Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis.

Decision-making capacity (DMC) among psychiatric inpatients is a pivotal clinical concern. A review by Okai et al. (2007) suggested that most psychiatric inpatients have DMC for treatment, and its assessment is reliable. Nevertheless, the high heterogeneity and mixed results from other studies mean there is considerable uncertainty around this topic. This study aimed to update Okai's research by conducting a systematic review with meta-analysis to address heterogeneity. We performed a systematic search across four databases, yielding 5351 results. We extracted data from 20 eligible studies on adult psychiatric inpatients, covering DMC assessments from 2006 to May 2022. A meta-analysis was conducted on 11 papers, and a quality assessment was performed. The study protocol was registered on PROSPERO (ID: CRD42022330074). The proportion of patients with DMC for treatment varied widely based on treatment setting, the specific decision and assessment methods. Reliable capacity assessment was feasible. The Mini-Mental State Examination (MMSE), Global Assessment of Function (GAF), and Brief Psychiatric Rating Scale (BPRS) predicted clinical judgments of capacity. Schizophrenia and bipolar mania were linked to the highest incapacity rates, while depression and anxiety symptoms were associated with better capacity and insight. Unemployment was the only sociodemographic factor correlated with incapacity. Assessing mental capacity is replicable, with most psychiatric inpatients able to make treatment decisions. However, this capacity varies with admission stage, formal status (involuntary or voluntary), and information provided. The severity of psychopathology is linked to mental capacity, though detailed psychopathological data are limited.

Diverging medical and legal perceptions of the need for legal guardianship in people with dementia: A qualitative study.

BACKGROUND: Dementia is assumed to alter mental capacity, which may necessitate legal guardianship. However, only limited research exists on how dementia affects mental capacity, and most studies have focused solely on a medical perspective and concentrate on memory functions. The aim of this qualitative study was to investigate physicians' and legal experts' perceptions on a broad range of cognitive and neuropsychiatric domains potentially affecting mental capacity and the need for guardianship in people with dementia. METHODS: Physicians (N = 30) and legal experts (N = 20) participated in semi-structured individual interviews. The data were analyzed by using content analysis and further semi-quantified according to the cognitive and neuropsychiatric domains. RESULTS: Physicians considered neuropsychiatric symptoms and executive dysfunction to be the most important deficits in the legal context, while legal experts highlighted episodic memory impairment and dyscalculia. Perceptions regarding the importance of several cognitive and neuropsychiatric symptoms varied between and within the professional groups. CONCLUSIONS: Physicians and legal experts diverged in their perceptions of cognitive and neuropsychiatric domains affecting mental capacity and the need for guardianship. The evaluation and influence of medical evidence among legal experts heavily rely on subjective opinions. Given the substantial potential impact on patients' equal access to their rights, developing standardized guidelines is essential.

Capacity to Consent to Treatment of Substance Use Disorders at Ontario's Consent and Capacity Board: A Review of Past Reported Decisions.

PLAIN LANGUAGE SUMMARY TITLE: An Ontario review of legal cases which have considered patients' ability to consent to substance use treatments.

In general, prescribers must consider whether informed consent was provided prior to starting a treatment. A patient is presumed to be capable to consent to a proposed treatment but could be incapable with respect to any medical treatment. While incapacity is often considered for psychiatric treatments, it could be relevant to substance use treatment like methadone or suboxone, which are also called "Opioid Agonist Therapies" or OAT. OAT is lifesaving and prevents relapse and overdose when a person has an opioid use disorder. If a patient is found incapable of consenting to a treatment, a Substitute Decisions Maker would become the decision maker. In such cases, the patient has the ability to contest or disagree with the finding, and this results in a tribunal hearing at the Consent and Capacity Board in Ontario (CCB). In certain circumstances, the CCB publishes what are known as its Reasons for Decision (RDs), which explain the tribunal's reasoning in coming to a decision in favour of the physician or the person found incapable. This information is publicly searchable. Our methods involved a search of all available CCB RDs in Ontario for search terms related to substance use treatment, such as "methadone". We found that between June 1, 2003 (the date on reporting of RDs began) and June 27, 2023, only 71 RDs involved substance use search terms, out of a total of 10,463 reported RDs. Only one case involved the CCB upholding a finding of incapacity with respect to methadone treatment. These results imply that there are few cases in which the CCB has considered incapacity with respect to substance use treatment, although it is possible that these cases are reported at a lower frequency than other cases.

Mental integrity, autonomy, and fundamental interests.

Many technology ethicists hold that the time has come to articulate neurorights: our normative claims vis-à-vis our brains and minds. One such claim is the right to mental integrity ('MI'). I begin by considering some paradigmatic threats to MI (§1) and how the dominant autonomy-based conception ('ABC') of MI attempts to make sense of them (§2). I next consider the objection that the ABC is overbroad in its understanding of what threatens MI and suggest a friendly revision to the ABC that addresses the objection (§3). I then consider a second objection: that the ABC cannot make sense of the MI of the non-autonomous This objection appears fatal even to the revised ABC (§4). On that basis, I develop an alternative conception on which MI is grounded in a plurality of simpler capacities, namely, those for affect, cognition, and volition Each of these more basic capacities grounds a set of fundamental interests, and they are for that reason worthy of protection even when they do not rise to the level of complexity necessary for autonomy (§5). This yields a fully general theory of MI that accounts for its manifestations in both the autonomous and the non-autonomous.

Bipolar disorder and competence.

In this paper, I examine the connections between bipolar disorder and consent. I defend the view that many (although far from all) individuals with bipolar disorder are competent to consent to a wide variety of things when they are in a manic state.

A healthcare approach to mental integrity.

The current human rights framework can shield people from many of the risks associated with neurotechnological applications. However, it has been argued that we need either to articulate new rights or reconceptualise existing ones in order to prevent some of these risks. In this paper, we would like to address the recent discussion about whether current reconceptualisations of the right to mental integrity identify an ethical dimension that is not covered by existing moral and/or legal rights. The main challenge of these proposals is that they make mental integrity indistinguishable from autonomy. They define mental integrity in terms of the control we can have over our mental states, which seems to be part of the authenticity condition for autonomous action. Based on a fairly comprehensive notion of mental health (ie, a notion that is not limited to the mere absence of illness), we propose an alternative view according to which mental integrity can be characterised both as a positive right to (medical and non-medical) interventions that restore and sustain mental and neural function, and promote its development and a negative right protecting people from interventions that threaten or undermine these functions or their development. We will argue that this notion is dissociated from cognitive control and therefore can be adequately distinguished from autonomy.

What it is like to be manic: a response to Director.

In a recent article, Director makes the case that many individuals with bipolar disorder have the capacity to consent to many decisions while acutely manic, even when those decisions are out of character and cause harm. Referring to recent qualitative evidence, I argue that Director overlooks a key mechanism of manic incapacity, an inflexible experience of the future that impairs one's ability to value. Without attention to the illness-specific experience of decision-making, capacity assessments risk false negatives in people with mania.

The ethics of overriding patient refusals during 5150s and other involuntary psychiatric holds.

Involuntary psychiatric holds, such as the 5150 hold in California, allow for an individual to be taken into custody for evaluation and treatment for up to 72 h when they present a risk of danger to themselves. 5150s and other coerced holds present a bioethical tension as patient autonomy is overridden to provide psychiatric care. I discuss two arguments that aim to provide ethical justifications for overriding patient autonomy during 5150 holds: the "clinical benefit" and "lack of capacity" arguments. By demonstrating that these arguments do not always hold, I argue that overriding patient autonomy during 5150 holds is not always ethical and can be harmful. Lastly, I make recommendations for the 5150 and similar involuntary psychiatric holds to minimize harmful breaches of patient dignity: creating consistent field guidelines for assessing prehospital capacity, educating prehospital providers about the potential harms of 5150s, and utilizing existing support structures within the social context of the patient when they have capacity to refuse further prehospital care.

Capacity to consent: a scoping review of youth decision-making capacity for gender-affirming care.

BACKGROUND: Transgender and gender expansive (TGE) youth often seek a variety of gender-affirming healthcare services, including pubertal suppression and hormone therapy requiring that TGE youth and their parents participate in informed consent and decision making. While youth must demonstrate the ability to understand and appreciate treatment options, risks, benefits, and alternatives as well as make and express a treatment choice, standardized approaches to assess the capacity of TGE youth to consent or assent in clinical practice are not routinely used. This scoping review identified the currently available data regarding adolescent capacity to consent to gender-affirming medical treatments. METHODS: Articles relevant to assessing adolescent capacity for clinical decision-making were identified using OVID Medline, Web of Science, and PubMed. Articles were reviewed and thematically analyzed. RESULTS: Eight relevant articles were identified using three tools for measuring adolescent clinical decision-making capacity: Measure of Understanding, Measure of Competence, and MacArthur Competence Assessment Tool (MacCAT). These studies explored hypothetical treatment decisions, mental health treatment decisions, HIV treatment decisions, genetic testing decisions, and gender-affirming medical decisions. Only one study specifically examines the capacity of TGE youth to consent to medical treatments. Age was correlated with capacity in most, but not all studies. Other studies found cognitive measures (IQ, literacy, numeracy) may impact important aspects of capacity (understanding and reasoning). CONCLUSIONS: For clinicians caring for TGE youth, tools such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) may prove useful, in conjunction with consideration of youth developmental abilities and utilization of shared decision-making practices. A standardized, collaborative approach to assessing TGE youth capacity would benefit TGE youth and their parents, and allow clinicians to more easily resolve ethical concerns.

Determining capacity of people with dementia to take part in research: an electronic survey study of researcher confidence, competence and training needs.

BACKGROUND: Researchers are required to determine whether a person has capacity to consent to a research study before they are able to participate. The Mental Capacity Act and accompanying Code of Practice for England and Wales provide some guidance on this process, but researchers have identified that it can be difficult to determine capacity to consent when a person has complex cognitive or communication needs. This study aimed to understand the experiences and opinions of researchers who recruit people with dementia to research projects, to inform the future development of training resources. METHODS: A mixed method, cross-sectional, electronic survey was circulated via social media and research networks in England and Wales. The survey remained open for ten weeks and included open and closed questions exploring respondents' confidence in determining capacity in the context of recruiting people with dementia to consent, their views on training and support they have experienced and their suggestions for future training and support needs. RESULTS: 60 respondents completed the survey from across England and Wales. Although 75% of respondents had experience of determining capacity to consent with people with dementia to research, only 13% rated themselves as feeling 'very confident' in this. Qualitative content analysis of open responses led to the generation of six themes, explaining researchers' confidence, competence and future training needs in this area: (1) Researcher uncertainties, (2) Lack of time, (3) Balancing information complexity with accessibility, (4) Gatekeepers, (5) Existing enablers and (6) Envisioning future training. CONCLUSIONS: Researchers would benefit from specific training in undertaking conversations around consent with people with dementia. People with dementia may have fluctuating capacity, and despite support from caregivers, researchers have little practical guidance on methods of determining a person's ability to understand or appreciate the information they have provided during the consent process. Given the development of large complex trials within dementia research, there is an urgency to develop specific and practical guidance and training for researchers working with people with dementia and their families.

Using Conversation Analysis to explore assessments of decision-making capacity in a hospital setting.

BACKGROUND: Healthcare professionals (HCPs) have a responsibility to conduct assessments of decision-making capacity that comply with the Mental Capacity Act 2005 (MCA). Current best-practice guidance, such as the Mental Capacity Code of Practice and National Institute for Health and Care Excellence decision-making and mental capacity guidance, does not stipulate how to accomplish this in practice, for example, what questions should be asked, how options and information should be provided. In addition, HCPs struggle to assess the capacity of individuals with communication difficulties. AIMS: This study was a service evaluation that aimed to objectively analyse, using Conversation Analysis (CA), how real-life capacity assessments were conducted in a hospital setting with patients with acquired brain injury (ABI)-related communication difficulties. A second aim was to establish the feasibility of using CA to advance knowledge of the conduct of capacity assessment. METHODS & PROCEDURES: Four naturally occurring capacity assessments were video-recorded. Recordings involved speech and language therapists, occupational therapists, neuropsychologists and patients with communication difficulties as a result of ABI. The methods and findings of CA were used to investigate the interactional behaviours of HCPs and patients during assessments of decision-making capacity. The analysis was informed by our knowledge of the MCA best practice guidance. OUTCOMES & RESULTS: An overall structure of capacity assessment that enacted some of the best-practice MCA guidance was identified in one recording, consisting of six phases: (i) opening, (ii) preparation, (iii) option-listing, (iv) test, (v) decision, and (vi) close. The preparation phase consisted of two sub-components: information gathering and information giving. Variation from this structure was observed across the dataset, notably in the way in which options were (or were not) presented. CONCLUSIONS & IMPLICATIONS: CA is a feasible empirical method for exploring the structure and conduct of capacity assessments. CA identifies and provides ways of describing interactional behaviours that align with and diverge from best-practice MCA guidance. Future CA studies including a wider range of health and social care professionals and patients have the potential to inform evidence based training for HCPs who conduct assessments of decision-making capacity. WHAT THIS PAPER ADDS: What is already known on this subject The Mental Capacity Act (MCA) is poorly implemented in practice. Healthcare professionals (HCPs) find it challenging to assess the decision-making capacity of individuals with communication difficulties, and people with communication difficulties are often excluded from or insufficiently supported during capacity assessment. Research is limited to self-report methods. Observational studies of capacity assessment are required. What this study adds This is the first study to use Conversation Analysis (CA) to explore how capacity assessments are conducted in a hospital setting by HCPs with people with communication difficulties as a result of acquired brain injury. One video-recorded capacity assessment was structured in six phases that aligned with best practice MCA guidance. However, other capacity assessments deviated from this structure. One phase, option listing, varied in practice and options were not always presented. What are the clinical implications of this work? CA revealed interactional behaviours that align with and diverge from best-practice MCA guidance. Future CA studies are warranted to inform training for health and social care professionals who conduct capacity assessments.

Neurobiological evidence and criminal competencies.

Neuroimaging and other neurobiological evidences are increasingly introduced in criminal litigation, especially when a neuropsychiatric disorder is suspected. Evaluations of criminal competencies are the most common type of criminal forensic assessment in forensic psychiatry and psychology. Given this, it is critical for forensic evaluators to understand how neuropsychiatric disorders may affect a defendant's criminal competencies and how neurobiological data may be used in competency determinations. This paper reviews the use of neurobiological data, particularly neuroimaging, while considering the limitations and potential misuse of such data in criminal competency evaluations.

Forensic psychiatric issues in intellectual disability.

Forensic psychiatrists and neuropsychiatrists are likely to encounter individuals with intellectual disability as they are over-represented in the judicial system. These individuals may have the full range of mental illnesses and comorbid conditions, including physical infirmity, sensory deficits, language impairment, and maladaptive behaviors. They are frequently disadvantaged in the judicial system due to lack of comprehension, lack of accommodations, and stigmatization. Decision making capacity may need to be assessed for health care, sexual autonomy, marriage, financial management, making a will, and need for guardianship. The usual approach to conducting an evaluation needs adaptation to fit the unique characteristics and circumstances of the individual with intellectual disability. The forensic consultant can assist attorneys, defendants, and victims in recommending accommodations and the expert witness can provide education to juries.

A County-Level Case Study of Early Psychosis in the Context of a Hybrid Juvenile Competency Restoration and Mental Health Problem-Solving Court and Linkage to Coordinated Specialty Care Services.

An important and unresolved question in the context of the implementation of coordinated specialty care (CSC) for early psychosis in the United States is the extent to which youth and young adults from marginalized backgrounds are able to equitably access CSC services. In this brief report, we describe pathways between a county hybrid juvenile competency restoration and mental health problem-solving court ('Court'), serving youth with high rates of psychosis and multiple risk factors for poor long-term outcomes, and local CSC services. We found that the Court was overall successful in linking youth with psychosis to care, but in the majority of cases this was not CSC programming more specifically. Drawing on Court and CSC records as well as family interviews, we report on factors contributing to low linkage to CSC, including family-side barriers (lack of transportation, preference for lower intensity / lower demand services) and provider-side barriers, including eligibility criteria such as duration of psychosis, that ultimately exclude otherwise eligible Court-involved youth.

Dementia and competency to stand trial in the United States: A case law review.

OBJECTIVE: Competency to stand trial (CST) is foundational to the U.S. criminal legal system. Dementia is increasingly prevalent in the United States, and older adults are becoming involved with the U.S. criminal legal system at unprecedented rates, which carries significant implications for legal professionals and clinicians involved in CST cases. Unfortunately, CST research to date has largely excluded considerations of dementia and aging. The present study addressed this gap by reviewing U.S. case law related to dementia and CST. HYPOTHESES: The present study had no hypotheses because of its descriptive nature. METHOD: This was a case law review of 118 U.S. court cases involving dementia and CST from 2002 through 2022. Relevant information was coded about the legal case, defendant demographics, clinical evaluation(s), and court determination. RESULTS: Competency was mostly raised by the defense (81%). Similar percentages of defendants were involved in one, two, and three or more evaluations, mostly conducted by experts appointed by courts or retained by the defense. Trends for court determinations were based on the number of evaluations conducted and experts' (dis)agreement about diagnosis and CST recommendation. Ultimately, 45% of defendants were determined incompetent, with trends appearing for dementia diagnosis, cognitive deficits, index offense, and jurisdiction, but not age. Ability to assist was the most cited reason for determinations of incompetence, often in combination with both factual and rational understanding or one of these psycholegal abilities alone. CONCLUSIONS: Dementia and related impairments appear especially relevant to CST among older adults and carry important implications for clinicians, legal professionals, and policymakers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Transcultural Psychiatry in Medical Ethics: Assessing Decision-Making Capacity within the Lens of an East African Refugee.

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

[MacCAT-T between Claim and Practice - Challenges of Assessing Capacity for Consent in Dementia]. / MacCAT-T zwischen Anspruch und Praxis ­ Herausforderungen bei der Beurteilung von Einwilligungsfähigkeit bei Demenz.

BACKGROUND: Consent is a prerequisite for medical diagnostic and therapeutic action. There is no standardised procedure for assessing the ability to give consent. The most widely used tool for structured assessment is the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). OBJECTIVES: People with dementia have impaired capacity to consent because of their disease. In order to answer the question to what extent structured assessment procedures can be usefully applied to people with dementia, we analyse the function, strengths and weaknesses of structured assessment procedures with a focus on the MacCAT-T and discuss suggestions for modification and further development of the tool. METHODS: Using the PubMed literature database, a systematic literature search and analysis was conducted on papers published since 2010, following PRISMA guidelines.Results Although the MacCAT-T is a valid and reliable tool, it cannot comprehensively address memory problems in people with dementia. It primarily measures cognitive functions. However, Decisions based on emotions, intuitions and values, are not captured by the MacCAT-T. Communicative limitations in people with dementia are not taken into account. CONCLUSIONS: It is recommended to provide information in simple language, written down and visualised for people with dementia. The development and elaboration of a graduated procedure for the examination of capacity to consent is indicated. The gradations of the scope and depth of the assessment to be determined should be based on the severity of the cognitive impairment, the benefit/risk ratio of the proposed medical intervention and the individual profile of affective functions and value-based imprints.

Insight and the Capacity to Refuse Treatment with Electroconvulsive Therapy.

All Australian jurisdictions have statutory provisions governing the use of electroconvulsive therapy. Cases in which the patient lacks insight into their psychotic illness and need for treatment and refuses to have ECT are particularly poignant. In Re ICO [2023] QMHC 1, the Queensland Mental Health Court considered whether a patient with a treatment-resistant psychotic illness had decision-making capacity to refuse ECT. The Court also considered whether the patient had been provided with an adequate explanation of the proposed treatment including the expected benefits, risks and adverse effects of ECT. As well as deciding whether ECT was appropriate in the circumstances, the Court considered whether there were alternative treatments including another trial of the oral antipsychotic clozapine. This article reviews issues relating to lack of insight in persons with psychotic illness and relevant considerations for determining capacity to decline ECT.

Capacity to Consent in Healthcare: A Systematic Review and Meta-Analysis Comparing Patients with Bipolar Disorders and Schizophrenia Spectrum Disorders.

Background: Mental capacity is a fundamental aspect that enables patients to fully participate in various healthcare procedures. To assist healthcare professionals (HCPs) in assessing patients' capacity, especially in the mental health field, several standardized tools have been developed. These tools include the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), and the Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD). The core dimensions explored by these tools include Understanding, Appreciation, Reasoning, and Expression of a choice. Objective: This meta-analysis aimed to investigate potential differences in decision-making capacity within the healthcare context among groups of patients with bipolar disorders (BD) and schizophrenia spectrum disorders (SSD). Methods: A systematic search was conducted on Medline/Pubmed, and Scopus. Additionally, Google Scholar was manually inspected, and a manual search of emerging reviews and reference lists of the retrieved papers was performed. Eligible studies were specifically cross-sectional, utilizing standardized assessment tools, and involving patients diagnosed with BD and SSD. Data from the studies were independently extracted and pooled using random-effect models. Hedges' g was used as a measure for outcomes. Results: Six studies were identified, with three studies using the MacCAT-CR, two studies the MacCAT-T, and one the CAT-PAD. The participants included 189 individuals with BD and 324 individuals with SSD. The meta-analysis revealed that patients with BD performed slightly better compared to patients with SSD, with the difference being statistically significant in the domain of Appreciation (ES = 0.23, 95% CI: 0.01 to 0.04, p = 0.037). There was no statistically significant difference between the two groups for Understanding (ES = 0.09, 95% CI:-0.10 to 0.27, p = 0.352), Reasoning (ES = 0.18, 95% CI: -0.12 to 0.47, p = 0.074), and Expression of a choice (ES = 0.23, 95% CI: -0.01 to 0.48, p = 0.60). In the sensitivity analysis, furthermore, when considering only studies involving patients in symptomatic remission, the difference for Appreciation also resulted in non-significant (ES = 0.21, 95% CI: -0.04 to 0.46, p = 0.102). Conclusions: These findings indicate that there are no significant differences between patients with BD and SSD during remission phases, while differences are minimal during acute phases. The usefulness of standardized assessment of capacity at any stage of the illness should be considered, both for diagnostic-therapeutic phases and for research and advance directives. Further studies are necessary to understand the reasons for the overlap in capacity between the two diagnostic categories compared in this study.

Important legal principles of consent and mental capacity.

Consent is an essential part of healthcare practice, allowing patients to make autonomous decisions. However, this changes when a patient has mental incapacity or is unable to make decisions for themselves for a duration of time. This month's Policy column looks at some of the key principles of the Mental Capacity Act 2005, and how this can be applied in community nursing practice.