A randomized trial of a decisional aid for mental capacity assessments.

The objective of this study was to evaluate the clinical utility of a decisional aid for mental capacity assessments which was developed using a group judgment methodology. This was carried out by a randomized, controlled trial. The subjects comprised 64 University of Toronto psychiatry residents in postgraduate years 1 through 4. Residents were randomized to carry out mental capacity assessments on simulated cases with, or without, the use of the decisional aid. The main outcome measure was the extent of agreement between the mental capacity determinations of residents and those of experts. There was no difference between the intervention and control groups with respect to the overall mean level of agreement with experts (0.87 vs 0.86, p = 0.88; 95% confidence interval for the difference between the study groups, -0.07 to +0.08). A logistic regression analysis, which adjusted for imbalances between the groups, also revealed no difference between the groups in their agreement with experts. The mean time per competency assessment was significantly longer in the intervention group (19.1 vs 10.8 min; p < 0.001). It was concluded that the decisional aid did not improve the ability of the psychiatry residents to make mental capacity assessments on simulated cases. Despite relatively limited formal training, the psychiatry residents had a high level of agreement with experts.

Measuring capacity to complete an advance directive.

OBJECTIVE: To validate reference standards for the assessment of capacity to complete an advance directive and to develop and test three simple screening instruments. METHODS: We administered five measures of capacity to 96 older subjects from nursing homes, retirement homes, and homes for the aged. The measures included two reference standard evaluations: an assessment by a specially trained nurse in collaboration with a multidisciplinary team (Competency Clinic assessment) and geriatrician assessment using a decisional aid. Three screening instruments were also included: a Generic Instrument designed for any advance directive, a Specific Instrument designed for the "Let Me Decide" advance directive, and the Standardized Mini-Mental Status Examination (SMMSE). The screening instruments and the geriatrician's assessment were administered twice to half of the respondents to determine interrater agreement. RESULTS: The chance-corrected agreement for the assessment by two geriatricians was 0.78, and for agreement between the geriatricians and Competency Clinic assessments it was 0.82. Agreement for the Generic and Specific screening instrument assessments by two observers was 0.77 and 0.90, respectively. The areas under the Receiver Operating Characteristic curve relating the results of the three screening instruments to the Competency Clinic assessment were 0.82 for the Generic Instrument, 0.90 for the Specific Instrument, and 0.94 for the SMMSE; chance is an unlikely explanation for the difference between these three values (P < or = .01). CONCLUSIONS: Using rigorous methods, health workers can make reproducible and valid assessments of capacity to complete an advance directive. The SMMSE accurately differentiates people who can learn about and ultimately complete advance directives from those who cannot.

The effect of age of onset on depression in the elderly.

In an attempt to examine the effects of age and age of onset on depressive illness, the records of 55 psychiatric inpatients with an average age of 77 years were reviewed. There was no correlation between age and presence of psychosis, severe cognitive impairment, positive family history, length of hospitalization, treatment, or treatment response. When the cases were grouped on the basis of age of first admission, only the rates of family history were significantly different. Although age per se may have little influence on the nature of depressive illness, age of onset may be important in distinguishing different types of depressive illness in the elderly, which suggests implications for treatment and prognosis.

A correlation between cognitive performance and daily functioning in elderly people.

The Mini-Mental State Examination (MMSE) is widely used to detect dementia, but the diagnosis of dementia also depends on a decline in the level of daily functioning. Little is known about the relationship between performance on the MMSE and daily living abilities. This relationship was investigated in this study of an elderly population by comparing scores on the MMSE with those on both a direct assessment of everyday tasks and an indirect questionnaire about activities of daily living and physical self-maintenance. Forty-five subjects with varying mental abilities participated in the study. A significant correlation was found between MMSE scores and the measures of functional abilities; but the specificity and sensitivity to the diagnosis of dementia would be increased by assessing functional status, even indirectly, as well as cognitive ability.

Measurement of individual preferences. The importance of "situation-specific" variables.

Women in two Ontario cities were asked to express their preferences about a medical decision: A fictitious patient with cancer was to be treated either conservatively without hope of cure, or radically, by a risky treatment having cure or immediate death as possible outcomes. Situation-specific variables were varied systematically across the sample by varying the levels of the fictitious patient's physical and psychosocial health and achievement motivation. The results obtained indicate that individual preferences shift in response to changes in the situation in which the decision is made. These findings raise questions about the uses to be made of measurements of preferences, especially in relation to what is meant by a "best decision."

Use of the life table method in determining attrition from treatment.

Life table analysis of attendance at an outpatient clinic indicates levels of attrition similar to those reported by follow-up and other studies of treatment for drug dependence. With appropriate qualifications, rates of attrition may be viewed as measures of treatment outcome.

Preliminary report on informed consent for mental capacity assessments.

The goal of the study was to investigate the issue of informed consent for mental capacity. Seventeen clients referred to the Competency Clinic at the Baycrest Centre for Geriatric Care were interviewed after the assessment had been completed. Their responses to questions regarding the reasons for and possible consequences of the assessment indicated a range of understanding and of capacity to give informed consent. The results are discussed in terms of the appropriateness of having a fairly low threshold for informed consent in situations where other capacities are already in question.

Agreement between professions on ethical decisions: an empirical demonstration.

The decisions of a multidisciplinary competency panel at the Baycrest Centre for Geriatric Care, Toronto, Canada, were studied to try to explain the high level of agreement on individual cases when determining mental capacity. The panel assessed its own judgments on a standardized form developed to capture the process of coming to a capacity determination. Though the relative weights given to decision-making variables varied with discipline, there was agreement on a group of criteria most relevant to capacity. Three alternative explanations are given for these results.

Bathing incompetent patients.

Bathing incompetent patients can be a difficult experience, both for the patient and the nurse. When incompetent patients express a wish not to be bathed, or actively resist being bathed, it is even more stressful.

New Directions in Assessing Mental Competence: How the concept of limited guardianship has changed the meaning of competence.

As guardianship laws have been reformed and the concept of partial guardianship has emerged, traditional definitions of competency have changed and traditional methods of competency assessment have become inadequate. Ways are needed to assess capacity for particular functions, or decision-specific competence. This article explores ethical, conceptual, and practical difficulties and outlines an assessment model.

A preliminary report on the discrepancy between clinical and test evaluations of competence.

This report demonstrates the discrepancy that can occur between clinical and test evaluations of competence. It presents retrospective examination of 35 assessments of competence performed on 24 subjects by a multidisciplinary competency panel. The findings of the panel are compared with the subjects' results on the Cognitive Competency Test and on the Mini-Mental State Examination. The results show that the multidisciplinary competency panel will more often find subjects competent than indicated by their psychometric test scores. A process approach to the use of tests is recommended. Reliance on tests to decide the outcome of difficult cases does not appear to be warranted.

Permissible errors in managing property: an approach to the threshold of capacity.

OBJECTIVE: To demonstrate a practical approach to describing the threshold of mental capacity. METHOD: A retrospective analysis of 62 cases of assessments for capacity to manage property was carried out to record the type and frequency of errors. RESULTS: For items on the Mini-Mental State Examination (MMSE), there was no clear demarcation of items associated with a judgement of capable. On the clinical criteria, several items almost completely distinguished capable from incapable subjects. CONCLUSIONS: The permissible error approach makes the threshold of capacity explicit. It is well suited to the emphasis put on functional performance in the evaluation of mental capacity.

Reflections on segregating and assessing areas of competence.

Various complexities that arise in the application of legal and/or clinical criteria to the actual assessment of competence/capacity are discussed, and a particular way of understanding the nature of such criteria is recommended.