Decision-making difficulties experienced by adults with autism spectrum conditions.

Autobiographical and clinical accounts, as well as a limited neuropsychological research literature, suggest that, in some situations, men and women with autism spectrum conditions (ASCs) may have difficulty making decisions. Little is known, however, about how people with ASCs experience decision-making or how they might best be supported to make decisions for themselves. In this study, we compared the decision-making experiences of adults with and without ASCs (n=38 and n=40, respectively) using a novel questionnaire and the General Decision Making Style inventory (GDMS, Scott & Bruce, 1995). The participants with ASCs reported experiencing several problems in decision-making more frequently than the comparison group, and were more likely to report avoidance of decision-making, as measured using the GDMS. The findings highlight areas of potential future research and inform suggestions for supporting adults with ASCs during decision-making.

An fMRI investigation of detection of semantic incongruities in autistic spectrum conditions.

The aim of this study was to investigate differences in the brain's haemodynamic response to semantically incongruent and congruent sentences in adults with an autistic spectrum condition (ASC) and a typically developing Control group. We used functional magnetic resonance imaging to measure regional variations in neural activity during detection of semantic incongruities within written sentences. Whilst the 12 controls showed a pattern of activity extending from posterior cingulate cortices bilaterally and the left occipitotemporal region to the left superior and inferior temporal lobes, right anterior cingulate and right inferior frontal gyrus, the 12 participants with an ASC presented a more spatially restricted activation pattern, including the left inferior frontal gyrus, left anterior cingulate cortex and right middle frontal gyrus. These results are coherent with the hypothesis that impaired integration of multiple neural networks in people with an ASC is related to previous observations that this group have difficulties in the use of context to predict the final word of sentences.

Respecting patient autonomy: understanding the impact on NHS hospital in-patients of legislation and guidance relating to patient capacity and consent.

OBJECTIVES: to determine the extent and nature of the decisions individuals are asked to make as in-patients, and whether doctors, nurses, other health care practitioners, and housekeepers engaged in routine (non-emergency) medical assessments, investigations and treatments, or acts of personal care observe the Reference Guide to Consent for Examination or Treatment, the principles of the Mental Capacity Act (England and Wales) 2005, and the guidance from the Dignity in Care Campaign. METHODS: hospital staff working on a general medical ward and a ward for older people in a large teaching hospital in England were observed for over 50 hours carrying out acts of medical and personal care. The observations were recorded using a semi-structured record sheet, complemented by unstructured field notes. Observations were subsequently categorized, coded and counted. RESULTS: a total of 206 acts were observed, 127 (62%) of which were acts of medical care and 79 (38%) were acts of personal care. Patients approached for acts of personal care were generally presented with choices and options (78%). In contrast, when approached for acts of medical care, they were rarely presented with a choice (6%); instead, health care practitioners either requested permission to perform a procedure (29%) or informed patients that they were about to perform a procedure (50%). Irrespective of the way in which health care practitioners approached patients about acts of medical care, in the overwhelming majority of instances, patients complied (80%, 99 cases), either by giving permission for the act to be performed, or by complying and/or cooperating with the health care practitioner. In only a minority of cases did patients either refuse or resist a proposed procedure (9%). CONCLUSIONS: patients were asked to make many varied decisions and the approaches taken by hospital staff differed depending on the nature of the decision and/or act in question. In contrast to personal care decisions, when health care practitioners approached patients in order to undertake routine acts of medical care, they generally did so in a manner that did not acknowledge that the patient had a right to exercise a choice. This is contrary to current law, policy and guidance. It seems to be rooted in the practical demands of running a hospital ward and uncertainties as to the purpose of securing patient consent before undertaking routine acts of medical care.

Hospital clinicians' attitudes towards a statutory advocacy service for patients lacking mental capacity: implications for implementation.

OBJECTIVES: To examine attitudes to the Mental Capacity Act's new statutory Independent Mental Capacity Advocate (IMCA) service in England and Wales and consider the implications for its delivery. METHODS: Quantitative data describing all referrals to the seven pilot IMCA services (January 2006-March 2007) and qualitative data from semi-structured interviews with 18 doctors, 21 senior nurses and one discharge planning manager in four general hospitals in England. RESULTS: Of 127 hospital-based referrals to the seven pilot IMCA services, 29 (23%) were for patients facing serious medical treatments, 52% of whom were judged to lack decision-making capacity due to a learning disability; ninety-eight (77%) were for patients facing a change of accommodation upon hospital discharge, 62% of whom were elderly and lacked capacity due to dementia. While aware of the potential benefits of the IMCA service, clinicians were generally negative about the contribution advocates could make to patients' medical care and thought they could only contribute usefully in a minority of ethically complicated decisions. In contrast, they were more positive about the involvement of advocates in hospital discharge decisions and hoped that they would improve current discharge practice. CONCLUSIONS: Clinicians held ambivalent attitudes towards the involvement of a statutory IMCA service in medical decisions, reflecting beliefs that the service was largely impractical and unnecessary given current procedures for making medical decisions in patients' 'best interests'. Conversely, clinicians were more likely to support advocacy in discharge decisions because they believed that non-medically qualified advocates could make a valuable contribution to decisions that were seen as predominantly social and where practice was frequently considered deficient. By holding these beliefs, clinicians are failing to have due regard for the IMCA service as a statutory measure for safeguarding patients' interests.