Search

This paper tells a story of environmental conflict and the attempted political resolution of issues of planning for native forests in Western Australia. It refers to the Western Australian Regional Forest Agreement and Draft Forest Management Plan processes to demonstrate how a range of actors utilise vari-ous discourses and network relations in attempts to influence governmental decision-making capacity. Adapting elements of a model of capacity-building for environmental decision-making, the paper indicates how traditional exclusionary decision networks serve to inhibit decision capacity, whilst more inclusive processes may be more likely to cope with challenges of reconciling multiple values and decision-making for managing the forests in the interests of society as a whole.

This study was designed to determine which elements professionals consider important for evaluation of decision-making capacity. Survey with a vignette case report of an individual with mild dementia was mailed to four groups of individuals: 1. members of the Academy of Psychosomatic Medicine, 2. chairs of Veterans Affairs (VA) Ethics Advisory Committees (EACs), 3. randomly selected geriatricians who were members of the Gerontological Society of America (GSA), and 4. randomly selected psychologists who were members of the GSA. Two hundred thirty-seven psychiatrists, 95 VA EAC chairs, 103 geriatricians, and 46 psychologists responded to this survey. The majority of the respondents endorsed all five basic elements as necessary for determination of decision-making capacity in the presented vignette, but only a minority of respondents endorsed all five basic elements, and a small proportion of respondents endorsed only one or two elements. The results indicate that physicians do not use uniform standards for assessment of decision-making capacity.

Organ donation from relatives or other persons with a close relationship to the patient has become a fairly routine procedure in many countries. However, donors should be chosen carefully not only to avoid medical or psychosocial risks but also ethically questionable outcomes. Prerequisites for living organ donation are reported together with a short review of the known risks for donors. Under the central maxim of averting harm for the donor, six cases are described to illustrate typical difficulties in the psychosomatic-ethical consultation-liaison service, and our own procedures are discussed. Suggestions are made as to how to approach the information, evaluation and selection of potential donors.

This paper begins with a discussion of why concerns about decision-making capacity are warranted in palliative medicine research. Next, procedures for assessing decision-making capacity are discussed. It concludes with recommendations to guide the judicious use of these procedures in the design of palliative care research.

Assessments of an accused person's fitness or competence to stand trial are common in the criminal justice system. They are intended to ensure that the rights of mentally disordered accused persons are not violated by subjecting them to legal processes that they are not equipped to understand or participate in meaningfully. This chapter focuses on the history of and current law governing fitness in the United Kingdom, Canada, and the United States. The concepts discussed herein have broader applicability and may be useful in understanding the law in other jurisdictions as well.

Decision-making capacity or mental competence is one of the most intensively discussed concepts in contemporary bioethics and medical ethics. In this paper I argue that anorexia nervosa, an eating disorder primarily afflicting adolescent girls and young women, seriously challenges what I label the traditional account of decision-making capacity. In light of these results, it may in addition be necessary to rethink a certain popular type of paternalistic argumentation that grounds the justification of compulsory treatment, for example of anorexic persons who refuse treatment, on a lack of decision-making capacity.

Research and developments in the field of plant varieties are on an all time rise. Taking this into account TRIPS and mandated that plant varieties needs to be protected. Though affording protection is a mandatory requirement, the methodology to be adopted for such protection is well within the decision making capacity of each Member State. India has opted a sui generis mechanism and has completely avoided the application of patent law to these innovations. The paper tries to look into the scope of this protection available in India particularly in the light of the US decision of Bowman v. Monsanto.

This report examines whether long-term care facilities should implement policies and procedures to support advance care planning by proxy for residents who lack decision-making capacity. The report focuses on advance care planning in the Department of Veterans Affairs. After reviewing clinical, legal, and ethical perspectives, the authors conclude that advance proxy planning is ethically sound and can improve patient care. However, because experience with advance proxy planning is still fairly limited, the authors do not recommend that a particular standardized approach be mandated at the national level. Instead, local facilities are advised to develop their own policies and then evaluate their effect. The report contains specific recommendations for the advance proxy planning process.

The authors conducted a preliminary examination of treatment-related decision-making capacity (DMC) in middle-aged and older psychosis patients. The MacArthur Competency Assessment Tool for Treatment (MacCAT-T) was administered to measure DMC among 16 patients with psychotic disorders and without dementia (mean age: 54.6 [SD 7.2] years). The impact of repeated learning trials on patients' understanding was assessed with the Hopkins Competency Assessment Test (HCAT). Subjects were also assessed with the Positive And Negative Syndrome Scale and Mattis' Dementia Rating Scale. There was a wide range of performance on the MacCAT-T; the levels and range of MacCAT-T scores were similar to those previously reported among younger acutely hospitalized patients in the MacCAT-T validation study. Patients' understanding of disclosed material on the HCAT improved significantly over repeated presentations. Although there were no statistically significant correlations observed between DMC and demographic characteristics, severity of symptoms, or global cognitive deficits, the sample size provided limited power to detect such associations. Results point to the importance of assessing DMC and to the potential modifiability of initial difficulties in understanding.

A patient’s right to give informed consent to treatment holds numerous challenges often faced by clinicians. The challenges can be further complicated in an older or elderly woman whose capacity to make an informed decision may be affected due to cognitive impairment secondary to age-related changes or dementia. Addressing the factors that are contributing to mental status changes, such as delirium or depression, can prevent cognitive impairment that can lead to an inability to provide a meaningful informed consent. Knowledge of the legal issues and outcomes of case law can give some guidance to the clinician in approaching the task of assessing decision-making capacity.

90 Background: To date it is unclear when patients with high grade glioma (HGG) lose their capacity to make decisions during the end-of-life (EoL) phase. EoL symptoms have not been prospectively assessed. The goal of this prospective single center study was to assess the symptom burden in terminal HGG patients with a special focus on symptoms related to decision making capacity during the last 3 months of life. Methods: Patients with HGG, failing 3rd line therapy, showing clinical and/or radiological progression with a Karnofsky Performance Status score < 60 were eligible for enrollment. A baseline MD Anderson Symptom Inventory Brain Tumor Module (MDASI-BT) was performed upon enrollment. Patients or surrogates received bi-weekly telephone calls to repeat the MDASI-BT. Calls continued until death, or refusal to participate. Symptoms were stratified by weeks prior to death. Mixed models were used to assess for symptom and interference changes over time. Overall time effect was tested at the 0.05 level. If significant, pairwise comparisons of the time groups were done. Testing level was set at 0.01 to take into account the large number of comparisons. Results: Symptom scores of 52 patients are available for analysis. Symptoms involved in decision making such as speaking, concentrating, drowsiness (all p < 0.001), and understanding (p < 0.011) started to decline severely 12 weeks prior to death. The cognitive construct (understanding, remembering, speaking, concentrating) was significantly impaired during the last 2 weeks of life and started to deteriorate after week 12 (p < 0.001). The decision making composite score (understanding, speaking, concentrating, fatigue, drowsiness) showed the same pattern (p < 0.001). Overall disease burden also significantly increases within the last 2 weeks of death. Conclusions: Patients with HGG have a high symptom burden during the active EoL phase, increasing significantly during the last 12 weeks prior to death. Symptoms interfering with decision making capacity increase after week 12 and reach their peak 2 weeks prior to death. These findings stress the importance of early initiation of palliative care and advance care planning in patients with HGG.

Context: Many physicians do not feel prepared to do DMCAs. Hence, we developed and administered an interactive DMCA Workshop to familiarize physicians with concepts of capacity, a protocol, documents, and case studies.

This talk will outline the regulatory framework (both mental health and social care) currently in place in Ireland for people with intellectual disability (I.D.) and mental health problems, in the context of the varied nature of available mental health services. As not all aspects of service are currently under the regulatory system, potential ethical issues arise, and will be discussed.In addition new legislation regarding the support of people with vulnerable decision making capacity will be outlined (Assisted Decision Making (Capacity) Act, 2015); potential ethical issues that are currently arising from this legislation will be explored and discussed.Disclosure of interestThe author has not supplied his declaration of competing interest.

In the article “Ethical Issues in Deep Brain Stimulation Research for Treatment-Resistant Depression: Focus on Risk and Consent,” Dunn and colleagues (2011) discuss the understanding and reasoning ...

The nature of neuropsychiatric disorders raises questions and concerns that must be addressed for research on these disorders to proceed ethically. This chapter discusses the rationale for both conceptual and empirical ethics work related to psychiatric research, focusing in particular on informed consent, decision-making capacity, and voluntarism. The extant literature regarding the abilities of people with mental illness to provide informed consent to research is reviewed. Also discussed are the ethical implications of co-occurring problems frequently faced by people with mental illness. Finally, the types of conceptual and empirical work that are needed to move psychiatric research ethics forward are discussed.

Surgeons obtain informed consent from patients for the procedures they perform. Occasionally, however, the medical consultant will be asked to assist with assessment of a particular patient’s capacity (or lack thereof) to consent to evaluation and/or treatment. Patients are presumed to possess decision-making capacity, unless a clinical evaluation suggests that it is lacking. Studies suggest, however, that clinicians frequently fail to recognize when patients lack decision-making capacity.

© 2014 Springer Verlag Berlin Heidelberg. Within the frameworks of shared decision making and participation in healthcare children’s ability to understand and appreciate information pertaining to illness and treatment is important. Physicians are mainly responsible for assessing decision making capacity (DMC) but may encounter difficulties arising from the limited basis of evidence with regard to this concept in pediatrics. Three issues contributing to this paucity of knowledge on DMC of children can be identified: (1) conceptual blurriness and absence of clear terminology (2) lack of validated tools to reliably assess DMC in the pediatric population and (3) a need to include a developmental framework to understand DMC in children and adolescents. The aim of this paper is to examine these three issues and provide practical recommendations to advance the concept and its assessment in pediatrics as a step to ensuring children’s developmentally appropriate participation in healthcare. Finally the paper highlights the ethical dimension of assessing DMC emphasizing the importance of physicians’ attitudes for the assessment process. Conclusion: A detailed understanding of DMC is necessary to inform developmentally appropriate participation. In order to achieve this pediatric practice needs to address challenges that are specific to providing healthcare for children including conceptual issues assessment and aspects of child development.

Anxiety and depression may have a major impact on a person's ability to make decisions. Characterization of symptoms that reflect anxiety and depression in family members visiting intensive care patients should be of major relevance to the ethics of involving family members in decision-making, particularly about end-of-life issues.Prospective multicenter study.Forty-three French intensive care units (37 adult and six pediatric); each unit included 15 patients admitted for longer than 2 days.Six hundred thirty-seven patients and 920 family members.Intensive care unit characteristics and data on the patient and family members were collected. Family members completed the Hospital Anxiety and Depression Scale to allow evaluation of the prevalence and potential factors associated with symptoms of anxiety and depression.Of 920 Hospital Anxiety and Depression Scale questionnaires that were completed by family members, all items were completed in 836 questionnaires, which formed the basis for this study. The prevalence of symptoms of anxiety and depression in family members was 69.1% and 35.4%, respectively. Symptoms of anxiety or depression were present in 72.7% of family members and 84% of spouses. Factors associated with symptoms of anxiety in a multivariate model included patient-related factors (absence of chronic disease), family-related factors (spouse, female gender, desire for professional psychological help, help being received by general practitioner), and caregiver-related factors (absence of regular physician and nurse meetings, absence of a room used only for meetings with family members). The multivariate model also identified three groups of factors associated with symptoms of depression: patient-related (age), family-related (spouse, female gender, not of French descent), and caregiver-related (no waiting room, perceived contradictions in the information provided by caregivers).More than two-thirds of family members visiting patients in the intensive care unit suffer from symptoms of anxiety or depression. Involvement of anxious or depressed family members in end-of-life decisions should be carefully discussed.

Background: A nursing care insurance system went into effect in April 2000 in Japan. Under the new system, the user (person requiring care) enters a contract directly with the service provider. Hence a pertinent issue is whether or not the user has the decision-making capacity to enter a contract (competency to contract) and the degree of that capacity. The aim of the present study was to gain an understanding of the competency to contract under the new system. Methods: The subjects were elderly residents who entered a care insurance facility after April 2000. Ten institutions from among the care insurance facilities in Aichi Prefecture cooperated in this study. The study was sufficiently explained to the elderly residents and their families, and written informed consent was obtained from both. Respective municipalities were requested to allow access to the results of the nursing care certification process of the subjects, with their consent and the consent of their families. In addition, the care manager of the facility gave the residents a Mini-Test that we had prepared to determine competency to contract. Results: The results revealed that most subjects had little understanding of the care system, and surprisingly, that they were not in the care insurance facility of their own volition. The competency to contract in the dementia group was significantly lower than in the non-dementia group. Conclusion: It may be unreasonable to believe that all such people are competent to enter a contract, especially those with dementia. However, the results suggest that people with a mild care grade, even if they have dementia, may have such competency. Further study including psychiatric assessment and diagnosis of the capacity to contract is necessary.

In English Law, an adult has the right to make decisions affecting his or her own life, whether the reasons for that choice are rational, irrational, unknown or even non-existent. This right remains even if the outcome of the decision might be detrimental to the individual (Re T (Adult: Refusal of Treatment), 1992) or to a viable foetus (Re S (Adult: Refusal of Medical Treatment), 1992). However, such a right to self-determination is meaningful only if the individual is appropriately informed, has the ability (capacity) to make the decision and is free to decide without coercion (Grisso, 1986).

A terminal patient expressed the wish to hasten her death and refused nutrition. The psychiatrist asked to render an opinion relevant to her competence employed questions in a semi-structured interview derived from a new instrument originally designed to determine competence to create ‘Advance Directives’. Although the patient ultimately demonstrated her resolve by totally ceasing fluid intake, the complexity of the case–including the question of the stability of her choice–illustrates the need for specific patient safeguards.

Mental competence, or decision‐making capacity, is an important concept in law, psychiatry, and bioethics. A major problem faced in the development and implementation of standards for assessing mental competence is the issue of objectivity. The problem is that objective standards are hard to formulate and apply. The aim here is to review the limited philosophical literature on the place of value in competence in an attempt to introduce the issues to a wider audience. The thesis that the assessment of competence must incorporate elements of value and rationality is defended, and some tentative suggestions offered about how this might be achieved in a clinical setting.

In this article some of the presuppositions that underly the current ideas about decision making capacity, autonomy and independence are critically examined. The focus is on chronic disorders, especially on chronic physical disorders. First, it is argued that the concepts of decision making competence and autonomy, as they are usually applied to the problem of legal (in)competence in the mentally ill, need to be modified and adapted to the situation of the chronically (physically) ill. Second, it is argued that autonomy and dependence must not be considered as two mutually exclusive categories. It is suggested that decision making may take on the form of a more or less conscious decision not to be involved in making all kinds of explicit and deliberate decisions. Elaborating on Agich's distinction between ideal and actual autonomy, the concept of “Socratic autonomy” is introduced.

The considerations for and challenges of developing an instrument for the assessment of oder adult descision-making capacity are discussed. A variety of conceptual and methodological issues are discussed, using experience with the development of the Hopemont Capacity Assessment Interview to illustrate the directions one might take in instrument development. Research questions are raised in the context of these conceptual and methodological issues.

Determining competence to request physician-assisted suicide should be no more difficult than determining competence to refuse life-prolonging treatment. In both cases, criteria and procedures should be developed out of the process of actually making capacity determinations; they should not be promulgated a priori. Because patient demeanor plays a critical role in capacity determinations, it should be made part of the record of such determinations through greater use of video- and audiotapes.

Summary The Mental Capacity Act 2005 has considerable implications for critical care practitioners and particularly in relation to treatment of elderly patients. The full Act came into force on 1st October 2007. The Act sets down decision specific criteria for the assessment of capacity, and "best interests" principles to enhance decision making for patients without capacity. Patients undergoing serious treatment must have an Independent Mental Capacity Advocate appointed if there is no one appropriate to consult in determining the patient's interests. A person may be appointed as personal attorney under a Lasting Power of Attorney to make decisions on the patient's behalf. Advance Decisions about the refusal of life-sustaining treatment are regulated statutorily for the first time. The decision-making framework for clinicians has been clarified and codified and patients' rights are enhanced.

For research with human subjects, the more things change, the more they remain the same. In the 50-odd years since the 10 principles of the Nuremberg Code were set forth by the U.S. judges who conv...

We aimed to survey the knowledge of psychiatrists on the assessment of decision-making capacity. Ninety-two psychiatrists of all grades and three other doctors attending a regional conference were marked on their verbal response to the question ‘What are the key elements in the assessment of a patient's capacity?’ On average, participants mentioned three out of the five elements in testing decision-making capacity. Scores were negatively correlated with age (Pearson's coefficient 0.275, sig 0.007). Section 12 status and grade had no impact on knowledge. Most psychiatrists of all grades have a reasonable knowledge of assessing decision-making capacity. Over a third of participants mentioned two or fewer of the five points, suggesting inadequate knowledge. Assessing decision-making capacity needs to be emphasised in training throughout psychiatrists' careers- not just at the start.

Physicians must obtain the informed consent of their patients before initiating treatments or ordering diagnostic procedures. Valid informed consent requires three elements. First, there must be adequate disclosure of information. Second, the decision must be voluntary. Third, the patient must have sufficient decision-making ability to use the provided information to reach a decision. The most commonly accepted approach to assessing decision-making capacity uses the ‘four abilities’ model that assesses the patient's ability to communicate a choice, understand, appreciate, and reason.

Choices about money have serious consequences both for individuals and society, as reckless spending by young adults and financial scamming of the elderly all too clearly demonstrate. Recent evidence from psychology and neuroscience suggests that financial decision making capacity may peak at middle age, with unique vulnerabilities manifesting early and late in life. In this chapter, we review age differences in performance on a series of financial decision making tasks, including those involving monetary gain and loss, learning and risk, and intertemporal choice. Taken together, the evidence suggests that older adults do well when making decisions that rely on accumulated life experience and perform suboptimally in uncertain and novel environments that require fluid learning. Brain imaging reveals declines in frontostriatal function in the elderly that may explain the observed challenges on these dynamic behavioral decision tasks. In an effort to translate these findings from the lab to society, a small and growing literature has identified real-world financial decision correlates of performance on laboratory tasks. Such studies hold enormous promise for developing tools that can identify individuals at greater risk for poor financial decision making.

Financial exploitation often presents to the practitioner in subtle ways. In this chapter, the author discusses common hints and warnings that a patient may be at increased risk of financial exploitation. The author also presents the possible ways that the victim of financial exploitation will appear, both mentally and physically. Elements of the exam that include assessment of the patient’s financial decision making capacity through interview and problem solving, as well as the importance of cognitive assessment are discussed.

New legislation should raise the moral standards of professional and personal life, but the proposed new mental health bill fails to deal with serious ethical problems in the existing act

Objective Patients with terminal illness often face important medical decisions that may carry ethical and legal implications, yet they may be at increased risk for impaired decisional capacity. This study examined the prevalence of impairment on the four domains of decisional capacity relevant to existing legal standards. Method Twenty-four adults diagnosed with a terminal illness completed the MacArthur Competence Assessment Tool for Treatment, a semi-structured measure of decision-making capacity and measures of cognitive functioning and psychological distress. Results Approximately one third of the sample demonstrated serious impairment on at least one domain of decisional capacity. The greatest proportion of impairment was found on subscales that rely heavily on verbal abilities. Decisional capacity was significantly associated with cognitive functioning and education, but not with symptoms of anxiety or depression. Conclusions This study is the first to examine decisional capacity in patients with terminal illness relative to legal standards of competence. Although not universal, decisional impairment was common. Clinicians working with terminally ill patients should frequently assess capacity as these individuals are called on to make important medical decisions. Comprehensive assessment will aid clinicians in their responsibility to balance respect for patient autonomy with their responsibility to protect patients from harm resulting from impaired decisional capacity.

BackgroundIs the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients?AimsTo compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice.MethodA secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool – Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability.ResultsMost people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P=0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, PPP=0.02).ConclusionsAmong those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting.