Management of hunger strike: A medical, ethical and legal conundrum

Hunger strike is a protest where an informed person refuses essential nourishment with the intention of accomplishing a specific goal. Hunger strikes conflict with medical, ethical, humanitarian and legal values. A multidisciplinary approach is important when dealing with hunger strike patients. On one hand, there is the wish to preserve life, and on the other to respect the strikers' autonomy and their wishes, values and advanced directives (or living will). Most hunger strikes are short-lived, but in complex and prolonged circumstances, legal advice must be sought from health service solicitors and a doctor's medical indemnity organisation. There is an emergent need to have defined guidelines for the management of these hunger strikes to be followed.

The U-ARE Protocol: A Pragmatic Approach to Decisional Capacity Assessment for Clinical Research

With increased longevity and growth in the number of older adults comes rising rates of individuals with cognitive impairment and dementia. The expansion of this population has important implications for research on aging and dementia syndromes, namely increased enrollment of older individuals in clinical research. Ethical prerogatives, as well as historical underrepresentation of persons with dementia in research studies due to the perceived burden of traditional decisional capacity evaluations, necessitates the development of pragmatic approaches to ascertain decisional abilities in research settings. We outline a protocol used in the Wisconsin Alzheimer's Disease Research Center (ADRC) that adopts a stepped approach to the evaluation of decisional capacity meant to maximize study visit efficiency while preserving participant safety and autonomy. The protocol specifies the structure of the consent process and incorporates a brief semi-structured interview based on Appelbaum & Grisso's theoretical model for evaluating a patient's decisional capacity to provide informed consent to participate in research. This protocol is easily implemented in a research study visit and is designed to minimize participant burden and ensure reliable assessment of decisional capacity in older adults across a wide range of research protocols. The protocol emphasizes capacity optimization, using memory aids and other compensatory strategies to preserve participant autonomy while protecting welfare.

Can women in labor give informed consent to epidural analgesia?

There are reasons to believe that decision-making capacity (mental competence) of women in labor may be compromised in relation to giving informed consent to epidural analgesia. Not only severe labor pain, but also stress, anxiety, and premedication of analgesics such as opioids, may influence women's decisional capacity. Decision-making capacity is a complex construct involving cognitive and emotional components which cannot be reduced to 'understanding' alone. A systematic literature search identified a total of 20 empirical studies focused on women's decision-making about epidural analgesia for labor pain. Our review of these studies suggests that empirical evidence to date is insufficient to determine whether women undergoing labor are capable of consenting to epidural analgesia. Given such uncertainties, sufficient information about pain management should be provided as part of prenatal education and the consent process must be carefully conducted to enhance women's autonomy. To fill in the significant gap in clinical knowledge about laboring women's decision-making capacity, well-designed prospective and retrospective studies may be required.

Critical analysis of the Council for International Organizations of Medical Sciences 2016 International Guidelines for health-related research involving humans

This paper presents a preliminary discussion of the Council for International Organizations of Medical Sciences (CIOMS), recently issued “International Ethical Guidelines for Health-related Research Involving Humans” (2016) that acknowledges the document’s declared concern of the protection of human subjects and awareness of their needs and interests in “low-resource settings”. Nevertheless, guideline recommendations present exceptional situations –vulnerability, mental incompetence- wherein voluntary and consented participation may be reduced or omitted under three concurrent conditions: compelling scientific value, the need to include persons that will not benefit directly from participation, exposure to minimal or slight risks. CIOMS 2016 extends the range of issues than need deliberation and regulation, but it does not clarify controversial issues in research ethics. The indetermination of special situations that would allow incomplete or absent informed disclosure weakens rigorous ethical norms and opens up to slippery slopes of permissiveness that may be harmful to host-nations and participants of biomedical studies.

Capacity and consent: Knowledge and practice of legal and healthcare standards

INTRODUCTION:

Healthcare practitioners have a legal, ethical and professional obligation to obtain patient consent for all healthcare treatments. There is increasing evidence which suggests dissonance and variation in practice in assessment of decision-making capacity and consent processes.

AIMS:

This study explores healthcare practitioners' knowledge and practices of assessing decision-making capacity and obtaining patient consent to treatment in the acute generalist setting.

METHODS:

An exploratory descriptive cross-sectional survey design, using an online questionnaire, method was employed with all professional groups invited via email to participate. Data were collected over 3 months from July to September 2015. Survey content and format was reviewed by the liaison psychiatry team and subsequently contained five sections (demographics, general knowledge and practice, delirium context, legal aspects and education/training). Descriptive, univariate and bivariate analysis of quantitative data and qualitative content analysis of qualitative data were undertaken.

ETHICAL CONSIDERATIONS:

The study was approved by the institutional Human Research and Ethics Committee and informed consent was taken to be provided by participants upon completion and submission of the de-identified survey.

RESULTS:

In total, 86 participants engaged the survey with n = 24, exiting at the first consent question. Almost two-thirds of respondents indicated that all treatments required patient consent. Knowledge of consent and decision-making capacity as legal constructs was deficient. Decision-making capacity was primarily assessed using professional judgement and perceived predominantly as the responsibility of medical and psychology staff. A range of patient psychological and behavioural symptoms were identified as indicators requiring assessment of decision-making capacity. Despite this, many patients with delirium have their decision-making capacity assessed and documented only sometimes. Uncertain knowledge and inconsistent application of legislative frameworks are evident. Many participants were unsure of the legal mechanisms for obtaining substitute consent in patients with impaired decision-making capacity and refusing treatment.

CONCLUSION:

The legal context of decision-making capacity and consent to treatment appears complex for healthcare practitioners. Professional, ethical and legal standards of care in this context can benefit from structured education programmes and supportive governance processes. An understanding of why 'duty of care' is being used as a framework within the context of impaired decision-making capacity is warranted, alongside a review of the context of Duty of Care within health policy, guidance and faculty teaching.

Could Ethical Tensions in Oral Healthcare Management Revealed by Adults with Intellectual Disabilities and Caregivers Explain Unmet Oral Health Needs? Participatory Research with Focus Groups

BACKGROUND

Cognitively impaired patients often present poor oral health status that may be explained by ethical tensions in oral healthcare management. This participatory study explored such tensions among adults with intellectual disabilities and with caregivers. The second objective was to specify, with caregivers, the points that should be developed in a future study among dentists.

MATERIALS AND METHODS

Three focus groups involving adults with intellectual disabilities, family caregivers and professional caregivers were organized in France in 2013.

RESULTS

The thematic content analysis identified discrepancies between experiences and expectations, which were particularly marked for the dentist's competence and attitudes, the dentist's role in decisions, the dental care management and the French socio-political context.

CONCLUSIONS

These discrepancies could partly explain multiple attempts to find the 'right' dentist or the fact that care was abandoned, and could at least contribute to oral health needs being unmet.

Electroconvulsive therapy without consent from patients: one-year follow-up study

INTRODUCTION

No previous study has been designed to analyze the reasons for electroconvulsive therapy (ECT) without patients' consent. In the present study we compared the clinical characteristics and one-year outcomes between patients with refusal to undergo ECT and patients without competency for ECT consent.

METHODS

In a retrospective cohort study, 29 patients were treated with ECT without providing consent between 1 January 2006 and 31 August 2010. A surrogate family member gave informed consent for ECT to meet current legal requirements. Patients were assigned to one of two groups: a consent-refusal group comprising patients who refused to give consent for ECT and could clearly say "no" or argue with psychiatric staff about receiving ECT; and a consent-incompetent group comprising patients who were incompetent for consent but underwent ECT passively or reluctantly without argument.

RESULTS

The patients were clinically diagnosed with schizoaffective disorder (n = 6), psychotic disorder (n = 12), bipolar I disorder (n = 8) and major depressive disorder with psychotic features (n = 3). The consent-incompetent patients had longer hospital stays and more recurrence in one year than the consent-refusal patients, which may be because the former group had more psychotic disorders and fewer mood disorders. All patients improved rapidly and efficiently. However, remission was temporal in two-thirds of patients and the rehospitalization rate in one year was 66% (n = 19).

DISCUSSION

ECT can be applied early, emergently and successfully to patients who have a wide range of psychiatric disorders and life-threatening conditions without threat of lawsuits, even during their first hospitalization.

Preliminary Turkish study of psychiatric in-patients' competence to make treatment decisions

INTRODUCTION

Competence is a prerequisite for informed consent. Patients who are found to be competent are entitled to accept or refuse the proposed treatment. In recent years, there has been an increased interest in studies examining competence for treatment in psychiatric patients. In this study, we aimed to investigate the decision-making competencies of inpatients with a range of psychiatric diseases.

METHODS

This study was carried out at the psychiatry clinic of Kocaeli University Hospital in Turkey from June 2007 to February 2008. Decision-making competence was assessed in 83 patients using the MacArthur Competence Assessment Tool-Treatment (MacCAT-T).

RESULTS

The study groups consisted of patients with mood (39.8%), psychotic (27.7%) and anxiety disorders (18.1%), and alcohol/substance addiction (14.5%). There was a significant relation between decision-making competence and demographic and clinical characteristics. Appreciation of the given information was more impaired in psychotic disorder patients than in other patients, but understanding and reasoning of the given information was similar in all groups.

DISCUSSION

These results reveal the importance of evaluating decision-making competencies of psychiatric patients before any treatment or intervention is carried out to ascertain their ability to give informed consent to treatment. Institutional and national policies need to be determined and put into practice relating to the assessment and management of competence in patients with psychiatric disorders.