Ryznar E, Hamaoka D, Lloyd RB. Pilot Study of an Online Self-Directed Learning Module for Medical Decision-Making Capacity. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2020; 44:408-412. [PMID: 32162167 DOI: 10.1007/s40596-020-01215-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/24/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE This study assessed the impact of an online, self-directed learning module on medical student knowledge and attitudes regarding decision-making capacity. METHODS The authors created a 15-min didactic video on decision-making capacity and sorted medical students on the psychiatry clerkship to teaching as usual or teaching as usual plus watching the video. The authors assessed student knowledge about and attitudes toward decisional capacity assessment using a pre/posttest design. RESULTS Thirty-eight students completed the study (24% of all psychiatry clerkship students in one academic year). Students who watched the video (n = 14) achieved higher scores on the posttest compared with students who did not watch the video (n = 24) (90% vs 84% on general knowledge and case examples), though this difference was small and not statistically significant. The degree of improvement from pretest to posttest was higher for students who watched the video but did not reach statistical significance. CONCLUSIONS Overall, students found the online teaching module to be a helpful augmentation strategy for learning decisional capacity assessment. The authors incorporated student feedback and additional review to create an enhanced video, which is available on ADMSEP's Clinical Simulation Initiative website.
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Affiliation(s)
- Elizabeth Ryznar
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Derrick Hamaoka
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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16
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Capacity and the COVID-19 Surge. PSYCHOSOMATICS 2020; 61:852-853. [PMID: 32798054 PMCID: PMC7335240 DOI: 10.1016/j.psym.2020.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 11/23/2022]
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17
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Usher R, Stapleton T. Occupational therapy and decision‐making capacity assessment: A survey of practice in Ireland. Aust Occup Ther J 2020; 67:110-120. [DOI: 10.1111/1440-1630.12629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Ruth Usher
- Discipline of Occupational Therapy School of Medicine Trinity College Dublin Dublin Ireland
| | - Tadhg Stapleton
- Discipline of Occupational Therapy School of Medicine Trinity College Dublin Dublin Ireland
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18
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John S, Rowley J, Bartlett K. Assessing patients decision‐making capacity in the hospital setting: A literature review. Aust J Rural Health 2020; 28:141-148. [DOI: 10.1111/ajr.12592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Shibu John
- Coffs Harbour Health Campus Mid North Coast Local Health District Coffs Harbour NSW Australia
| | - Joanne Rowley
- Coffs Harbour Health Campus Coffs Harbour NSW Australia
| | - Kerry Bartlett
- Coffs Harbour Health Campus Mid North Coast Local Health District Coffs Harbour NSW Australia
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19
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Wicki MT. Advance Care Planning for Persons with Intellectual Disabilities. GEROPSYCH-THE JOURNAL OF GERONTOPSYCHOLOGY AND GERIATRIC PSYCHIATRY 2018. [DOI: 10.1024/1662-9647/a000187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Abstract. As people live longer, they become more likely to die from prolonged, incurable, chronic illnesses occurring more frequently in old age. This study explores the usefulness, quality, and reliability of documented advance care planning interviews to determine the decision-making capacity of persons with intellectual disabilities (IDs). A volunteer sample of 60 persons rated the capacity to consent to treatment of four persons deciding on two end-of-life decisions. Sensitivity, specificity, and percent agreement were calculated. Interrater reliability was assessed using Fleiss’ κ and Krippendorff’s α. A Yates’ corrected χ2 was used to analyze differences in ratings between groups of raters. The sensitivity value was 62%; the specificity value was 95%. The percent agreement for all participants was 70%, Fleiss’ κ was 0.396, and Krippendorff’s α was 0.395. Of the participants, 72 found documented advance care planning discussions useful for diagnosing the decision-making capacity of people with IDs. The documented interviews helped to identify those persons with IDs who had the decision-making capacity. Documented interviews on end-of-life decisions could make a valuable contribution to fostering their self-determination in end-of-life issues.
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Affiliation(s)
- Monika T. Wicki
- Institute for Professionalization and System Development, University of Applied Sciences of Special Needs Education, Zurich, Switzerland
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Iseli LM, Wangmo T, Hermann H, Trachsel M, Elger BS. Evaluating Decision-Making Capacity. GEROPSYCH-THE JOURNAL OF GERONTOPSYCHOLOGY AND GERIATRIC PSYCHIATRY 2018. [DOI: 10.1024/1662-9647/a000186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Abstract. The study identified factors that make an evaluation of decision-making capacity (DMC) difficult for clinicians in their daily work. Semistructured interviews were carried out with 24 healthcare professionals from Switzerland and subsequently thematically analyzed. The challenges they faced when evaluating DMC stemmed from three main concerns: patient characteristics that impede DMC evaluation; differing opinions and consequences of DMC evaluation; and familial and legal situations that complicate such evaluations. Physicians must be adequately trained to evaluate DMC as it is closely related to basic ethical principles of respect for patients’ autonomy and beneficence. Extensive training on DMC evaluation and the legal concept of capacity should be part of pre- and postgraduate education.
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Affiliation(s)
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Switzerland
| | - Helena Hermann
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Manuel Trachsel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Bernice S. Elger
- Institute for Biomedical Ethics, University of Basel, Switzerland
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[Refusal of treatments by an adult cancer patient]. Bull Cancer 2018; 105:234-244. [PMID: 29478572 DOI: 10.1016/j.bulcan.2017.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/18/2017] [Accepted: 11/21/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Refusal of treatment questions the treatment's adequacy as well as the quality of the care relationship. A rigorous analysis of these situations is necessary in order to respect the patient's fundamental right to decide for him/herself while preventing a potential loss of chance. This paper proposes practical guidelines for assessment and management of the refusal of treatment by adult cancer patients. METHODS The French Association for Supportive Care in Cancer and the French Society for Psycho-Oncology formed a task force that applied a consensus methodology to draft guidelines. RESULTS We propose five guidelines: (1) be informed of the conditions most often associated with refusal of treatment so as to reinforce adequate support measures; (2) understand the complexity of the process of refusal and accurately identify what is precisely refused; (3) apply an approach of systematic analysis to refusal, to try and increase the possibilities of finding an agreement while reinforcing the respect of the patient's position; (4) establish a legal procedure to address refusal of treatment that safeguards the stakeholders when no accord can be found; and (5) know the indications for ethical collective decision-making. CONCLUSION A systematic assessment procedure of treatment refusal is necessary in order to ensure that all the physical, psychological and contextual aspects of it are taken into account, and to provide patients with the best treatment possible. The setting of good care relationship, the improvement of communication skills training and of comprehensive multidisciplinary care are all crucial elements in the prevention of these situations.
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Boazak M, Peterson MJ, Smith WR, Hudson Z, Schwartz AC. "You Aren't Going to Cut On Me!" Urgent Medical Decisions for Patients With Schizophrenia. PSYCHOSOMATICS 2018; 59:506-511. [PMID: 29598977 DOI: 10.1016/j.psym.2018.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Mina Boazak
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta GA
| | - Michael J Peterson
- University of Wisconsin School of Medicine and Public Health, Madison WI
| | - William R Smith
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta GA; Department of Philosophy, University of Notre Dame, Notre Dame, IN
| | - Zachary Hudson
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta GA
| | - Ann C Schwartz
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta GA.
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Larkin A, Hutton P. Systematic review and meta-analysis of factors that help or hinder treatment decision-making capacity in psychosis. Br J Psychiatry 2017; 211:205-215. [PMID: 28882828 DOI: 10.1192/bjp.bp.116.193458] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/04/2017] [Accepted: 02/14/2017] [Indexed: 11/23/2022]
Abstract
BackgroundThe evidence on factors that may influence treatment decisional capacity ('capacity') in psychosis has yet to be comprehensively synthesised, which limits the development of effective strategies to improve or support it.AimsTo determine the direction, magnitude and reliability of the relationship between capacity in psychosis and a range of clinical, demographic and treatment-related factors, thus providing a thorough synthesis of current knowledge.MethodWe conducted a systematic review, meta-analytical and narrative synthesis of factors that help or hinder treatment decision-making capacity in psychosis, assessing the direction, magnitude, significance and reliability of reported associations.ResultsWe identified 23 relevant studies (n = l823). Psychotic symptoms had small, moderate and strong associations with appreciation, understanding and reasoning respectively. Both verbal cognitive functioning and duration of education had small to moderate correlations with understanding and reasoning. Better capacity was also associated with better insight, better metacognitive ability, higher anxiety and lower perceived coercion. No linear relationship with depression was observed. Interventions linked to improved capacity over time were in-patient care, information simplification, shared decision-making and metacognitive training.ConclusionsAlthough much is known about the role of symptoms and other clinical variables, effective and acceptable psychological interventions to support capacity in this group are lacking.
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Affiliation(s)
- Amanda Larkin
- Amanda Larkin, DClinPsych, Psychosis Research Unit, Greater Manchester Mental Health National Health Service Foundation Trust, Prestwich; Paul Hutton, DClinPsych, School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Paul Hutton
- Amanda Larkin, DClinPsych, Psychosis Research Unit, Greater Manchester Mental Health National Health Service Foundation Trust, Prestwich; Paul Hutton, DClinPsych, School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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Pesanti S, Hamm B, Esplin B, Karafa M, Jimenez XF. Capacity Evaluation Requests in the Medical Setting: A Retrospective Analysis of Underlying Psychosocial and Ethical Factors. PSYCHOSOMATICS 2017; 58:483-489. [DOI: 10.1016/j.psym.2017.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/20/2017] [Accepted: 03/25/2017] [Indexed: 11/17/2022]
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Rooney W, Schuklenk U, van de Vathorst S. Are Concerns About Irremediableness, Vulnerability, or Competence Sufficient to Justify Excluding All Psychiatric Patients from Medical Aid in Dying? HEALTH CARE ANALYSIS 2017. [DOI: 10.1007/s10728-017-0344-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Pariwatcharakul P, Singhakant S. Mental Capacity Assessments Among Inpatients Referred to the Consultation-Liaison Psychiatry Unit at a University Hospital in Bangkok, Thailand. Psychiatr Q 2017; 88:65-73. [PMID: 27155827 DOI: 10.1007/s11126-016-9439-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Clinicians routinely assess patients' mental capacity on a daily basis, but a more thorough assessment may be needed in complex cases. We aimed to identify the characteristics of inpatients in a general hospital, who were referred to a liaison psychiatry service for mental capacity assessment, reasons for the referrals, and the factors associated with their mental capacity. A 6-year retrospective study (2008-2013) was conducted using data collected routinely (e.g., age, gender, diagnosis, Thai Mental State Examination score, reasons for the referral, and the outcome of capacity assessment) on referrals for mental capacity assessment to a Consultation-liaison Psychiatry Unit at a university hospital in Thailand. Among 6194 consecutive referrals to the liaison-psychiatry services, only 0.6 % [n = 37, mean age (SD), 59.83 (20.42)] were referred for capacity assessment, 43.24 % of which lacked mental capacity. The most common requests from referring physicians were for assessment of testamentary capacity (15 assessed, 53.33 % lacking capacity), financial management capacity (14 assessed, 50 % lacking capacity), and capacity to consent to treatment (9 assessed, 22.22 % lacking capacity). Delirium, rather than dementia or other mental disorders, was associated with mental incapacity (p < 0.001) and being more dependent during the admission (p = 0.048). There were no significant differences for mean age (p = 0.257) or Thai Mental State Examination score (p = 0.206). The main request from referring clinicians was to assess testamentary capacity. Delirium and being more dependent during the admission were associated with lack of mental capacity, whereas age and dementia were not.
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Affiliation(s)
- Pornjira Pariwatcharakul
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Supachoke Singhakant
- Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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Lamont S, Stewart C, Chiarella M. Documentation of Capacity Assessment and Subsequent Consent in Patients Identified With Delirium. JOURNAL OF BIOETHICAL INQUIRY 2016; 13:547-555. [PMID: 27468831 DOI: 10.1007/s11673-016-9741-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/08/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Delirium is highly prevalent in the general hospital patient population, characterized by acute onset, fluctuating levels of consciousness, and global impairment of cognitive functioning. Mental capacity, its assessment and subsequent consent are therefore prominent within this cohort, yet under-explored. AIM This study of patients with delirium sought to determine the processes by which consent to medical treatment was attempted, how capacity was assessed, and any subsequent actions thereafter. METHOD A retrospective documentation review of patients identified as having a delirium for the twelve months February 2013 to January 2014 was undertaken. Inclusion and exclusion criteria were used; demographic and descriptive data collected. A total of n=1153 patients were identified with n=310 meeting inclusion criteria. RESULT A random sample of one hundred patients were subsequently reviewed. One third of patients (n=33) had documentation relating to consent, while four patients had documentation relating to capacity. Median delirium duration was three days, with treatment refusal occurring in twenty-two patients and "duty of care" being used as an apparent beneficent related treatment framework in twelve patients. CONCLUSIONS While impaired decision-making was indicated, the review was unable to indicate what patient characteristics flag the need for capacity assessment. Documentation relating to consent processes (whether patient or substitute) appeared deficient for this cohort.
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Affiliation(s)
- Scott Lamont
- Prince of Wales Hospital, Level 1 East Wing, Edmund Blackett Building, Sydney, NSW, 2031, Australia.
| | - Cameron Stewart
- Sydney Law School, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Mary Chiarella
- Sydney Nursing School, The University of Sydney, Sydney, NSW, 2006, Australia
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Doernberg SN, Peteet JR, Kim SYH. Capacity Evaluations of Psychiatric Patients Requesting Assisted Death in the Netherlands. PSYCHOSOMATICS 2016; 57:556-565. [PMID: 27590345 DOI: 10.1016/j.psym.2016.06.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 06/23/2016] [Accepted: 06/26/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Euthanasia or physician-assisted suicide (EAS) of psychiatric patients is legal in some countries but remains controversial. OBJECTIVE This study examined a frequently raised concern about the practice: how physicians address the issue of decision-making capacity of persons requesting psychiatric EAS. METHODS A review of psychiatric EAS case summaries published by the Dutch Regional Euthanasia Review Committees. Directed content analysis using a capacity-specific 4 abilities model (understanding of facts, applying those facts to self, weighing/reasoning, and evidencing choice) was used to code texts discussing capacity. A total of 66 cases from 2011-2014 were reviewed. RESULTS In 55% (36 of 66) of cases, the capacity-specific discussion consisted of only global judgments of patients' capacity, even in patients with psychotic disorders. Further, 32% (21 of 66) of cases included evidentiary statements regarding capacity-specific abilities; only 5 cases (8%) mentioned all 4 abilities. Physicians frequently stated that psychosis or depression did or did not affect capacity but provided little explanation regarding their judgments. Physicians in 8 cases (12%) disagreed about capacity; even when no explanation was given for the disagreement, the review committees generally accepted the judgment of the physician performing EAS. In one case, the physicians noted that not all capacity-specific abilities were intact but deemed the patient capable. CONCLUSION Case summaries of psychiatric EAS in the Netherlands do not show that a high threshold of capacity is required for granting EAS. Although this may reflect limitations in documentation, it likely represents a practice that reflects the normative position of the review committees.
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Affiliation(s)
| | - John R Peteet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Scott Y H Kim
- Department of Bioethics, National Institutes of Health, Bethesda, MD.
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Kim SYH, Lemmens T. Should assisted dying for psychiatric disorders be legalized in Canada? CMAJ 2016; 188:E337-E339. [PMID: 27328688 DOI: 10.1503/cmaj.160365] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Scott Y H Kim
- Department of Bioethics (Kim), National Institutes of Health, Bethesda, Md.; Faculty of Law and Dalla Lana School of Public Health (Lemmens), University of Toronto, Toronto, Ont.
| | - Trudo Lemmens
- Department of Bioethics (Kim), National Institutes of Health, Bethesda, Md.; Faculty of Law and Dalla Lana School of Public Health (Lemmens), University of Toronto, Toronto, Ont
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Do Consultation Psychiatrists, Forensic Psychiatrists, Psychiatry Trainees, and Health Care Lawyers Differ in Opinion on Gray Area Decision-Making Capacity Cases? A Vignette-Based Survey. PSYCHOSOMATICS 2016; 57:472-9. [PMID: 27400660 DOI: 10.1016/j.psym.2016.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 04/14/2016] [Accepted: 04/15/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds. METHOD Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS. RESULTS Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson χ(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers. CONCLUSIONS As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity.
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Life or Limb: Family as Decision Makers for a Psychotic Patient With Life-Threatening Gangrene. PSYCHOSOMATICS 2015; 56:691-5. [DOI: 10.1016/j.psym.2015.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/02/2015] [Accepted: 07/06/2015] [Indexed: 11/18/2022]
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Rovner M, Jackson WM, Dinwiddie SH. Evaluating Patients for Impaired Medical Decisional Capacity: An Overview of Ethical and Clinical Issues. Psychiatr Ann 2015. [DOI: 10.3928/00485713-20150803-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sjöstrand M, Karlsson P, Sandman L, Helgesson G, Eriksson S, Juth N. Conceptions of decision-making capacity in psychiatry: interviews with Swedish psychiatrists. BMC Med Ethics 2015; 16:34. [PMID: 25990948 PMCID: PMC4447019 DOI: 10.1186/s12910-015-0026-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/29/2015] [Indexed: 12/01/2022] Open
Abstract
Background Decision-making capacity is a key concept in contemporary healthcare ethics. Previous research has mainly focused on philosophical, conceptual issues or on evaluation of different tools for assessing patients’ capacity. The aim of the present study is to investigate how the concept and its normative role are understood in Swedish psychiatric care. Of special interest for present purposes are the relationships between decisional capacity and psychiatric disorders and between health law and practical ethics. Methods Eight in-depth interviews were conducted with Swedish psychiatrists. The interviews were analysed according to descriptive qualitative content analysis in which categories and sub-categories were distilled from the material. Results Decision-making capacity was seen as dependent on understanding, insight, evaluation, reasoning, and abilities related to making and communicating a choice. However, also the actual content of the decision was held as relevant. There was an ambivalence regarding the relationship between psychiatric disorders and capacity and a tendency to regard psychiatric patients who made unwise treatment decisions as decisionally incapable. However, in cases relating to patients with somatic illnesses, the assumption was rather that patients who made unwise decisions were imprudent but yet decisionally capable. Conclusions The respondents’ conceptions of decision-making capacity were mainly in line with standard theories. However, the idea that capacity also includes aspects relating to the content of the decision clearly deviates from the standard view. The tendency to regard imprudent choices by psychiatric patients as betokening lack of decision-making capacity differs from the view taken of such choices in somatic care. This difference merits further investigations. Electronic supplementary material The online version of this article (doi:10.1186/s12910-015-0026-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Manne Sjöstrand
- Center for Bioethics, Harvard Medical School, Boston, MA, USA. .,Stockholm Centre for Healthcare Ethics, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
| | - Petter Karlsson
- Stockholm Centre for Healthcare Ethics, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
| | - Lars Sandman
- Academy for Care, Work Life and Welfare, University College of Borås, Borås, Sweden and National Centre for Priority Setting in Health Care, Linköping University, Linköping, Sweden.
| | - Gert Helgesson
- Stockholm Centre for Healthcare Ethics, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
| | - Stefan Eriksson
- Centre for Research Ethics and Bioethics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
| | - Niklas Juth
- Stockholm Centre for Healthcare Ethics, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
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Kontos N, Querques J, Freudenreich O. Capable of more: some underemphasized aspects of capacity assessment. PSYCHOSOMATICS 2014; 56:217-26. [PMID: 25648077 DOI: 10.1016/j.psym.2014.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/13/2014] [Accepted: 11/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The 4-abilities model of decision-making capacity is vulnerable to constricted application and teaching. OBJECTIVE The authors attempt to assert the fundamentally clinical nature of capacity evaluations, while acknowledging that the concept of decision-making capacity must be legally grounded. METHODS Relevant aspects of clinical care are examined and emphasized as they apply to the evaluation of capacity for medical decision making. RESULTS Accessing patients' maximal abilities, attending to noncognitive aspects of choice, and identifying diagnostic explanations for patients' difficulties are important components of these assessments. DISCUSSION The evaluation of medical decision-making capacity is not a purely forensic task; it is enhanced by an approach that bridges the clinical-forensic divide.
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Affiliation(s)
- Nicholas Kontos
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA..
| | - John Querques
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Park EM, Sockalingam S, Ravindranath D, Aquino PR, Aggarwal R, Nemeroff SFP, Gerkin JS, Gitlin DF. Psychosomatic medicine training as a bridge to practice: training and professional practice patterns of early career psychosomatic medicine specialists. PSYCHOSOMATICS 2014; 56:52-8. [PMID: 25619674 DOI: 10.1016/j.psym.2014.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The number of interested candidates for psychosomatic medicine (PM) training programs has not matched the growing need for psychiatrists trained to care for complex medically ill patients. The reasons for this lack of growth may be found in the experience of new entrants into the subspecialty. OBJECTIVE To investigate this issue, we conducted a survey of early career psychiatrists (ECPs) practicing PM to identify the personal and professional characteristics of ECP PM specialists and to examine the relevance of PM training to professional practice. METHODS ECPs who attended the 2012 Academy of Psychosomatic Medicine annual meeting or who were registered members of the Academy of Psychosomatic Medicine completed a survey on training and work experiences. Decisional factors associated with pursuit of subspecialty fellowship education and professional practice patterns were identified using descriptive statistics and chi-square tests. RESULTS A total of 102 ECPs completed the survey. Of the respondents, 67 (67%) had completed a PM fellowship. Motivating factors for pursuing fellowship training included (1) obtaining additional clinical training, (2) developing a special interest in PM training, and (3) improving job candidacy. Overall, 80% of ECPs desired inpatient consultation-liaison positions at the time of fellowship graduation. Overall, 22% reported difficulty in obtaining employment in PM after training. Chi-square tests between subjects who pursued a PM fellowship and those who did not proved nonsignificant. CONCLUSIONS PM fellowship training remains relevant and important to ECPs in this sample. The survey results can be used to shape institutional and professional supports to better meet early career transition needs for PM psychiatrists.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC (EMP, SFPN, JSG).
| | | | | | | | | | | | - Jonathan S Gerkin
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC (EMP, SFPN, JSG)
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Assessing Decision-Making Capacity: A Primer for the Development of Hospital Practice Guidelines. HEC Forum 2014; 26:159-68. [DOI: 10.1007/s10730-014-9234-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Evaluation of decision-making capacity (DMC) for treatment is challenging. Owen et al, in this issue of the Journal, compare the abilities (understanding, appreciation and reasoning) relevant to DMC in medical and psychiatric patients. Here I discuss three key issues their article raises and that are relevant to the direction of future research.
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Affiliation(s)
- Scott Y H Kim
- Scott Y. H. Kim, MD, PhD, Department of Bioethics, 10 Center Drive, 1C118, Clinical Center, National Institutes of Health, Bethesda, Maryland 20892, USA.
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