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We read with interest the article in the July 2001 issue of APT ([Bellhouse et al , 2001][1]) regarding decision-making capacity in adults. The authors have summarised leading legal cases in the area of consent to treatment, and then focused on the practical assessment of capacity. In doing so they

A recent case report described a 62-year-old woman who had suffered a stroke and subsequently had global aphasia, hemiplegia, and could not respond consistently to yes-no questions. She remained hospitalized for four years and throughout this period was irritable, uncooperative, and often refused food. Her care providers considered it very likely that she was depressed and treated her with antidepressant medication, but these drugs did not have beneficial effect.Her situation subsequently deteriorated. She refused food and water to a greater extent and lost 22 pounds over one month. At that time electroconvulsive therapy was instituted. Thereafter, presumably responding to electroconvulsive therapy, she became pleasant and cooperative and drank and ate heartily.

Physicians frequently are asked to assess whether a patient has the capacity to make informed decisions about his or her medical care. Such assessments may be difficult and controversial. There are few explicit legal standards for judging competency to make medical decisions. Furthermore, clinical practices for evaluating decision-making capacity are problematic. The following case illustrates some of these problems.Mrs. C., a 74 year old widow with congestive heart failure, angina pectoris, and mild dementia, has been admitted to the hospital for shortness of breath and chest pain. In the past three years she has suffered two heart attacks. During the past two months, her symptoms have worsened despite several medications, including maximally tolerated doses of diltiazem, furosemide and enalapril. She now develops shortness of breath and chest pain when walking one block. Because there are no other medical treatments for her condition, her physician recommends angioplasty or bypass surgery in order to ameliorate her symptoms.

Editor—We agree with Doyal and Sheather that mental health legislation should respect decision making capacity because patients with a mental disorder should not be discriminated against. 1 The current legal test of capacity and the criteria of capacity in the forthcoming mental capacity act in England and Wales largely focus …

In reply Dr MacLean's letter raises important issues concerning limitations of objective approaches to the assessment of competency. We agree that competency assessment ultimately involves a moral judgment, that clinicians need more conceptual clarity regarding competency, and that competency judgments should not be reduced to "a technical medical determination." What should not be overlooked, however, is the important relationship of standardized assessment approaches to the conceptual and moral basis of competency judgments. Clinical assessment of competency to consent is currently a subjective, and even idiosyncratic, process. We previously reported data concerning a lack of agreement among experienced physicians when assessing the competency of patients with mild and moderate dementia to consent to treatment.1More recently, we found that five physicians experienced in competency assessment differed markedly in their competency judgments for patients with mild Alzheimer's disease, but not for older controls. The physicians achieved virtually perfect judgment agreement for

Marson et al 1 have recognized that decisionmaking capacity (DMC) is task specific and that impairment of DMC can occur in degrees, rather than being all or nothing. In so doing theyare in good company with nursing home clinicians, 2-5 legal scholars, 6,7 and ethicists. 8,9 The prevalence of "limited DMC," intermediate between full DMC and none, was recently studied among residents of our hospital-based nursing home. Limited DMC was defined as demonstrating an inability to independently make 1 or more decisions in the civil, personal, financial, or health care domains while still showing the ability to recognize significant family members or others and designate them as power-of-attorney. A substantial number of residents fell in the limited DMC category, ranging from 17% in a long-stay unit to 40% in a short-stay postacute unit 10 ( Table ). Such residents require assessment of capacity to make decisions on a caseby-case basis for

During the twentieth century, American governments progressed from essentially no use of government budgeting to experimentation with a host of budgeting strategies designed to improve the control, efficiency, and decision making capacity of governing agencies. In 1984, the Government Finance Officers Association of the United States and Canada sought to synthesize many of these approaches into a broad definition of budgetary excellence by the establishment of an Award for Distinguished Budget Presentation. This article reviews the effort to define budgetary excellence, then offers a discussion of the lessons learned during the first years of the program's operation. he of the products of the program's operation.

We report on an interview-based study of decision-making capacity in two classes of patients suffering from depression. Developing a method of second-person hermeneutic phenomenology, we articulate the distinctive combination of temporal agility and temporal inability characteristic of the experience of severely depressed patients. We argue that a cluster of decision-specific temporal abilities is a critical element of decision-making capacity, and we show that loss of these abilities is a risk factor distinguishing severely depressed patients from mildly/moderately depressed patients. We explore the legal and clinical consequences of this result.

Since the Rivers v. Katz decision in 1986, clinicians in New York State have been required to assess patient decision-making capacity before judicial review of petitions to administer involuntary medication. The authors examined 42 capacity assessments made by psychiatrists at a large state hospital in New York City. Although the capacity assessments were often incomplete and rarely addressed the treatment decision, most clinicians judged patients as lacking capacity to make treatment decisions. The findings suggest that psychiatrists may view capacity assessments as irrelevant because of the manifestly grave nature of patients' illnesses or may not differentiate the capacity assessment from the mental status examination. The capacity assessment may nonetheless be a useful tool because it encourages clinicians to discuss the proposed treatment with patients and to present information more effectively in court.

Background: Patient outcome after serious brain injury is highly variable. Following a period of coma, some patients recover while others progress into a vegetative state (unresponsive wakefulness syndrome) or minimally conscious state. In both cases, assessment is difficult and misdiagnosis may be as high as 43%. Recent advances in neuroimaging suggest a solution. Both functional magnetic resonance imaging and electroencephalography have been used to detect residual cognitive function in vegetative and minimally conscious patients. Neuroimaging may improve diagnosis and prognostication. These techniques are beginning to be applied to comatose patients soon after injury. Evidence of preserved cognitive function may predict recovery, and this information would help families and health providers. Complex ethical issues arise due to the vulnerability of patients and families, difficulties interpreting negative results, restriction of communication to "yes" or "no" answers, and cost. We seek to investigate ethical issues in the use of neuroimaging in behaviorally nonresponsive patients who have suffered serious brain injury. The objectives of this research are to: (1) create an approach to capacity assessment using neuroimaging; (2) develop an ethics of welfare framework to guide considerations of quality of life; (3) explore the impact of neuroimaging on families; and, (4) analyze the ethics of the use of neuroimaging in comatose patients. Methods/Design. Our research program encompasses four projects and uses a mixed methods approach. Project 1 asks whether decision making capacity can be assessed in behaviorally nonresponsive patients. We will specify cognitive functions required for capacity and detail their assessment. Further, we will develop and pilot a series of scenarios and questions suitable for assessing capacity. Project 2 examines the ethics of welfare as a guide for neuroimaging. It grounds an obligation to explore patients' interests, and we explore conceptual issues in the development of a quality of life instrument adapted for neuroimaging. Project 3 will use grounded theory interviews to document families' understanding of the patient's condition, expectations of neuroimaging, and the impact of the results of neuroimaging. Project 4 will provide an ethical analysis of neuroimaging to investigate residual cognitive function in comatose patients within days of serious brain injury. © 2014 Weijer et al.; licensee BioMed Central Ltd.

This study aimed to assess the decision-making capacity for treatment of patients hospitalized in an internal medicine ward of a General Hospital in Greece, and to examine the views of treating physicians regarding patients' capacity. All consecutive admissions to an internal medicine ward within a month were evaluated. A total of 134 patients were approached and 78 patients were interviewed with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the Mini Mental State Examination (MMSE) questionnaire. Sixty-eight out of 134 patients (50.7%) were incompetent to decide upon their treatment. The majority of them (n=56, 41.8%) were obviously incapable because they were unconscious, or had such marked impairment that they could not give their own names, and the rest (n=12, 8.9%) were rated as incompetent according to their performance in the MacCAT-T. Neurological disorders, old age and altered cognitive function according to MMSE were negatively correlated with decision making capacity. Physicians sometimes failed to recognize patients' incapacity. Rates of decision-making incapacity for treatment in medical inpatients are high, and incapacity may go unrecognized by treating physicians. Combined patient evaluation with the use of the MacCAT-T and MMSE, could be useful for the determination of incapable patients.

Background: Within psychiatric practice and policy there is considerable controversy surrounding the nature and assessment of impairments of decision-making capacity (DMC) for treatment in persons diagnosed with affective disorders. We identify the problems of “cognitive bias” and “outcome bias” in assessment of DMC for treatment in affective disorder and aim to help resolve these problems with an analysis of how time is experienced in depression and mania. Sampling and Methods: We conducted purposeful sampling and a qualitative phenomenological analysis of interview data on patients with depression and mania, exploring temporal experience and decision-making regarding treatment. Results: In both severe depression and mania there is a distinctive experience of the future. Two consequences can follow: a loss of evaluative differentiation concerning future outcomes and, relatedly, inductive failure. This temporal inability can compromise an individual’s ability to appreciate or “use or weigh” treatment information. Conclusions: The decision-making abilities required for self-determination involve an ability to evaluate alternative future outcomes. Our results show that, within severe depression or mania, anticipation of future outcomes is inflexibly fixed at one end of the value spectrum. We therefore propose a temporal model of decision-making abilities, which could be used to improve assessment of DMC in affective disorder.

The convergence of the aging of our society, the increase in blended families, and an enormous intergenerational transfer of wealth has greatly expanded the incidence and importance of capacity assessment of older adults. In this article we discuss the emergence of capacity assessment as a distinct field of study. We review research efforts in two domains: medical decision-making capacity and financial capacity. Existing research in these two areas provides a first pass at many key questions related to capacity assessment, but additional studies that replicate, extend, and improve on this research are urgently needed. An agenda for future is detailed that recommends studies of a wide range of capacity constructs, focusing on clinical markers of diminished capacity, methods to improve clinical assessment, and the many intersections of law and clinical practice. (Reprint w/permission from Journal of Gerontology: PSYCHOLOGICAL SCIENCES 2007, Vol. 62B, No. 1, P3– P11)

Background: Individuals’ right to be involved with decisions regarding their health and social care is the cornerstone for modern patient-centred care. Decision-making is a complex process ...

Psychiatric disorders in the perinatal period can lead to a deterioration in one's judgment and decision-making ability. These disorders may cause sensitive and complex legal and ethical issues relating to psychiatric, obstetric, and neonatal care. Clinicians should ethically respect the autonomy of the individual, but at the same time, they must assess the individual's decision-making process with the use of forensic psychiatric and consultation-liaison psychiatric practice. While the literature related to mental disorders in pregnancy has been increasing, there is limited information regarding the medico-legal and ethical aspects of this topic. Herein, we present two cases who are pregnant and have psychiatric disorders, and we aim to discuss their evaluation process of uterine evacuation.