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Annotation. The article is devoted to the study of the peculiarities of the transformation of professionally important psychophysiological qualities of military pilots, practically healthy and with stage I hypertension (80 people). Statistical analysis of the data was performed using the methods of variation statistics, nonparametric statistics – correlation (Spearman’s correlation coefficient), cluster analysis (k-means method) using the software package STATISTICA 13.3. It has been established that hypertension affects the structure of correlations of psychophysiological functions of the body, which indicates a difference in the mechanisms of regulation of these functions during the development of the disease. It is shown that even healthy military pilots have different levels of mental capacity and can show their psychophysiological qualities in different ways, especially in extreme conditions. In addition, it was found that in the presence of hypertension in the body of a third of pilots show compensatory reactions to increase the activation of body functions, which, in turn, increases the physiological cost of professional activity, to reduce which must periodically apply treatment and rehabilitation measures.

When is it lawful not to resuscitate and when is it unlawful? What is the meaning of mental capacity on the part of the patient and what is meant by patient autonomy? What is the extent of clinical discretion in decisions not to resuscitate? Does the presumption in favour of life still obtain? What about the risks in cardiopulmonary resuscitation? What have the judges decided about decisions not to resuscitate, and what is the contemporary role of the doctor in this area? Is there any need for change or reform?

Purpose Deprivation of Liberty Safeguards (DoLS), as part of the Mental Capacity Act 2005 (DoLS, 2007), was established to provide a legal framework for decision-making in respect of adults who lack capacity to make decisions in relation to their care and residence in England and Wales. The purpose of this study was to explore the DoLS decision-making process from the perspectives of health and social care practitioners when working with individuals with an acquired brain injury (ABI). Design/methodology/approach A total of 12 health and social care practitioners were interviewed in 2019–2020 about their experiences of using and making or supporting decisions in the DoLS framework with ABI survivors. Data were analysed, and a tentative explanation of variations in DoLS decision-making was developed. Findings Three distinct approaches emerged capturing different decision-making styles (risk-averse, risk-balancing and risk-simplifying) which appeared to influence the outcome of DoLS assessments. A range of mediating factors seemed to account for the variability in these styles. The wider contextual challenges that impact upon practitioners’ overall experiences and use of DoLS processes in their ABI practice were noted. Research limitations/implications The findings highlight a need for changes in practice and policy in relation to how DoLS or similar processes are used in decision-making practice with ABI survivors and may be relevant to the implementation of the Liberty Protection Safeguards that are replacing the DoLS system. Originality/value To the best of the authors’ knowledge, this is the first study to explore accounts of DoLS decision-making practices in ABI service.

Introduction The Hammersmith and Fulham Community Independence Service (CIS), runs a “virtual ward” to allow people to remain independent in their own homes where possible. Place-of-care decisions made for community-dwelling older people who lack capacity are formulated in a best-interest meeting (BIM), involving health and social care professionals, family and carers. Often BIMs centre around beliefs and wishes of the patient or family but fail to objectively evaluate risks and mitigants of staying at home versus placement. We observed that BIMs were not being held on a consistent basis, and when held lacked the necessary structure for an effective decision-making forum. Even experienced professionals find it difficult to chair BIMs because of the complexity of the decision-making process. Not all involved parties may be represented. We found BIMs more likely to be held, attended and effective when structured to identify the major relevant considerations. Method The CIS “virtual ward” team developed a BIM decision toolkit, comprising: a check-list of risks and mitigants for home versus care home; a list of required attendees; who should document and chair the meeting; and who should action the interventions raised. From 6th January to 25th October 2019, BIMs were held for 48 patients on the CIS “virtual ward”. Results 234 interventions were carried out following toolkit-led BIMs. 1 month after BIM, 34 of 44 patients’ wishes (77%) were honoured (3 not recorded, 1 died). 3 months after BIM, 23 of 31 patients’ wishes (74%) were honoured (15 not recorded, 2 died). Case studies are included in the presentation. Conclusion We developed a toolkit to support decision-making for older community dwellers who lack capacity regarding their place of care. The toolkit assures standardisation and structure to minimise bias, whilst recognising personal beliefs and preferences. It enables any member of the multidisciplinary team to hold and lead a BIM, to reliably identify appropriate interventions and care plans which may not otherwise have been implemented or recognised. The majority of the patients reviewed using the BIM toolkit remained in their preferred place of care well after the team’s interventions. Further evaluation is required to compare CIS BIM toolkit-based outcomes against other community services which do not use this toolkit, and appraise the toolkit in a hospital setting.

Objectives:To perform a meta-analysis of clinical studies on the differences in treatment or research decision-making capacity among patients with Mild Cognitive Impairment (MCI), Alzheimer’s disease (AD), and healthy comparisons (HCs).Design:A systematic search was conducted on Medline/Pubmed, CINAHL, PsycINFO, Web of Science, and Scopus. Standardized mean differences and random-effects model were used in all cases.Setting:The United States, France, Japan, and China.Participants:Four hundred and ten patients with MCI, 149 with AD, and 368 HCs were included.Measurements:The studies we included in the analysis assessed decisional capacity to consent by the MacArthur Competence Assessment Tool for Treatment (MAcCAT-T), MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), Capacity to Consent to Treatment Instrument (CCTI), and University of California Brief Assessment of Capacity to Consent (UBACC).Results:We identified 109 potentially eligible studies from 1672 records, and 7 papers were included in the meta-analysis. The meta-analysis showed that there was significant impairment in a decision-making capacity in MCI patients compared to the HCs group in terms of Understanding (SMD = −1.04, 95% CI: −1.31 to −0.77, P < 0.001; I2 = 52%, P = 0.07), Appreciation (SMD = −0.51, 95% CI: −0.66 to −0.36, P < 0.001; I2 = 0%, P = 0.97), and Reasoning (SMD = −0.62, 95% CI: −0.77, −0.47, P < 0.001; I2=0%, P =0.46). MCI patients scored significantly higher in Understanding (SMD = 1.50, 95% CI: 0.91, 2.09, P = 0.01, I2 = 78%, P = 0.00001) compared to patients affected by AD.Conclusions:Patients affected by MCI are at higher risk of impaired capacity to consent to treatment and research compared to HCs, despite being at lower risk compared to patients affected by AD. Clinicians and researchers need to carefully evaluate decisional capacity in MCI patients providing informed consent.

According to what we propose to call “the competence model,” competence is a necessary condition for valid informed consent. If a person is not competent to make a treatment decision, the decision must be made by a substitute decision-maker on her behalf. Recent reports of various United Nations human rights bodies claim that article 12 of the Convention on the Rights of Persons with Disabilities involves a wholesale rejection of this model, regardless of whether the model is based on a status, outcome, or functional approach to competence. The alleged rationale of this rejection is that denying persons the right to make their own treatment decisions based on an assessment of competence necessarily discriminates against persons with mental disorders. Based on a philosophical account of the nature of discrimination, we argue that a version of the competence model that combines supported decision-making with a functional approach to competence does not discriminate against persons with mental disorders. Furthermore, we argue that status- and outcome-based versions of the competence model are discriminatory.

The aim: Study of psychophysiological features of children depending on gender in the dynamics of the school year and the action of parents on preventive measures among primary school children Materials and methods: The study of biological adaptation of primary school students was conducted in two stages among second-graders (children 7-8 years) in the dynamics of the week and year. A total of 46 children (24 girls and 22 boys). The psychophysiological part of the study included electroencephalography (EEG) recording to assess the individual characteristics of the nervous system and determine mental performance. The next step was to determine mental performance, which is one of the important criteria for the health of schoolchildren, which characterizes the relationship between the functional state of the child’s body and learning load. The analysis of mental capacity was conducted at school with the permission of parents during the first school week and the last school week. Results: Based on the recorded EEG, the average values of the peak frequencies in each lead in the five ranges were calculated. When comparing the average values of indicators recorded in the modes of quiet wakefulness and mental load (mental account) at the beginning of the year, using a nonparametric criterion of signs revealed significant (p 0.05) by the end of the week , and had the largest number of signs on Wednesday (127.4 ± 4.2) but had no significant difference Conclusions: Preventive measures such as sleep and rest, walks in the fresh air aimed at promoting health can be the same for both girls and boys, but more attention and control over the implementation of these measures should be paid to boys.

This paper considers the potential for the Mental Capacity Act (MCA) of England and Wales to incentivise the exclusion of people with dementia from research. The MCA is intended to standardise and safeguard the inclusion of people with cognitive impairments in research. This entails various procedural requirements, which in pressurised research contexts can lead researchers to exclude people with dementia as a means of simplifying bureaucratic constraints. I consider the risks of an ‘unethical ethics’, wherein procedural ethics indirectly causes the exclusion of people with dementia from research, undermining historic successes toward increased inclusivity. I suggest several solutions, including enhanced sensitivity to impairments and shifting the burden of proof from justifying inclusion to justifying exclusion. The paper responds to the ‘ethics creep’ tradition in procedural ethics, and critical appraisals of capacity legislation in dementia research. This approach recognises that institutional research ethics is itself a major ethical concern and can unwittingly beget unethical practices. Dementia researchers must be alert to such unethical ethics.

The doctrine of consent (or informed consent, as it is called in North America) is built upon presumptions of mental capacity. Those presumptions must be tested according to legal rules that may be difficult to apply to COVID-19 patients during emergency presentations. We examine the principles of mental capacity and make recommendations on how to assess the capacity of COVID-19 patients to consent to emergency medical treatment. We term this the CARD approach (Comprehend, Appreciate, Reason, and Decide).

PurposeThe purpose of this study is to inform those who are supporting persons who are dying and are responsible for planning, commissioning or delivering palliative care about the need to support and maximise the decision-making ability and choices of persons with advanced dementia or severe frailty.Design/methodology/approachThis article will consider the legal and human rights principles applicable to Scotland, and indeed to other jurisdictions, which govern decisions about care and treatment of persons with and without capacity and the application of these principles to palliative care situations.FindingsIt is important that those involved in the care and support of the dying are fully aware of the need to support and maximise their decision-making ability concerning palliative care and treatment choices.Research limitations/implicationsIt is a well-established legal and human rights principle that the decisions of a person with capacity must be respected, including decisions about palliative care and treatment at the end of life. Moreover, recent developments in international human rights law reinforce the message that this principle applies equally to all. Applying this principle into persons with advanced dementia or severe frailty therefore requires skilled assessment and supported decision-making in order to optimise capacity and respect autonomy.Originality/valueThe discussion applies the United Nations Convention on the Rights of Persons with Disabilities approach concerning equality of rights enjoyment and supported decision-making to palliative care and treatment situations.

Established as an amendment to the Mental Capacity Act 2005 , the deprivation of liberty safeguards were introduced to ensure that anyone who lacks capacity to consent to their care, and was being deprived of their liberty, has rights equivalent to those held under the Mental Health Act 1983 . These rights include someone to oversee any deprivation of liberty, the right of appeal and the guarantee of review of appeal in a timely manner. This article outlines how deprivation of liberty safeguards work, how a deprivation of liberty safeguards is applied for and obtained, what to discuss with the next of kin, and some special circumstances to consider. It also provides information about the criteria by which deprivation of liberty safeguards applications are assessed and the process by which this is done. This provides an overview for junior doctors working in secondary care, to increase their knowledge and confidence when patients require a deprivation of liberty safeguards application.

In psychiatric practice, professionals tend to split patients into those who are responsible for their actions, and those who are not. This approach does a disservice to both groups. Patients assumed to retain agency may be blamed, and those assumed to lack agency are disempowered. Professionals should adopt a more nuanced approach to agency and control, recognising that it is impaired in most psychiatric disorders, but absent in very few. This is possible without making stigma worse.

The ban on marriages by persons suffering from serious mental disorders or affected by impaired mental capacity has been present in the Polish family legislation for many years. Therefore, there is a question whether the reasons followed by the legislator introducing it several dozen years ago into the legal system remain valid. The author tries to answer this question, at the same time indicating arguments in favour of reviewing the existing legal status. These are arguments raised not only in legal sciences, but also in medical sciences including psychiatry.

The studies were conducted with participation of 290 people (145 people were divided into 3 experimental groups and 145 people represented 3 control groups) aged 55 to 90 years. During the study, the testees were in darkened rooms at rest (sitting position) in groups of 10-12 people. For the experimental group the essential oil of winter savory was sprayed in the room for 10, 20 or 30 minutes in a concentration of I mg / m3, alongside with psychorelaxation recording. The main components of the essential oil are: carvacrol (45.22%) and n-cymene (31.26%), in much smaller quantities - karyophyllenoxide (3.33%), l-octene-3-ol (2.44%), karyophyllene (1.66%), sabinenhydrate (1.20%), the remaining components are in a concentration not higher than I %. Participants in the control group were played only psychorelaxation recording lasting 10, 20 or 30 minutes. The condition of the testees before and after treatments in control and experimental groups was assessed using hospital scale of anxiety and depression test, word recognition testing with missing letters, correction task, well-being questionnaire according to the method Dembo-Rubinstein in the modification of A. M. Prikhozhan. The obtained data were statistically processed using Student's t-test for bound and unbound series. It was found that inhalation of vapors of winter savory essential oil ( Satureja montana L.) in a concentration of I mg / m3 at all durations of the procedure (10, 20 and 30 minutes) has a pronounced positive effect on the psycho-emotional state of the elderly, but weakly and rather negatively affects the performance of both simple and complex mental work.

Alzheimer’s disease (AD) is atrophy of brain cells that lead to decline in the mental capacity and memory. This study investigated the mechanism which postulates that intraneuronal accumulation of ...

SUMMARYThere is much Mental Capacity Act 2005 (MCA) case law emanating from the Court of Protection. This article reviews an important and unique case when the court specifically addressed for the first time the question of fluctuating capacity, a not uncommon clinical problem that can often be complex. It describes how the Court of Protection in Royal Borough of Greenwich v CDM [2019] legally approached an issue of fluctuating capacity in a 64-year-old woman with a personality disorder and chronic diabetes. In doing so it elucidates a new conceptual framework to apply when assessing fluctuating capacity in terms of considering micro- and macro-decisions which can be used in routine clinical practice.

Context: Advance directive (AD) is being used in psychiatric care in developed countries for the last two decades. Although the AD is bound to offer patient autonomy and beneficence, evidence for its effectiveness and feasibility are limited. By the enactment of the Mental Health Care Act, 2017, India is going to implement AD. Aims: This study aimed to find perspectives on AD in psychiatric practice by different stakeholders in Kerala, India. Subjects and Methods: A qualitative study using focus group discussion and in-depth interview was done among mental health service users such as patients and carers, providers such as psychiatrists, clinical psychologists and psychiatric social workers, and advocates. Transcribed information was coded by R package for Qualitative Data Analysis, a free software. Results: The predominant themes identified were freedom of choice, issues of documentation, suitability in a crisis, apprehension about future care, mental capacity at the time of making the AD, issues about nominated representative, limitations in the exercise of treatment options by doctors, and the possibility of defensive practice in psychiatry. Half of the patients supported the AD, whereas the other half did not. Advocates agreed that patients should be given the freedom to choose and hence supported the AD. Some mental health service providers favored AD, whereas others were apprehensive. Conclusions: Although ADs help patients in preserving their autonomy, many uncertainties, practical issues, and legal issues are to be tackled for its effective implementation.

Toby has 26 years’ experience of working with people with severe mental health problems, and expertise in the fields of mental health in later life, dementia, and mental capacity, with an empha- sis on self-management, peer support, quality of life, rights, social inclusion and empowerment. Toby has written articles on values-based practice (VBP), co-authored a book on values-based prac- tice and mental health and mental capacity law for psychiatric nurses, produced VBP ‘key card’ information for the social care workforce throu- gh Skills for Care and is currently co-authoring a book on VBP and dementia. He is also a part time lecturer on a Masters course in dementia care at the University of West London (UWL). werment. Toby has written articles on values-based practice (VBP), co-authored a book on values-based prac- tice and mental health and mental capacity law for psychiatric nurses, produced VBP ‘key card’ information for the social care workforce throu- gh Skills for Care and is currently co-authoring a book on VBP and dementia. He is also a part time lecturer on a Masters course in dementia care at the University of West London (UWL).

In Re: AB (Termination of Pregnancy), the Court of Appeal was asked to consider an assumption made about the future living arrangements of a pregnant patient, and the weight to be ascribed to her wishes and feelings when she had no real understanding of her predicament. This commentary explores the importance of taking into account the perspective of the patient, even if suffering from a mental disorder, and it will analyse the existing common law to show that the weaker the ability of the patient to form her own wishes and feelings, the more appropriate it would be to rely on the remaining evidence.

Those with mental illness, learning disabilities, and speech and language difficulties continue to be over represented in the global criminal justice system, create immense difficulties for these individuals in navigating the system itself, and the prison environment, and contribute to the revolving door of incarceration. Very little is known with regard to the situation of the mentally ill and mentally incapacitated in African criminal justice systems. In this Commentary we discuss how the Criminal Procedure Act in South Africa still does not fully comply with the or the Protocol to the African Charter on the Rights of Person with Disabilities in criminal proceedings. An urgent review of due process is warranted where the existence of capacity based defense needs are to be considered. It is vital to distinguish between intellectual and psycho-social disability, regarding assessment and issuance of appropriate court orders to the specific needs of the person, the identified disability and the interest of justice. Consistency in mental capacity or illness assessment using validated screening tools and specialist expert reports provided to the court should comply with the general requirements of expert evidence.

This chapter covers the Mental Health Act 2005 and includes topics on The Core Test for Mental Capacity, The Obligation to Assist a Person to Gain Capacity, The Best Interests Assessment when a Patient Lacks Capacity, Non-Discrimination in Best Interests Assessment, Derivation of Liberty: General Principles, Derivation of Liberty: Life-Saving Treatment, Protection for Those Wrongly Assessing Capacity Or Best Interests, Definition of a Lasting Power of Attorney, General provisions on advanced directives, Effect of an advance decision, The Effect of Advance Decisions, Things that the Mental Capacity Act cannot authorise, and Authorising of Deprivation of Liberty.

The Queensland Police Service (QPS) and Queensland Ambulance Service may detain and transport persons experiencing major disturbances in their mental capacity to an ED for urgent care. Queensland's new mental health legislation (March 2017) makes this legal intervention difficult to scrutinise. For a large non-metropolitan region, QPS records for emergency examination orders (EEOs) and emergency examination authorities (EEAs) were compared with annual reports of Queensland's Director of Mental Health and Chief Psychiatrist. From 2009-2010 to March 2017, QPS-registered EEOs totalled 12 903 while annual reports attributed 9441 to QPS (27% fewer). From March 2017 to 2019-2020, QPS-registered EEAs totalled 6887. Annual reports declared 1803 EEAs in total for this period, without distinguishing those registered by QPS from the Queensland Ambulance Service. Past year proportions of EEOs, however, indicate perhaps ~1100 originated with QPS (84% fewer). Information crucial for considered emergency mental healthcare responses for thousands of people is no longer readily available.

Background: Heart failure is increasingly prevalent in the growing elderly population and commonly associated with cognitive impairment. This study compared trends in place of death (PoD) of heart failure patients with / without comorbid dementia over the period of implementation of the Mental Capacity Act (MCA) in October 2007, this legislation supporting patient-centred decision making for those with reduced agency.Methods: Analyses of death certification data for England between January 2001 and December 2018, describing the PoD and sociodemographic characteristics of all people ≥ 65 years registered with heart failure as the underlying cause of death, with / without a mention of comorbid dementia. Multiple Poisson regression modelling was used to determine the prevalence ratio (PR) of dying at home or in care homes compared to dying in hospital. Covariates included year of death, age, gender, marital status, comorbidity burden, index of multiple deprivation and urban / rural settings.Results:120,068 heart failure-related death records were included of which 8199 mentioned dementia as a contributory cause. The overall prevalence of dementia was 6.8%, the trend significantly increasing from 5.6% to 8.0% pre- and post-MCA (pConclusions: Our analyses suggest the MCA did not materially affect the PoD of heart failure decedents with comorbid dementia, likely reflecting difficulties implementing this legislation in real-life clinical practice.

The right of autonomous patients to make decisions about their care is core to medical practice. However, we are frequently faced with situations where a patient is unable to make those decisions because of their medical status, mental health or intellectual ability. Here we consider the legal framework for the treatment of those who lack the capacity to decide for themselves, and some of the factors that influence how such decisions are made.

The four pillars of medical ethics – autonomy, beneficence, non-maleficence and justice – provide a clinical framework for decision-making. Usually the patient has capacity for making decisions based on being given accurate information in a format that is understandable and applicable to their situation. The Mental Capacity Act 2005 has created a legal framework for decision-making when people may lack capacity. Capacity may fluctuate, may be partly impaired and must be carefully assessed when all efforts to support a person to make their own decision have failed. Capacity assessment must evaluate functional capacity, which is time and decision specific. When a person lacks capacity a decision must be taken that is in their best interests, and accords as much as possible with their wishes, feelings, values and beliefs.

It is well documented that people with moderate-to-severe traumatic brain injury (TBI) can undergo personality changes, including becoming more impulsive in terms of how they behave. Legal guidance and academic commentary support the view that impulsiveness can render someone decisionally incompetent as defined by English and Welsh law. However, impulsiveness is a trait found within the healthy population. Arguably, impulsiveness is also a trait that gives rise to behaviours that should normally be tolerated even when they cause harm to the person enacting the behaviours. The purpose of this paper is to show why both of these considerations present as significant challenges to the law in England and Wales.

Purpose The purpose of this paper is to evaluate staff knowledge of Mental Capacity Act (MCA) capacity assessments within the Learning Disabilities division of a Mental Health and Learning Disabilities Trust. The limited research available suggests staff knowledge tends to be poor, particularly concerning who is the decision maker. Design/methodology/approach A 12-item multiple choice questionnaire, which reflects the five core principles of MCA (2005), was developed. Questionnaires were completed by 262 health and social staff members who support people with LD. Findings Results show high variability of MCA capacity assessment knowledge within the LD division. However, qualified staff and those from health services scored significantly higher across all categories on the questionnaire compared to non-qualified and social care staff, respectively. On average, all staff scored poorly when asked to identify “who is the decision maker?” in a case scenario question. Research limitations/implications The main limitation is that we did not collect data on how many previous capacity assessments and discussions each person had been involved with. The findings clearly suggest current methods of training lack efficacy in helping staff apply MCA knowledge to their clinical work. Originality/value Compared to past literature, this study utilised a novel and more comprehensive questionnaire. This focused on case scenario questions to assess staff situational judgement. In addition, the findings add to a sparse evidence base that provides a foundation for future research.

In severe dysphagia, risk of aspiration or choking can make it unsafe to swallow food and drink. Nutrition can instead be delivered via tube feeding with a gastrostomy, but this can be contraindicated and denies patients the pleasure and social connection of eating and drinking. Therefore, patients may prefer to continue unsafe oral intake, known as risk feeding. Patients should undergo assessment of dysphagia and be asked about their preferences before deciding how to proceed. According to the Mental Capacity Act 2005, if patients are not competent to provide valid informed consent, a person with power of attorney or treating clinician must make the decision in their best interests and in respect to their previously expressed or implied wishes. Decision-making should be shared between members of the multidisciplinary team and the patient's family. Huntington's disease is a progressive neurological condition that, in its later stages, is associated with dysphagia and cognitive or communication impairments that can hinder capacity to consent. A case study is presented of a patient with Huntington's and dysphagia, which illustrates the importance of a collaborative, structured approach to advanced care planning for managing nutrition in a progressive neurological disease in an inpatient setting.

Purpose Brain Injury Case Managers (BICMs) work closely with individuals with Acquired Brain Injury (ABI), assessing needs, structuring rehabilitation interventions and providing support, and have significant experience of clients with impairments to decision making. The purpose of this paper is to explore the application of the Mental Capacity Act (MCA) and its guidance when applied to ABI survivors. This research aimed to: first, highlight potential conflicts or tensions that application of the MCA might pose, and second, identify approaches to mitigate the problems of the MCA and capacity assessments with ABI survivors. It is hoped that this will support improvements in the services offered. Design/methodology/approach Using a mixed method approach, 93 BICMs responded to an online questionnaire about decision making following ABI. Of these, 12 BICMs agreed to take part in a follow-up semi-structured telephone interview. Findings The data revealed four main themes: disagreements with other professionals, hidden disabilities, vulnerability in the community and implementation of the MCA and capacity assessments. Practical implications The findings highlight the need for changes to the way mental capacity assessments are conducted and the need for training for professionals in the hidden effects of ABI. Originality/value Limited research exists on potential limitations of the application of the MCA for individuals with an ABI. This paper provides much needed research on the difficulties surrounding mental capacity and ABI.

Background Research involving adults who lack the capacity to provide informed consent can be challenging. In England and Wales there are legal provisions for consulting with others who know the person with impaired capacity. The role of the ‘proxy’ (or ‘surrogate’) is to advise researchers about the person’s wishes and feelings or to provide consent on the person’s behalf for a clinical trial of a medicine. Information about the study is usually provided to the proxy; however, little information is available to proxies about their role, or the appropriate legal and ethical basis for their decision, to help inform their decision-making. The aim of this study was to analyse the written information that is provided to consultees and legal representatives. Methods Studies including adults lacking capacity to consent which utilised consultees or legal representatives were identified using the UK Clinical Trials Gateway database. A representative sample (n = 30) were randomly selected. Information sheets and other study documents provided to proxies were obtained, and relevant content was extracted. Content analysis was conducted through four stages: decontextualisation of the unit of analysis, recontextualisation, categorisation, and compilation. The data were summarised narratively according to each theme and category. Results Considerable variation was found in the written information sheets provided to proxies. Most directed proxies to consider the wishes and feelings of the person who lacked capacity and to consult with others during the decision-making process. However, a small number of studies extended the scope of the proxy’s role to consider the person’s suitability or eligibility for the study. Particular discrepancies were found in information provided to those acting as consultees or legal representatives in a professional, as opposed to a personal, capacity. Incorrect uses of terminology were frequently found, and a small number of studies inaccurately interpreted the law. Conclusions Despite undergoing ethical review, study documents lacked essential information, incorrectly used terminology, and conflated professionals’ clinical and representation roles. Future recommendations include ensuring proxies are provided with adequate and accurate information which complies with the legal frameworks. Further research is needed to explore the information and decision-making needs of those acting as consultees and legal representatives. Electronic supplementary material The online version of this article (10.1186/s13063-019-3340-5) contains supplementary material, which is available to authorized users.

Qualquer procedimento médico, terapêutico ou interventivo sobre o paciente deve estar voltado à preservação da dignidade da pessoa humana submetida aos instrumentos de manutenção vital. Tratamentos terapêuticos altamente invasivos podem não representar solução adequada ao futuro da restauração física do paciente. Em muitos casos, mesmo após a utilização de vários instrumentos para restauração da capacidade física e mental do paciente terminal, a situação apresentada não justifica a continuidade da utilização dos meios terapêuticos invasivos. Projetos pioneiros no Brasil vêm estabelecendo a implementação de políticas públicas de saúde denominadas de cuidados paliativos. A proposta é garantir a terminalidade da vida com qualidade, livre da dor e em ambiente que respeite a autonomia do paciente. Essa determinação pela não sujeição a tratamentos de prolongamento da vida e da dor, pode ser manifestada em instrumento denominado de diretivas antecipadas de vontade. O modelo, por representar a interrupção ou suspensão dos procedimentos e terapêuticas médicas, permite que a doença siga seu curso normal o que resultará na morte do paciente. Palavras-Chave: Cuidados Paliativos. Direitos Fundamentais. Sistema Único de Saúde.

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. \ud \ud Implications for rehabilitation: Mental 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.

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This case reports an ethical dilemma in which a mother who had recently delivered a baby through cesarean section after sustaining life-threatening injuries in a car accident did not have documented wishes whether she wanted to breastfeed. Her medical condition rendered her temporarily mentally incapacitated and critically ill, and the lactation medicine team was consulted about whether lactation choice should be preserved by pumping. Complicating considerations in this case were (1) lack of family or designated decision-makers available at the time of injury and emergent delivery, (2) lack of prenatal care, and (3) complex social situation, including prior history of illicit substance use, and state removal of other children into foster care. This case raises important ethical considerations regarding breastfeeding decision-making when a mother is incapable of making the decision, and if there is an intrinsic right for an infant to be breastfed in situations where maternal choice to lactate or to formula feed is unknown. Ultimately, the mother chose to discontinue breastfeeding once she was able to voice her own opinion. The issues discussed in this study may be relevant for future cases when providing guidance on the ethical argument to preserve maternal choice when a mother is critically ill and mentally incapacitated.

Despite efforts of Parliament, the Home Office, police forces and health practitioners, the number of people detained under Section 136 of the Mental Health Act 1983 continues to rise. By analyzing quantitative data from Hampshire Constabulary, this study describes in detail police engagement with the mentally ill. Findings showed how people in mental crisis were increasingly detained by the ambulance service using the Mental Capacity Act and taken to A&E Departments. Nationally, police officers were also found to be increasingly taking Section 136 detainees to A&E. The majority of people contacting Hampshire displayed delusions which were unlikely to result in a police response and may disproportionately account for the overall growth in contact with the police. The data suggest that ‘Triage’ schemes alone will not be effective in reducing detentions. Hampshire’s partnership and discretionary approach is successful in reducing detentions. Recommendations for policy, practice, and further research are provided.

Autism is found to be associated with mind perception, in particular reduced perception of human agency. Prior work has shown that more autistic individuals in the general population tend to view others as less capable of doing and thinking. Autism is, by contrast, not meaningfully associated with the mind attribution to other types of entities examined in past work, including children, nonhuman animals, supernatural agents, and so forth. In this paper, more types of entities—toy objects and selves—were investigated. Across two normal adult samples and a meta-analysis, autism was found to be associated with decreased perception of both experiential and agentic mental capacity in other adult humans, as well as in oneself. More autistic individuals tend to consider others and themselves less capable of both doing and feeling. Autism was also associated with increased mind perception of toy objects, such that more autistic individuals tend to consider toy objects more capable of doing and feeling. These findings partially replicated and meaningfully extended previous work on autism and mind perception, thus providing insight into the relationship of autism with potentially different perceptions and treatments of others, selves, and toy objects.

In many Western countries, especially if they have good palliative care services, dementia is now more feared than cancer and surveys consistently show that most indigenous citizens would not want to continue living once dementia had become severe or even moderately severe. If they were to develop a life-threatening condition at this stage of the illness, most would not want to be resuscitated, yet that is what commonly happens. In Britain and Canada, most would like the option of an advance request for medical assistance in dying (MAID) in the form of euthanasia when dementia reaches a certain degree of severity. That is legal in the Benelux countries but even doctors sympathetic to MAID may find the process difficult. The only alternatives, restricted to people with early dementia, are MAID by medically assisted rational suicide (MARS, available in Switzerland) voluntary euthanasia (available in Benelux countries and probably now Canada) or voluntarily stopping eating and drinking (VSED—legal in most countries) before they lose mental capacity. Surveys also show important differences between religious groups in their attitudes to MAID in all diagnostic contexts after discussing some of the ethical, philosophical, religious and diagnostic issues that MAID raises, and this chapter presents some case histories of patients who chose and received MARS in Switzerland.

This article explores how the law of England and Wales1 has responded thus far to medical and clinical advances that have enabled patients with prolonged disorders of consciousness to survive. The authors argue that, although the courts have taken account of much of the science, they are now lagging behind, with the result that some patients are being denied their legal rights under the Mental Capacity Act 2005. The article further argues that English law does not comply with the United Kingdom’s commitments under the United Nations Convention on the Rights of Persons with Disabilities. Stressing the need for the law to keep in step with advances in science, the article concludes with robust recommendations for improvements, based on the latest research in neuroscience, to the way in which life-sustaining treatment decisions are made. This would mean that the wishes of patients, including those with covert awareness, can be better reflected in best interests assessments.

The legal doctrine of capacity, which governs legally-authorized intervention in the decision-making of persons with dementia, has been subject to recent scholarly criticism and reform efforts. Such efforts require a coherent normative theory of when and how intervention in the decision-making of those with dementia is appropriate. This mixed-methods study sought to understand the perspectives of seniors on this normative question.A survey, including closed- and open-ended questions and conversational interviews, was conducted.Quantitative results of 236 seniors were heterogeneous but showed important patterns. Qualitative results from survey data and interviews of 25 seniors presented 6 key themes: (1) a difficulty of giving concrete answers; (2) reliance on professional opinions; (3) concern for personal identity; (4) fear of abuse; (5) trust of family; and (6) fear of dementia.The study suggests support among seniors for: (1) a model of "supported decision-making" rather than "surrogate decision-making;" (2) a presumption that in order to preclude a person with dementia from making more "personal" decisions a more heightened showing of incapacity is required; and (3) a shift to a model of capacity as based more on features such as long term memory and relationships rather than cognitive functions or values. In reforming our understandings of capacity, ethicists and practitioners will have to navigate tensions found in the qualitative data, including: (1) between participants' fear of abuse and their expressions of trust in family members to decide when intervention is appropriate; and (2) between expressions of confidence in medical professionals' ability to tell participants when they are no longer able to make decisions and participants' own understanding of the question in terms of the philosophical construct of personal identity.

Much of the spotlight for coronavirus disease 2019 (COVID-19) is on the acute symptoms and recovery. However, many recovered patients face persistent physical, cognitive, and psychological symptoms well past the acute phase. Of these symptoms, fatigue is one of the most persistent and debilitating. In this “perspective article,” we define fatigue as the decrease in physical and/or mental performance that results from changes in central, psychological, and/or peripheral factors due to the COVID-19 disease and propose a model to explain potential factors contributing to post-COVID-19 fatigue. According to our model, fatigue is dependent on conditional and physiological factors. Conditional dependency comprises the task, environment, and physical and mental capacity of individuals, while physiological factors include central, psychological, and peripheral aspects. This model provides a framework for clinicians and researchers. However, future research is needed to validate our proposed model and elucidate all mechanisms of fatigue due to COVID-19.

This article discusses the importance of residence capacity – an individual’s mental capacity to decide where they should live – and suggests how it should be assessed. People with dementia or intellectual disabilities, as well as those with other mental disorders, are sometimes required to make this decision. Assessments of capacity must be conducted with considerable care, given the implications for the individual and for their human rights. The assessment must be objective and functional: the assessor must be able specifically to demonstrate a lack of decision-making ability. Yet assessments of capacity still require evaluative decisions to be made. We suggest some basic information that should be conveyed to the person faced by the prospect of a change of residence where there is a doubt about capacity.