The role of competence and capacity in relation to consent for treatment in adult patients

Informed consent in psychiatry outpatients

Background & objectives

Comprehension and process of consent are important for persons with mental illness as they may not be impaired in considering research participation. The American Psychiatric Association developed a detailed Cultural Formulation Interview (CFI). The present study was a part of field testing of CFI, aimed to standardize cultural information affecting the patients' management in India. This paper describes the process and conclusions from the consent-seeking process of this study.

Methods

The purpose and procedures about field trial of the CFI were introduced and the patient and caregiver were requested for participation. Consent process was carried out step by step, by reading out the consent form to the first new patient of the day in the psychiatry outpatients department of a tertiary care hospital in north India, inviting questions followed by the 'comprehension' questions. The entire process was audiotaped without any personal identifiers. The process was repeated if not comprehended.

Results

A total of 67 patients consented, 11 refused and majority were educated more than secondary school. Some concerns shown by the patients and caregivers included risk of participation, loss or benefits of participation, privacy, etc. All types of mentally ill patients participated in the study.

Interpretation & conclusions

Translations of consent forms used simple words, consonant with understanding of the potential participants. Patients' belief that participating in this long process would improve their care, and serve humanity, influenced their decision to participate. Except for intoxication and severe psychosis, patients could understand and comprehend issues around consent. Main issues were confidentiality and culture. Our experience in the psychiatry OPD refutes the commonly held belief that mentally ill persons lack comprehension and ability to consent.

Patient competence in relation with medical and psychosocial characteristics in cardiology context: A cross-sectional study

BACKGROUND

Growth of cardiovascular disease (CVD), variation in provision of medical services, rising costs, and increasing information availability through the media are making patients more actively involved in decision-making process of their treatment. The aim of this study was to better understand the components of patient competence in the context of coronary artery disease (CAD) and to further evaluate their relations with medical, demographic, and psychosocial characteristics.

METHODS

In this cross-sectional study, 148 patients with at least one year diagnosis of acute coronary syndrome (ACS) were enrolled in the study from April to June 2014. Data on demographic characteristics, depression, anxiety, quality of life (QOL), social support, and drug adherence were collected from participants. Pearson correlation, one way analysis of variance (ANOVA), and multiple linear regression tests were performed for analyzing data.

RESULTS

The mean age of patients was 53.63 ± 5.15. Of the participants, 58 (39.5%) and 61 cases (41.5%) were found to be depressed and anxious, respectively. Higher levels of self-regulation correlated with higher education years and social support, and also with lower depression and anxiety (P < 0.050). Stress management and confronting the threat were linked to education years, depression, anxiety, QOL, and social support (P < 0.050).

CONCLUSION

The patients with CAD, in order to be involved in the proper treatment process and manage their emotions during this process, need to have the required competencies. Patient competence as a whole and its components have been related to medical, demographic, and psychosocial characteristics.

Medico-Legal Considerations in Providing Emergency Dental Care in Practice

The unpredictability of unscheduled emergency dental care carries its own clinical, communication and management challenges with associated medico-legal risks. Providing emergency dental treatment for unfamiliar patients in an unfamiliar environment amplifies the hidden pitfalls which failure to avoid can create potentially damaging critical incidents in a practitioner's professional life. These are preferably avoided through consistent attention to best practice and risk management. Day to day processes, such as excellent record-keeping, valid consent and effective communication are under the spotlight in the event that a patient complains, raises a concern with a regulator or seeks compensation following alleged negligent care. This paper aims to highlight the dento-legal pitfalls that may be pertinent in such a challenging situation.

Level of knowledge and understanding of informed consent amongst the training grade group orthodontists in England, Wales and Northern Ireland

OBJECTIVE

To assess the level of knowledge and understanding of informed consent in UK orthodontic trainees.

DESIGN AND SETTING

A cross-sectional, written questionnaire-based study.

SETTING

Hospital orthodontic departments in England, Wales and Northern Ireland.

SUBJECTS AND METHOD

A one page questionnaire which covered a range of legal issues pertinent to informed consent was circulated to 207 members of the Training Grades Group (TGG) of the British Orthodontic Society (BOS). The questionnaire consisted of four open questions with 11 responses, which the investigators considered to be ideal, seven closed questions requiring yes/no responses and one question requiring a yes/no response followed by two open responses. Following the initial circulation, a second posting to non-responders was conducted.

RESULTS

The response rate was 61% (N=126). The mean number of complete answers to the 21 questions was 13 (62%; median 13; mode 14). There were a low number of complete responses to specific questions in the following areas - explanations patients need from clinicians prior to obtaining consent; how to fully judge if a patient is capable of consenting; how to manage a patient incapable of giving consent; the legal status of fathers consenting on behalf of their children; whether consent forms have to be re-signed if the start of treatment is delayed by six months or more and responsibility for obtaining consent for dental treatment under general anaesthesia.

CONCLUSIONS

There was a disappointingly high proportion of incomplete answers to questions testing the knowledge and understanding of the law as it pertains to informed consent exists amongst members of the TGG of BOS.

An audit of the level of knowledge and understanding of informed consent amongst consultant orthodontists in England, Wales and Northern Ireland

OBJECTIVE

To determine the level of knowledge and understanding of informed consent amongst consultant orthodontists.

DESIGN

A questionnaire which covered a range of legal issues on informed consent as it pertains to clinical practice in three of the four nations of the United Kingdom.

SETTING

Hospital orthodontic departments in England, Wales, and Northern Ireland.

SUBJECTS AND METHODS

A questionnaire was initially issued to 14 consultant orthodontists working in the East of England as a regional audit project on informed consent in 2005. After the completion of the audit in 2006, the pilot data were used to refine the questionnaire for wider circulation. The project was then submitted to the British Orthodontic Society (BOS) clinical effectiveness committee which subsequently gave its endorsement for national circulation. The questionnaire was then sent to 216 other consultants in June 2007, with two further postings to non-responders before the survey was closed four months later. The standard required for clinical practice to be lawful is that all of the questions should be answered correctly.

RESULTS

Of the 233 consultant orthodontists who were invited to participate, 183 complied (78.5%) and 50 did not (21.5%). Of those who responded, 179 answered the questionnaire (76.8%) while four had either resigned or retired (1.7%). Out of the 21 answers to the 11 questions that were posed, the mean, median and mode correct response rates were 12 (57%), 11 (52%), and 10 (48%) respectively. The areas which were found to have the poorest level of understanding included what explanations patients need from clinicians in order for them to give consent, how to fully judge if a patient is capable of giving consent, how to manage a patient deemed incapable of giving consent, the legal status of fathers consenting on behalf of their children, whether consent forms have to be re-signed if the start of treatment is delayed by six months or more, and that dentists referring a patient for treatment requiring a general anaesthetic have the same duty to receive consent for the anaesthesia as do the clinicians who will be performing the surgical procedure.

CONCLUSIONS

The results of this audit indicate certain key areas of deficiency in the knowledge and understanding of informed consent amongst consultant orthodontists. The findings provide an opportunity for all clinicians to improve their education and therefore their potential to comply with both the ethical obligation and the legal requirement of gaining valid consent before the start of any treatment.