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The assessment of decision-making capacity in patients with acquired brain injury presents a range of clinical and legal challenges. The existing guidance on the conduct of such assessments is often generic; guidance specific to patients with brain injury is sparse and coarse grained. We report on the results of an interview-based study of decision-making capacity in patients suffering from acquired brain injury and organic personality disorder. We identify the clinical and legal challenges associated with the assessment of decision-making capacity in this patient population, review three bodies of relevant research from cognitive neuropsychology and neurophysiology, and draw on phenomenological analysis to identify three distinct abilities that play a role in decision making, but that can be compromised in patients with organic personality disorder. We address the challenge of translating clinical findings into legally attestable results.KEYWORDS

Background: In health care settings, a person’s ability to make decisions may be questioned as a result of neurological disease or injury that can affect cognitive function. To determine whether a person is able to make a decision, health care professionals are required to carry out an assessment of decision-making capacity (DMC; also known as capacity assessments). For individuals with aphasia, these types of assessment may be problematic because they rely heavily on language abilities. There is a growing body of literature available on capacity assessments of individuals with aphasia, yet there are few studies on the perspectives of speech-language pathologists (SLPs) related to DMC assessments of individuals with aphasia, including barriers and facilitators to valid assessments.Aims: The purpose of this study was to explore perspectives of SLPs on assessments of DMC with individuals with aphasia. The following research questions were of interest: (1) What do SLPs know about capacity assessment? (2) Wha...

Rationale, aims and objectives The author proposes a new model for the assessment of decision-making capacity based on the principles of narrative medicine. The narrative method proposed by the author addresses the hidden power realtionships implicit in the current model of capacity assessment. Methods Sample cases are reviewed using the traditional model in comparison with the narrative model. Results Narrative medicine provides an effective model for the assessment of decision-making capacity. Conclusions Deficiencies in the traditional model capacity assessment can be effectively addressed using narrative strategies.

It is widely believed that respecting patient autonomy obligates practitioners to accede to all patients’ preferences and requests regardless of potential consequences to their health or to the professional integrity of the practitioner. This is a false belief that misrepresents the basic theoretical concepts surrounding the principles of autonomy and respect for persons, which must be balanced with other core medical ethical principles. There are many situations in which there are limits to autonomy. This clinical ethics article, intended for clinicians, will discuss various conditions in which autonomy-limiting principles and concepts apply, which are specific to the thyroid oncology context. The ethical and legal obligations of thyroid oncologists in such situations will also be explored.

Background: Adults who lack decision-making capacity and a surrogate (“unbefriended” adults) are a vulnerable, voiceless population in health care. But little is known about this population, including how medical decisions are made for these individuals. Objective: This integrative review was to examine what is known about unbefriended adults and identify gaps in the literature. Methods: Six electronic databases were searched using 4 keywords: “unbefriended,” “unrepresented patients,” “adult orphans,” and “incapacitated patients without surrogates.” After screening, the final sample included 10 data-based articles for synthesis. Results: Main findings include the following: (1) various terms were used to refer to adults who lack decision-making capacity and a surrogate; (2) the number of unbefriended adults was sizable and likely to grow; (3) approaches to medical decision-making for this population in health-care settings varied; and (4) professional guidelines and laws to address the issues related to this population were inconsistent. There have been no studies regarding the quality of medical decision-making and its outcomes for this population or societal impact. Conclusion: Extremely limited empirical data exist on unbefriended adults to develop strategies to improve how medical decisions are made for this population. There is an urgent need for research to examine the quality of medical decision-making and its outcomes for this vulnerable population.

Interprofessional relationships may impact the decision making of patients in a clinical setting. The objective of this study was to analyse the decision-making capabilities of patients from nurses' perspectives of interprofessional relationships using Foucauldian ethics. This qualitative study was based on poststructuralist Foucault references with in-depth interviews of nurses working in internal medicine and specialties in a general hospital. The patients constantly appeared in the definition of teamwork, but also as a passive element used by every professional to communicate with others. Nurses continue modelling a type of patient passivity, or what Foucault called passive subjectivity in relation to oneself, because the patient is guided and directed to take charge of a truth provided by professionals. Nurses must break the rigid design of sections or professional skills, and adopt a model of teamwork that meets the needs of the patient and increases their decision-making power. The quality of care will increase to the extent that professionals establish a relationship of equality with the patient, allowing the patient to make real decisions about their care. An egalitarian model of teamwork is beneficial to the patient, abandoning the idea of a team where the patient and family are constantly excluded from decisions about their care., Research funded by the Advanced Research Chair in the College of Nurses of the Balearic Islands (349/11).

Background Many of the elderly in nursing homes are very ill and have a reduced quality of life. Life expectancy is often hard to predict. Decisions about life-prolonging treatment should be based on a professional assessment of the patient’s best interest, assessment of capacity to consent, and on the patient’s own wishes. The purpose of this study was to investigate and compare how these types of decisions were made in nursing homes and in hospital wards. Methods Using a questionnaire, we studied the decision-making process for 299 nursing home patients who were treated for dehydration using intravenous fluids, or for bacterial infections using intravenous antibiotics. We compared the 215 (72%) patients treated in nursing homes to the 84 (28%) nursing home patients treated in the hospital. Results The patients’ capacity to consent was considered prior to treatment in 197 (92%) of the patients treated in nursing homes and 56 (67%) of the patients treated in hospitals (p

The emergency department (ED) presents a unique context for patients leaving the acute care setting against medical advice (AMA). We review three common cases, establish definitions, discuss the peer-reviewed literature, debunk the myths and common practices, cover the law and the effect of technology, and finally return to the clinical scenarios to make concrete recommendations for handling patients requesting to leave the ED prior to completion of their episode of care. The advice contained within this chapter will help a practitioner of emergency medicine capably navigate the sometimes murky waters of balancing and accommodating a patient’s request and defending a professional’s responsibilities to the health-care system. It will also serve the wider health-care community to gain insight into the complex environment of health-care delivery in the ED that only gets trickier when patients request to leave.

Sammendrag Medisinsk behandling uten pasientens samtykke er i strid med EMK artikkel 8 og pasient- og brukerrettighetsloven § 4-1. Noen ganger velger samtykkekompetente pasienter å nekte livsnødvendig medisinsk behandling basert på objektivt sett feilaktige premisser og til skade for seg selv, og på tross av at legene gjør sitt ytterste for å forklare pasienten konsekvensene av valget. Denne artikkelen drøfter rettslige og etiske aspekter ved utøvelse av selvbestemmelsesretten når pasientens manglende samtykke til anbefalt behandling kommer i konflikt med pasientens beste og får store konsekvenser for pasientens nærmeste.

When a patient appears to have a mental disorder, doubts may arise about his or her decision-making capacity. Health professionals must then assess the patient’s capacity in order to make sure of the validity of his or her consent or refusal. Incapacity has indeed legal consequences, as law provides for the appointment of a surrogate decision-maker in case of incapacity. With Belgian law as a point of departure, this contribution is aiming at identifying the role of law in capacity assessment itself, prior to the decision about (in)capacity. In order to protect the patient’s rights and to support the task of those carrying out the assessment, law should provide for a global definition of decision-making capacity and for a frame-procedure guiding this assessment. In my opinion, it is possible for law to contribute to the complex task of capacity assessment without interfering embarrassingly with healthcare practice.

This article highlights the complexity of ethical challenges that can arise in treatment planning for patients with serious medical and mental health conditions. The patient presented here is terminally ill with an acute exacerbation needing an urgent procedure; she is pregnant with a previable fetus and her mental status is unstable. In this case, the role of the psychiatrist extends beyond merely assessing her decision-making capacity; the psychiatrist should also help to identify the patient’s values, which, along with the ethical concepts of the fetus as a patient, beneficence, and respect for autonomy, can then guide treatment planning by the care team and the patient’s surrogate decision-maker. The psychiatrist can also help to identify countertransference to allow for the least biased decision-making. [ Psychiatr Ann . 2015;45(2):89–93.]

It is not typical that an urgent psychiatry consultation regarding decision-making capacity is required to save a life; however, this was the case for a middle-aged woman with schizophrenia who presented with a myocardial infarction and was fully oriented to the situation yet was refusing potentially life-saving treatment. Although this case brings up classic yet complicated issues relating to decision-making capacity with a presentation that is rarely reported, it also raises questions about how the current emphasis on patient autonomy can affect patient care in the current medical-ethical-legal landscape.

Given the ethical implications of assessments of decision-making capacity, adequate definitions and appropriate assessment criteria are essential, especially with regard to clinical practice in psychiatry. Currently applied standards have been criticized for emphasizing exclusively cognitive abilities. In particular, the present paper questions the adequacy of the current reasoning criterion. Referring to dual-process models of decision making, it is argued that the reasoning standard embraces only one side of the duality that is rational deliberation, and fails to take proper account of intuitive decision making. An outline of intuition’s potency in health care decisions informs the present account of why the current reasoning standard fails to take adequate account of patients’ decision-making preferences and of major deficits in intuitive reasoning. Toward a more comprehensive understanding, a possible reconceptualization of reasoning as the ability to decision-related self-reflection is advanced, and implications for evaluation, challenges, and limitations are discussed.

Background Decision-making capacity of patients with schizophrenia remains a highly debated subject, both in terms of understanding the effects of the illness, and in the challenges presented by clinical scenarios. Clinicians are frequently asked to evaluate decision-making capacity in patients with schizophrenia admitted to medical/surgical services, and these cases pose many clinical and ethical challenges. Objective/Method Two cases are presented of individuals with schizophrenia that refused emergent surgical care. Results Evaluation by the psychiatry consultation-liaison service deemed both patients to lack decision-making capacity, yet, in light of patient- and case-specific factors, surgery was performed in only one case. Discussion Acute medical conditions may complicate the evaluation of decision-making capacity in patients diagnosed with schizophrenia. Frequently, the psychiatrist has additional time pressure for their assessment, particularly when a patient presents with an acute or unstable condition requiring emergent intervention, such as surgery. Additionally, irreversible consequences due to refusal of intervention provokes provider discomfort, particularly given the opposing tension to respecting patient autonomy. In contrast, surgical providers may be unwilling to surgically intervene on patients deemed to lack capacity, as the patient may have a lower chance of recovery. Either extreme poses ethical dilemmas: forcing invasive treatment on a patient, or withholding medical interventions from certain psychiatric patients. Conclusion In cases of great complexity, decision making capacity assessments should be guided by a sliding scale, and when evaluating for the appropriateness of treatment in patients lacking capacity, clinicians should utilize the core ethical values to guide their decisions.

Patients' right to decide what happens to their bodies, especially around the end of life, is enshrined in legislation across the world, but questions often arise about whether a patient is capable of meaningfully participating in such decisions. Because of uncertainties about capacity, care providers and administrative agencies often must decide whether to honor, or even to elicit, patients' wishes. General decision-making capacity has been well studied, but few clear protocols exist for ascertaining capacity at the end of life. Without clear guidelines about how to assess capacity, medical staff may ignore assessment and operate from invalid assumptions. In the interests of protecting patients' agency, we propose a straightforward protocol for assessing capacity to make decisions about end-of-life interventions.

Consent is an integral component of health law and is a requirement for all healthcare treatments. However there is now support for increasing healthcare practitioner understanding of the legal theory which underpins consent processes, as it may be poorly understood. This study explores healthcare practitioners’ knowledge of and practices in assessing decision-making capacity and obtaining patient consent to treatment in the acute generalist setting. This study employed a mixed-methods multiphase design involving the following phases: legal research exploring case law and statute law relevant to decision-making capacity and consent; mental health act certificate use in acute generalist settings; documentation review of decision-making capacity assessment and consent processes in patients identified with delirium; and finally a health practitioner survey relating to decision-making capacity and consent processes. Results highlighted gaps in understanding of decision-making capacity and consent as legal constructs; also knowledge and practice inconsistencies in relation to what treatments require consent and who should obtain it. Similarly in relation to decision-making capacity; which healthcare practitioners are responsible for assessment of this, and when it should be assessed. Inconsistencies in common law and legislative framework knowledge and application associated with decision-making capacity and consent were also evident. This study highlights a complex area of healthcare delivery requiring attention, and is essential in providing new knowledge and a foundation to develop healthcare practices consistent with international and local legislative and policy requirements. A reluctance to transparently engage these issues could have legal, ethical and professional implications for organisations and individuals working within. Recommendations for clinical practice; health policy, guidance and governance; faculty and health service education; and future research are discussed.

Changes in cognition, behaviour and emotion frequently occur in patients with primary and secondary brain tumours. This impacts the ability to make considered decisions, especially following surgical resection, which is often overlooked in the management of patients. Moreover, the impact of cognitive deficits on decision making ability affects activities of daily living and functional independence. The assessment process to ascertain decision making capacity remains a matter of debate. One avenue for evaluating a patient's ability to make informed decisions in the context of brain tumour resection is neuropsychological assessment. This involves the assessment of a wide range of cognitive abilities on standard measurement tools, providing a robust approach to ascertaining capacity. Evidence has shown that a comprehensive and tailored neuropsychological assessment has greater sensitivity than brief cognitive screening tools to detect subtle and/or specific cognitive deficits in brain tumours. It is the precise nature and severity of any cognitive deficits that determines any implications for decision making capacity. This paper focuses on cognitive deficits and decision making capacity following surgical resection of both benign and malignant, and primary and secondary brain tumours in adult patients, and the implications for patients' ability to consent to future medical treatment and make decisions related to everyday activities.

OBJECTIVE: Despite the clinical, ethical and legal magnitude of end-of-life decision-making, the capacity of terminally ill patients to make the medical decisions they often face is largely unknown. In practice, clinicians are responsible for determining when their patients are no longer competent to make treatment decisions, yet the accuracy of these assessments is unclear. The purpose of this study was to explore decision-making capacity and its assessment in terminally ill cancer patients. METHOD: Fifty-five patients with advanced cancer receiving inpatient palliative care and 50 healthy adults were administered the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to evaluate decision-making capacity with regard to the four most commonly used legal standards: Choice, Understanding, Appreciation and Reasoning. Participants made a hypothetical treatment decision about whether to accept artificial nutrition and hydration for treatment of cachexia. Participants’ physicians independently rated their decision-making capacity. RESULTS: Terminally ill participants were significantly more impaired than healthy adults on all MacCAT-T subscales. Most terminally ill participants were able to express a treatment choice (85.7%), but impairment was common on the Understanding (44.2%), Appreciation (49.0%) and Reasoning (85.4%) subscales. Agreement between physician-rated capacity and performance on the MacCAT-T subscales was poor. CONCLUSIONS: The use of the MacCAT-T revealed high rates of decisional impairment in terminally ill participants. Participants’ physicians infrequently detected impairment identified by the MacCAT-T. The findings from the present study reinforce the need for establishing comprehensive advance directives for patients with advanced cancer.

Dementia is a common condition that impacts the patient, the family, and society. Currently, a diagnosis of dementia evokes hopelessness in the afflicted, and society provides few resources or systematic support for caregivers or for demented patients. In this commentary, we discuss the origins of hopelessness in dementia, the World Health Organization's six-stage framework of dementia care, and barriers to "normalizing" the experience of dementia in order to provide beneficent and humane care for patients with dementia. We also offer recommendations for clinicians who care for patients who feel that a life with dementia is not worth living.

Engaging in sexual activity is an essential Human Right protected under article 12 of the European Convention on Human Rights ( Council of Europe, 1950 ) and should be free from state interference. District nurses, however, often express concern over the possibility that adults with acquired brain injury or a learning disability cannot give a real consent to participate in sexual activity and so should be prevented from doing so. In this article Richard Griffith reviews the case law in relation to the capacity to consent to sexual activity.

A conclusion that a person lacks decision making capacity is not an off-switch for his or her rights[1][1] It is usual practice after a needle-stick injury for the source patient, with consent, to be tested for blood-borne viruses (BBV) to guide the need for HIV prophylaxis and to organise

Objective: To examine the training needs of family physicians (FPs) regarding Decision-Making Capacity Assessments (DMCAs) and ways in which training materials, based on a DMCA Model, might be adapted for use by FPs.

How psychiatric symptoms affect patients' decision making in practice can inform how we think-theoretically and conceptually-about what it means for those patients to have decision-making capacity. Assessment of a patient's decisional capacity allows those with adequate capacity to make choices regarding treatment and protects those who lack capacity from potential harm caused by impaired decision making. In analyzing a case in which a patient with stage II breast cancer refuses further treatment, we review the conceptual model of informed consent and approaches to assessing decision-making capacity that are in accordance with the American Medical Association Code of Medical Ethics as well as tools to assess decisional capacity.

In Western medicine, a central component of respecting a person's ability to make decisions governing what happens to herself is ensuring that she is provided with sufficient relevant information to make a rational choice. For patients who lack the cognitive capacity to do so because of either inborn or acquired deficits or because of youth, the extent to which they can participate in medical decisions is variable. Minors present a unique challenge, as their ability to understand and process information usually increases with age. The case presented here poses special problems because of the parents' desire to shield their child from certain information deemed important by his physicians. I consider whether minors, particularly older ones, have a right to know that supersedes their parents' wishes.

Objective: In response to evidence of deteriorating outcomes of people with schizophrenia we recently published a critical review in the journal concerning why outcomes for schizophrenia are not improving. A published commentary on our review raised criticisms that we aim to address herein. Method: Published data related to four issues raised in the commentary were reviewed. Results: There is a body of evidence that supports the possibility of dramatic improvements in treatment effectiveness, presented in our critical review, and these can be achieved within existing financial resources and present day understanding of the pathophysiology of schizophrenia. However, the commentary leads us to highlight four current obstacles to improving treatment effectiveness: (1) the belief of many psychiatrists that long-term antipsychotic medication raises the cardiovascular mortality rate in schizophrenia when the opposite is almost certainly the case; (2) the need to improve psychiatrist training in diagnostic and communication skills, especially with first episode presentations; (3) the requirement for comprehensive and structured assessment of the highly prevalent deficits in insight and decision making capacity associated with schizophrenia; and (4) the need for improved intervention design to minimise the impact of these deficits on treatment choice and refusal. Conclusion: With a sense of professional urgency, a genuinely respectful and caring partnership between clinicians, affected individuals and their families, and researchers, with relative little innovation, we conclude that the standard of care can definitely be raised now in the treatment of schizophrenia.

Medical decision-making capacity refers to the assessment of a patient's ability to make a specific clinical choice. Systematic evaluation of capacity includes a review of the core components of decision making, alongside consideration of potential outcomes associated with the choice. At the end of life, assessing capacity may be complicated by drastic shifts in the risk–benefit profile of acute medical interventions, along with changes to a patient's affect, behavior, and cognition. Maintaining an appreciation for the elements of capacity, the process of assessing capacity, and the associated challenges at the end of life can help palliative care clinicians to ensure provision of respectful, patient-centered care. This manuscript provides an overview of decision-making capacity in the palliative care population, while clarifying common barriers to capacity at the end of life, and offering considerations for appropriate involvement of psychiatric consultants in this process.

Hemodialysis (HD) is routinely offered to patients with end-stage renal disease in the United States who are ineligible for other renal replacement modalities. The frequency of HD among the US population is greater than all other countries, except Taiwan and Japan. In US, patients are often dialyzed irrespective of age, comorbidities, prognosis, or decision-making capacity. Determination of when patients can no longer dialyze is variable and can be dialysis-center specific. Determinants may be related to progressive comorbidities and frailty, mobility or access issues, patient self-determination, or an inability to tolerate the treatment safely for any number of reasons (e.g., hypotension, behavioral issues). Behavioral issues may impact the safety of not only patients themselves, but also those around them. In this article the authors present the case of an elderly patient on HD with progressive cognitive impairment and combative behavior placing him and others at risk of physical harm. The authors discuss the medical, ethical, legal, and psychosocial challenges to care of such patients who lack decision-making capacity with a focus on variable approaches by regions and culture. This manuscript provides recommendations and highlights resources to assist nephrologists, dialysis personnel, ethics consultants, and palliative medicine teams in managing such patients to resolve conflict.

Decision-making capacity (DMC) is an indispensable prerequisite for medical treatment choices, including consent to treatment, treatment discontinuation, and refusal of treatment. In patients with dementia, DMC is often affected. A particular challenge in assessing DMC are cognitive fluctuations that may lead to a fluctuation in DMC as well. Cognitive fluctuations are a diagnostic core feature of dementia with Lewy bodies and occur in Parkinson’s and Alzheimer’s diseases. In this article, these challenges are discussed and suggestions for assessing the DMC of patients with dementia with cognitive fluctuations are presented.

Decisions about percutaneous endoscopic gastrostomy (PEG) can be clinically and ethically challenging, particularly when patients lack decision-making capacity. As the age of the UK population rises, with the associated increase in prevalence of dementias and neurodegenerative diseases, it is becoming an increasingly important issue for clinicians. The recent review and subsequent withdrawal of the Liverpool Care Pathway highlighted feeding as a particular area of concern. The authors undertook a 1-year retrospective review of individuals referred to the feeding issues multidisciplinary team (FIMDT) at Addenbrooke's Hospital, Cambridge, UK, in 2011. The majority of patients referred (n = 158) had a primary diagnosis of cancer (44%). The second largest group was those who had had a stroke or brain haemorrhage (13%). Twenty-eight per cent of patients had no, or uncertain, decision-making capacity on at least one occasion during decision-making. There are reflections on the role of a multidisciplinary team in the process of decision-making for these complex patients.

A 15-year-old advance directive made when the patient was in much better health and not updated can bring more confusion than clarity to the decision-making process.

Because nursing homes are both a residence and a treatment setting, care providers are faced with the challenge of balancing resident autonomy and safety on a daily basis. While there are standardized approaches for determining a capacity to make larger decisions such as providing consent for medical procedures, there are virtually no methods for assessing capacity to make everyday decisions (e.g., food choices, smoking, navigating outside the nursing home). While it is easier for staff to prevent residents from making decisions they deem risky, to truly offer person-centered care, it is important to support a resident’s right to make decisions if they have the capacity to do so. Currently, little is known about how nursing home staff conceptualize and determine everyday decision-making capacity and how that information is used in care planning. To understand the current processes and language nursing home staff use when considering a resident’s decision-making capacity, we conducted interviews with 37 staff at two Veterans Affairs (VA) Community Living Centers (VA-operated nursing homes; CLCs). Using qualitative content analysis, we coded the transcribed interviews and identified several overarching themes: autonomy vs. safety, communication (e.g., pathways, with caregivers, with residents), determining capacity (e.g., information gathering, assessment, assumptions, indicators, interdisciplinary team member roles, referrals), interventions (e.g., legal and staff-led), and terminology used. We will describe how the findings from this study can be used to tailor development and adaptation of tools to help nursing home staff assess resident everyday decision-making capacity and to incorporate the results into person-centered care approaches.

The question of decision-making capacity for informed consent to experimental brain surgery for severely ill anorectic patients is about as dramatic an ethical issue one can imagine. Sabine Muller ...

Speech-language pathologists' scope of practice is currently unclear in relation to their contribution to the multi-disciplinary assessment of decision-making capacity for clients with aphasia and related neurogenic communication disorders. The primary aim of the current research study was to investigate the common practices of speech-language pathologists involved in assessments of decision-making capacity. The study was completed through the use of an online survey. There were 51 of 59 respondents who indicated involvement in evaluations of decision-making. Involvement in this kind of assessment was most commonly reported by speech-language pathologists working in inpatient acute and rehabilitation settings. Respondents reported using a variety of formal and informal assessment methods in their contributions to capacity assessment. Discussion with multidisciplinary team members was reported to have the greatest influence on their recommendations. Speech-language pathologists reported that they were dissatisfied with current protocols for capacity assessments in their workplace and indicated they would benefit from further education and training in this area. The findings of this study are discussed in light of their implications for speech-language pathology practice.

Our hospital's policy and procedures for "Patients Without Surrogates" provides for gradated safeguards for managing patients' treatment and care when they lack decision-making capacity, have no advance directives, and no surrogate decision makers are available. The safeguards increase as clinical decisions become more significant and have greater consequences for the patient. The policy also directs social workers to engage in "rigorous efforts" to search for surrogates who can potentially provide substituted judgments for such patients. We describe and illustrate the policy, procedures, and kinds of expected rigorous efforts through our narration of an actual but disguised case for which we provided clinical ethics guidance and social work expertise. Our experience with and reflection on this case resulted in four recommendations we make for health care facilities and organizations that aim to provide quality care for their own patients without surrogates.

Although there have been a limited number of case reports of human bilateral hippocampal injury, none of these have addressed the impact of such injuries on medical decision making capacity. The authors present a case of an elderly man with discrete bilateral hippocampal injury. As a result of his injury, the patient was hopelessly “lost in the present” and only retained the basic cognitive functions necessary to have decision making capacity for a limited period of time. He was unable to appreciate the nature of his injury, the potential risks involved in his decisions, and the recommended course of treatment longer than a few minutes. The patient’s resultant neurocognitive deficits left him lacking medical decision making capacity, a likely outcome for patients with persistent anterograde amnesia.

Recent neuroscientific findings suggest that functional magnetic resonance imaging (fMRI)-based brain–computer interfaces may be a viable strategy for detecting covert awareness in patients clinically diagnosed as being in a vegetative state. This research may open a promising new avenue for developing neuroimaging techniques that provide prognostic and diagnostic information that complements current behavioral tests for assessing disorders of consciousness, thereby increasing the effectiveness of diagnostic screening. These techniques may also permit patients who are behaviorally nonresponsive yet retain high levels of preserved cognition to meaningfully engage in clinical decision making. Before this application can occur, certain ethical issues associated with decision-making capacity must be addressed. Although it is not currently possible to assess decision-making capacity through neuroimaging methods, it may be in the future, provided that certain conceptual and empirical steps are taken to demonstrate that brain–computer interfaces satisfy requisite criteria of capacity assessment. In this article we lay out the conceptual foundations for a mechanistic explanation of capacity that would allow the necessary empirical steps for incorporating neuroimaging techniques into the standard capacity assessment battery utilized in clinical practice.

Elder abuse is a pervasive problem that can have lasting emotional and physical consequences, increasing its victims’ risk of mortality. Healthcare providers are frequently involved in the detection and intervention of elder abuse. Because of the complexity of these cases, applying treatment interventions within an interdisciplinary care team has been recommended to ensure older adults’ safety and welfare. Psychologists in particular are frequently relied upon in these situations because of their expertise in cognitive, psychiatric, and capacity assessment, as well as their ability to intervene in a variety of difficult situations. The following is a report examining the case of Mr. B, who was a victim of elder abuse involving financial exploitation and undue influence. Assessment and treatment interventions were used within the context of an interdisciplinary care team, using a bio-psychosocial approach. A decision-tree model describing the steps to take in assessing and treating financial elder abuse is proposed.

There have now been several cases where the Court of Protection has been critical of the approach to the assessment of decision-making capacity adopted by health and social care professionals. There is concern that the rights of the frail and vulnerable to make unwise decisions about their health and residence are not being respected and that there is a return to the paternalistic, ‘professional knows best’ approach to care and treatment. In this article, Richard Griffith and Cassam Tengnah argue that community nurses can learn valuable lessons from recent cases in the Court of Protection that can be applied in practice when they are required to assess decision-making capacity.

$\textbf{BACKGROUND}$: There is continuing public debate about treatment preferences at the end of life, and the acceptability and legal status of treatments that sustain or end life. However, most surveys use binary yes/no measures, and little is known about preferences in neurological disease when decision-making capacity is lost, as most studies focus on cancer. This study investigates changes in public preferences for care towards the end of life, with a focus on measures to sustain or end life. $\textbf{METHODS}$: Large-scale international public opinion surveys using a six-stage patient vignette, respondents chose a level of intervention for each stage as health and decision-making capacity deteriorated. Cross-sectional representative samples of the general public in Great Britain and the USA (N = 2016). Primary outcome measure: changes in respondents' preferences for care, measured on a four-point scale designed before data collection. The scale ranged from: maintaining life at all costs; to intervention with agreement; to no intervention; to measures for ending life. $\textbf{RESULTS}$: There were no significant differences between GB and USA. Preference for measures to sustain life at all costs peaked at short-term memory loss (30.2%, n = 610). Respondents selecting 'measures to help me die peacefully' increased from 3.9% to 37.0% as the condition deteriorated, with the largest increase occurring when decision-making capacity was lost (10.3% to 23.0%). Predictors of choosing 'measures to help me die peacefully' at any stage were: previous personal experience (OR = 1.34, p

Palliative and end of life care is changing, becoming more widespread and improving for patients. Yet, the current literature in the field suggests that the evidence for palliative and end of life care is somewhat limited. Research on treatment decisions, family care, and advance directions are just a few of the areas that need rigorous research efforts. Palliative care research is essential in order to continue providing effective treatments to those suffering in the last stages of life. Indeed, the goal of good palliative care research is to relieve suffering and to improve quality of life. Similar to any other field, palliative care programs must develop on a research base, and patient care will suffer if it is not backed by sound research. However, weighted against this need are some who maintain that the ethical and practical challenges of palliative care research are unique and insurmountable. This analysis considers if distinct ethical guidelines are needed for palliative care research.