[Euthanasia in an advanced state of dementia: a verdict and its reception in the medical world]. / Euthanasie bij gevorderde dementie.

The most controversial issue in the Dutch euthanasia practice concerns the performance of euthanasia in a case of a patient in an advanced state of dementia on the basis of a request that is laid down in an advance directive. This is particularly controversial when such a patient, although lacking decisional capacity on the matter, shows signs of a wish to live. In two important verdicts of April 21 2020 the Dutch Supreme Court has ruled that a request that has been made competently cannot be revoked incompetently. In this comment I consider two recent documents from Dutch professional organisations that are contrary to these decisions, in particular a guideline stating that on a proper understanding of decisional capacity the expression of a wish to live of a demented person, however inarticulate, should always be considered to be made competently.

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).

Legal and Ethics Considerations in Capacity Evaluation for Medical Aid in Dying.

Evaluating decisional capacity for patients seeking medical aid in dying (MAID) raises challenging legal, logistical, and ethics questions. The existing literature on the subject has been shaped largely by early disagreements over whether effective capacity assessment for such patients is ever possible, which in turn stemmed from debates over the ethics of MAID itself. In attempting to establish meaningful criteria for assessments, many jurisdictions have sought either to apply or to adapt models of capacity evaluation designed for other forms of medical decision-making, such as the widely used "four skills" model, failing to account for the fundamental differences in kind between these other decisions and MAID. This article seeks to reexamine these questions with a focus on two logistical matters (the appropriate credentialing for the evaluator and the potential liability of the evaluator) and three clinical matters (level of understanding, clinical scrutiny and certainty, and impairment) in an effort to raise legal and ethics concerns that remain unresolved, even as MAID is permitted in an increasing number of jurisdictions.

Using Technology to Improve the Mental Capacity Assessment and Deprivation of Liberty Safeguards Process.

The process of mental capacity act (MCA) assessment and depravation of liberty safeguarding (DoLS) was identified as an area for improvement. The project aimed to ensure that patients admitted to hospital for care and treatment were appropriately assessed if there is doubt about their mental capacity and that the subsequent legal process of DoLS is followed as needed. The project group sought to address this issue using clinical informatics through the electronic health record and data reports to re-design the process. User involvement was key to ensure the process and key pieces of documentation were designed to be easy for staff to use with responsibilities clearly defined. The importance of operational staff having good visibility of the end-to-end process was key to allow staff to identify and address any gaps in the process in real time without the need for escalation by the safeguarding team. A robust data report further supports the safeguarding team to effectively manage this group of vulnerable patients. The project has significantly increased appropriately the number of MCA assessments undertaken and subsequent DoLS applications submitted to local authority partners.

Assessment of the informed consent related to healthcare decisions for medically fragile child in italy: a pilot study.

Background: In Italy, the law n. 219/2017 regarding informed consent states that "Communication time between doctor and patient constitutes treatment time". Legal guardian is designated as a proxy to consent on the child's behalf. The issue of proxy informed consent should be approached with a model for parent-child decision-making that is participatory, collaborative, respects and supports the autonomy of child by recognizing their evolving capacities. We aim to assess the informed consent related to healthcare decisions for medically fragile child, using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Materials and Methods: An observational study has been conducted at a Child Neuropsychiatry Service, administering a semi-structured interview with customized questionnaire to examine their capacities in four areas of the MacCAT-T. Results were evaluated with the Pearson correlation coefficient for the cognitive and adaptive levels of the Wechsler-Intelligence-Scale-for-Children (WISC-IV) and the Vineland-Adaptive-Behavior-Scales-II (VABS-II). Conclusions: The MacCAT-T domains Understanding, Appreciation, Reasoning, Expressing a Choice were correlated with the cognitive and adaptive levels of the WISC-IV and the VABS-II. Understanding, Appreciation and Expressing a choice have positive correlation with the Communication and Socialization scores of VABS-II; Reasoning has positive correlation with the Working-Memory-Index scores of the WISC-IV. The study enabled to assess the informed consent processes in vulnerable children and although demonstrating how they participate in their care process in a mostly unconscious way, making the frail children more involved in their own care process was possible. Future studies should assess the impact of incorporating MacCAT-T into standard informed consent in other settings.

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.

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.

A Primer for Increasing Competency in Forensic Psychiatry Research.

Empirical research is foundational to the discipline of forensic psychiatry. Candilis and Parker provide a cogent systematic review of the empirical literature on restoration of competence to stand trial using National Institutes of Health quality metrics. Components of the study methodology are highlighted, as they represent current best practices for conducting a systematic review. A discussion of strategies to increase empirical research uptake in forensic psychiatry is pursued alongside concrete examples of how the American Academy of Psychiatry and the Law Research Committee can help facilitate this goal.

An Assessment of the Quality of Competence Restoration Research.

A systematic review of the literature on restoration of competence to stand trial identified a predominance of retrospective case studies using descriptive and correlational statistics. Guided by National Institutes of Health (NIH) quality metrics and emphasizing study design, sample size, and statistical methods, the authors categorized a large majority of studies as fair in quality, underscoring the need for controlled designs, larger representative samples, and more sophisticated statistical analyses. Implications for the state of forensic research include the need to use large databases within jurisdictions and the importance of reliable methods that can be applied across jurisdictions and aggregated for meta-analysis. More sophisticated research methods can be advanced in forensic fellowship training where coordinated projects and curricula can encourage systematic approaches to forensic research.

Mute by Visitation of God, Competency to Stand Trial and Fitness to Plead.

Laws on competency to stand trial and fitness to plead are said to derive from "mute by visitation of God," a medieval English legal term referring to the inability to speak through no fault of one's own. The paper describes the relevant historical background, illustrative cases, and legal commentaries. Muteness by visitation of God arose to address a particular set of difficulties caused by the need to have medieval defendants agree to be tried. Competency to stand trial and fitness to plead, on the other hand, arose to address more general and enduring concerns, that putting people on trial when they were unable to understand or participate compromised the dignity and fairness of criminal proceedings. The origins of competency to stand trial and fitness to plead do not lie in medieval English attempts to persuade silent defendants to speak. They warrant their own historical exegesis.

Mediating disputes under the Mental Capacity Act 2005: relationships, participation, and best interests.

This article analyses the use of mediation to resolve mental capacity law disputes, including those that arise in the healthcare context. It draws on original empirical data, including interviews with lawyers and mediators, and analysis of a mediation scheme, to argue that mediation has the potential to be an effective method of resolution in mental capacity law. It highlights the relationship benefits of mediation while acknowledging the challenges of securing P's participation and best interests. The final section of the article considers how mediation can operate in one of the most challenging healthcare environments, the Intensive Care Unit. The article emphasizes that the challenges we see in mediation are not unique and exist across the spectrum of Court of Protection practice. Therefore, the article concludes that mediation may be used effectively but the jurisdiction would also benefit from a clearer regulatory framework in which it can operate.

Deprivation of liberty and the community nurse.

In this month's Policy column, Iwan Dowie discusses the 'deprivation of liberty' - which is used to safeguard patients who may be lacking sufficient mental capacity to manage their own safety. The author, through previous legal cases, shares how the Deprivation of Liberty Safeguards (DoLS)-an amendment to the Mental Capacity Act 2005-came into being, and the importance of community nurses in knowing the DoLS.

Practical implications of overlapping mental capacity assessments.

Richard Griffith, Senior Lecturer in Health Law at Swansea University, considers the practical implications of undertaking mental capacity assessments with a person across a range of different decisions.

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.

Characteristics associated with criminal responsibility assessment outcomes among women in Central Canada.

The number of women involved with forensic mental health systems internationally is rising, however, limited research has explored the characteristics of those assessed for criminal responsibility. We investigated the demographic, psychiatric, and criminological characteristics of women recommended as eligible or ineligible for the defence of Not Criminally Responsible (NCR) on account of mental disorder following a criminal responsibility assessment in Central Canada. Data were collected through retrospective chart reviews of court-ordered criminal responsibility assessments for 109 women referred for evaluations between 2003 and 2019. Accused were an average age of 34.55 years, predominately identified as Indigenous (37.7%) or Caucasian (20.8%), and had often been charged with assault (47.7%). Women identified in the reports as NCR-eligible were significantly more likely to be employed, experience delusions during the index offence, and have expert reports linking their mental health symptoms to NCR legal criteria. They were also significantly less likely to have a personality disorder, substance-related diagnosis, or have used substances during the index offence. Delusions during the index offence significantly predicted assessment recommendations when controlling for age at assessment order, current substance-related diagnosis, and whether the expert report linked mental health symptoms to NCR legal criteria. Findings indicate the key factors considered by forensic mental health professionals when conducting criminal responsibility assessments with women. Meaningful differences exist between women identified as NCR-eligible and ineligible, with findings illustrating who may be more likely to receive services within the Canadian forensic mental health system.

Artificial intelligence and mental capacity legislation: Opening Pandora's modem.

People with impaired decision-making capacity enjoy the same rights to access technology as people with full capacity. Our paper looks at realising this right in the specific contexts of artificial intelligence (AI) and mental capacity legislation. Ireland's Assisted Decision-Making (Capacity) Act, 2015 commenced in April 2023 and refers to 'assistive technology' within its 'communication' criterion for capacity. We explore the potential benefits and risks of AI in assisting communication under this legislation and seek to identify principles or lessons which might be applicable in other jurisdictions. We focus especially on Ireland's provisions for advance healthcare directives because previous research demonstrates that common barriers to advance care planning include (i) lack of knowledge and skills, (ii) fear of starting conversations about advance care planning, and (iii) lack of time. We hypothesise that these barriers might be overcome, at least in part, by using generative AI which is already freely available worldwide. Bodies such as the United Nations have produced guidance about ethical use of AI and these guide our analysis. One of the ethical risks in the current context is that AI would reach beyond communication and start to influence the content of decisions, especially among people with impaired decision-making capacity. For example, when we asked one AI model to 'Make me an advance healthcare directive', its initial response did not explicitly suggest content for the directive, but it did suggest topics that might be included, which could be seen as setting an agenda. One possibility for circumventing this and other shortcomings, such as concerns around accuracy of information, is to look to foundational models of AI. With their capabilities to be trained and fine-tuned to downstream tasks, purpose-designed AI models could be adapted to provide education about capacity legislation, facilitate patient and staff interaction, and allow interactive updates by healthcare professionals. These measures could optimise the benefits of AI and minimise risks. Similar efforts have been made to use AI more responsibly in healthcare by training large language models to answer healthcare questions more safely and accurately. We highlight the need for open discussion about optimising the potential of AI while minimising risks in this population.

Informed consent in clinical practice: Old problems, new challenges.

Informed consent is a fundamental tenet of patient-centred clinical practice as it upholds the ethical principle of patient autonomy and promotes shared decision-making. In the medicolegal realm, failure to meet the accepted standards of consent can be considered as medical negligence which has both legal and professional implications. In general, valid consent requires three core components: (1) the presence of mental capacity - characterised by the patient's ability to comprehend, retain information, weigh options and communicate the decision, (2) adequate information disclosure - based on the 'reasonable physician' or 'reasonable patient' standards and (3) voluntariness in decision-making. Nonetheless, in real-world clinical settings, informed consent is not always optimally achieved, due to various patient, contextual and systemic factors. In this article, I herein discuss three major challenges to informed consent in clinical practice: (1) patient literacy and sociocultural factors, (2) psychiatric illnesses and elderly patients with cognitive impairment and (3) artificial intelligence in clinical care, and sought to offer practical mitigating strategies to address these barriers.