Capacidad e internamiento involuntario de pacientes con anorexia nerviosa: un estudio cualitativo sobre percepciones y actuación de psiquiatras y psicólogos clínicos / Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists

RESUMEN Introducción: La anorexia nerviosa plantea un importante problema bioético, ya que los pacientes, a menudo, rechazan el tratamiento a pesar del peligro que ello supone para su salud, y no está claro que su decisión sea autónoma. El objetivo de este trabajo es investigar las percepciones/actuación de psiquiatras y psicólogos clínicos ante la capacidad y el internamiento involuntario de pacientes con anorexia nerviosa. Métodos: Se entrevistó a 7 psiquiatras, 4 psicólogas clínicas y 1 psicóloga residente de tercer año. Se utilizó un enfoque de investigación cualitativa basado en la teoría fundamentada. Resultados: El análisis de datos mostró que estos profesionales articulan la atención del paciente en torno a una categoría principal, a saber, el internamiento como último recurso y la búsqueda de la voluntariedad, lo que implica un cambio en la dinámica asistencial habitual. En torno a esa categoría central, se erigen algunos conceptos importantes; estrés de rol, coerción informal, peso, familia y cronicidad. Conclusiones: La dificultad de conciliar demandas profesionales puede suponer un menoscabo en la calidad de la asistencia y en la propia satisfacción laboral, lo que pone en evidencia la necesidad de reflexionar e investigar sobre los fundamentos de las atribuciones asumidas.

ABSTRACT Introduction: Anorexia nervosa poses an important bioethical quandary, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa. Methods: Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used. Results: The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity. Conclusions: The difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.

Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists.

INTRODUCTION: Anorexia nervosa poses an important bioethical dilemma, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa. METHODS: Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used. RESULTS: The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity. CONCLUSIONS: It is concluded that the difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.

Mental health professionals' attitudes towards mental competency and involuntary commitment in anorexia nervosa: Construction, validation and results of the ACINOVAN questionnaire.

INTRODUCTION: Anorexia nervosa is a serious disorder that causes high rates of morbidity and mortality. Involuntary treatments are only legally admissible if the patient is not competent. However, assessing their capacity can be really complex. This implies that the final decision can be influenced by the individual attitudes of the physician. OBJECTIVE: To create and empirically validate a questionnaire in Spanish that makes it possible to measure the attitude towards capacity and involuntary commitment and compare between categorical groups. METHODS: The sample consisted of 338 mental health professionals. The items were validated by groups of experts. An exploratory factor analysis and group comparisons were carried out. RESULTS: Favourable evidence was obtained of a 13-item model consisting of three factors: pro-intervention, lack of competence and chronicity. Professionals tend to believe in the lack of capacity and the need for involuntary interventions, as well as differential suitability due to chronicity. Support prior to involuntary interventions was significantly related to the pro-intervention and absence of capacity factors, and training in bioethics to chronicity. CONCLUSIONS: The resulting instrument is valid and reliable. Its use can be useful to professionals, patients and society.

Actitudes de los profesionales de la salud mental ante la capacidad y el internamiento no voluntario en anorexia nerviosa: construcción, validación y resultados del cuestionario ACINOVAN / Mental Health Professionals' Attitudes Towards Mental Competency and Involuntary Commitment in Anorexia Nervosa: Construction, Validation and Results of the Acinovan Questionnaire

RESUMEN Introducción: La anorexia nerviosa es un trastorno grave que causa tasas elevadas de morbilidad y mortalidad. La aplicación de una intervención no voluntaria solo es legalmente admisible si el paciente no es competente. Sin embargo, la evaluación de su capacidad puede ser extremadamente compleja. Ello conlleva que la decisión final pueda verse influida por las actitudes individuales del facultativo. Objetivo: Crear y validar empíricamente un cuestionario en español que permita medir la actitud hacia la capacidad y el internamiento no voluntario y comparar entre grupos categóricos. Métodos: Formaron la muestra 338 profesionales de salud mental. Los ítems fueron validados por grupos de expertos. Se realizaron un análisis factorial exploratorio y comparaciones grupales. Resultados: Se obtuvo un modelo de 13 ítems formado por 3 factores: prointervención, ausencia de capacidad y cronicidad. Los profesionales tienden a creer en la ausencia de capacidad y la necesidad de la intervención no voluntaria, así como en la idoneidad diferencial en virtud de la cronicidad. El respaldo previo a intervenciones involuntarias se relacionó significativamente con los factores prointervención y ausencia de capacidad y la formación en bioética, con la cronicidad. Conclusiones: El instrumento resultante es válido y fiable. Puede ser útil a profesionales, pacientes y sociedad.

ABSTRACT Introduction: Anorexia nervosa is a serious disorder that causes high rates of morbidity and mortality. Involuntary treatments are only legally admissible if the patient is not competent. However, assessing their capacity can be really complex. This implies that the final decision might be influenced by the individual attitudes of the physician. Objective: To create and empirically validate a questionnaire in Spanish that makes it possible to measure the attitude towards capacity and involuntary commitment and compare between categorical groups. Methods: The sample consisted of 338 mental health professionals. The items were validated by groups of experts. An exploratory factor analysis and group comparisons were carried out. Results: Favourable evidence was obtained of a 13-item model consisting of three factors: pro-intervention, lack of capacity and chronicity. Professionals tend to believe in the lack of capacity and the need for involuntary interventions, as well as differential suitability due to chronicity. Having ever supported involuntary interventions was significantly related to the pro-intervention and lack of capacity factors, and training in bioethics to chronicity. Conclusions: The resulting instrument is valid and reliable. Its use can be useful to professionals, patients and society.

Mental Health Professionals' Attitudes Towards Mental Competency and Involuntary Commitment in Anorexia Nervosa: Construction, Validation and Results of the Acinovan Questionnaire. / Actitudes de los profesionales de la salud mental ante la capacidad y el internamiento no voluntario en anorexia nerviosa: construcción, validación y resultados del cuestionario ACINOVAN.

INTRODUCTION: Anorexia nervosa is a serious disorder that causes high rates of morbidity and mortality. Involuntary treatments are only legally admissible if the patient is not competent. However, assessing their capacity can be really complex. This implies that the final decision might be influenced by the individual attitudes of the physician. OBJECTIVE: To create and empirically validate a questionnaire in Spanish that makes it possible to measure the attitude towards capacity and involuntary commitment and compare between categorical groups. METHODS: The sample consisted of 338 mental health professionals. The items were validated by groups of experts. An exploratory factor analysis and group comparisons were carried out. RESULTS: Favourable evidence was obtained of a 13-item model consisting of three factors: pro-intervention, lack of capacity and chronicity. Professionals tend to believe in the lack of capacity and the need for involuntary interventions, as well as differential suitability due to chronicity. Having ever supported involuntary interventions was significantly related to the pro-intervention and lack of capacity factors, and training in bioethics to chronicity. CONCLUSIONS: The resulting instrument is valid and reliable. Its use can be useful to professionals, patients and society.

Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists. / Capacidad e internamiento involuntario de pacientes con anorexia nerviosa: un estudio cualitativo sobre percepciones y actuación de psiquiatras y psicólogos clínicos.

INTRODUCTION: Anorexia nervosa poses an important bioethical quandary, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa. METHODS: Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used. RESULTS: The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity. CONCLUSIONS: The difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.

MacArthur Competence Assessment Tool for Treatment in Alzheimer disease: cross-cultural adaptation / MacArthur Competence Assessment Tool for Treatment na doença de Alzheimer: adaptação transcultural

ABSTRACT Objective: We adapted the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to Brazilian Portuguese, pilot testing it on mild and moderate patients with Alzheimer's disease (AD). Methods: The cross-cultural process required six steps. Sixty-six patients with AD were assessed for competence to consent to treatment, global cognition, working memory, awareness of disease, functionality, depressive symptoms and dementia severity. Results: The items had semantic, idiomatic, conceptual and experiential equivalence. We found no difference between mild and moderate patients with AD on the MacCAT-T domains. The linear regressions showed that reasoning (p = 0.000) and functional status (p = 0.003) were related to understanding. Understanding (p = 0.000) was related to appreciation and reasoning. Awareness of disease (p = 0.001) was related to expressing a choice. Conclusions: The MacCAT-T adaptation was well-understood and the constructs of the original version were maintained. The results of the pilot study demonstrated an available Brazilian tool focused on decision-making capacity in AD.

RESUMO Objetivo: Adaptamos o MacArthur Competence Assessment Tool for Treatment (MacCAT-T) para o português brasileiro, realizando estudo piloto em amostra de pessoas com doença de Alzheimer (DA) leve e moderada. Métodos: O processo transcultural apresentou seis passos. Posteriormente, avaliamos competência para consentimento do tratamento, cognição global, memória de trabalho, consciência da doença, funcionalidade, sintomas depressivos e gravidade da doença de 66 pessoas com DA. Resultados: Os itens apresentaram equivalência semântica, idiomática, conceitual e experiencial. Não encontramos diferenças entre pessoas com DA leve e moderada nos domínios do MacCAT-T. Regressões lineares demonstraram que raciocínio (p = 0.000) e funcionalidade (p = 0.003) estavam relacionados à compreensão. Compreensão (p = 0.000) estava relacionada ao julgamento e raciocínio. Consciência da doença (p = 0.001) estava relacionada à expressão da escolha. Conclusões: A adaptação da MacCAT-T foi bem compreendida e os constructos da versão original mantidos. Resultados do estudo piloto apontaram disponibilidade de ferramenta brasileira sobre tomada de decisões na DA.

Comentarios de la psiquiatría forense al concepto de inimputabilidad en Colombia / Comments forensic psychiatry the concept of criminal responsibility in Colombia

Este artículo de reflexión presenta los aspectos relevantes de la figura jurídica de la inimputabilidad, desde el punto de vista de la psiquiatría forense con base en el análisis de la legislación penal colombiana al respecto. Se define el concepto de imputabilidad, se muestran las asociaciones jurídicas psiquiátricas forenses que se correlacionan con los hallazgos psicopatológicos más frecuentes, que determinan la defensa por insania mental, a la luz del nuevo sistema penal acusatorio en Colombia. Luego se discuten las medidas de seguridad asignadas a los enfermos mentales nominados insanos mentales e inimputables.

This reflection paper presents relevant aspects of the legal concept of Mental Insanity Defense, from the viewpoint of forensic psychiatry, based on the analysis of the Colombian criminal legislation in this regard. As an introduction examples of the concept of criminal responsibility in regulation of some countries and legal aspects are showed and discussed. The concept of liability is defined; forensic psychiatric legal associations correlated to the most frequent psychopathological findings are showed and it is explained that they determine the mental insanity defense in light of the new accusatory penal system in Colombia. Then, we discuss the security measures assigned to mentally ills, named mentally ills or insanes.

[The adaptation and validation to Spanish of the questionnaire Aid to Capacity Evaluation (ACE), for the assessment of the ability of patients in medical decision-making]. / Adaptación y validación al español del cuestionario Aid to Capacity Evaluation (ACE) , para la valoración de la capacidad del paciente en la toma de decisiones médicas.

OBJECTIVE: To adapt and validate the Spanish version of the Aid to Capacity Evaluation scale, designed to assess the capacity of the adult in medical decision-making, both in diagnosis and treatment processes. DESIGN: Observational study of prospective validation. SETTING: Primary and hospital care of the basic health area of Jaen. PARTICIPANTS: One hundred twenty-nine patients. MAIN MEASUREMENTS: Questionnaire which included sociodemographic variables, concerning the decision (scope, type of decision, the need for written informed consent), assessment of the capacity to the Aid to Capacity Evaluation scale and other related comorbidity (hearing loss, alcoholism, cognitive level variables with the Mini-Mental State Examination and depression by Goldberg or Yesavage test). RESULTS: The tool is considered viable. The conclusions of the expert panel were favorable. The result of the criteria' validity, comparing the results with the assessment of the experts (forensic and psychiatrist) was very satisfying (P<.001). The intra-observer reliability was low (kappa=0,135). Interobserver reliability remained high (kappa=0.74). The internal consistency was awarded an alpha of Cronbach's 0,645 for the reduced model of 6 items. CONCLUSIONS: The Aid to Capacity Evaluation scale was adapted to Spanish, demonstrating adequate internal consistency and construct validity. Its use in clinical practice could contribute to the identification of patients unable to make a particular medical decision and/or to give an informed consent.

[Evaluation of the capacity of elderly patients to make decisions about their health]. / Evaluación de la capacidad de toma de decisiones sobre su salud en pacientes ancianos.

OBJECTIVE: To assess the decision-making capacity and variables related to this, in elderly patients in a home care program. MATERIAL AND METHODS: A cross-sectional study was conducted on 130 patients assigned to home care program or in social welfare residences of an urban health centre. Demographic variables, as well as comorbidities, social support, institutionalisation, number of drugs used, degree of dependence (Barthel Index), cognitive function (Pfeiffer) were collected. The primary endpoint was the capacity for decision-making about their health assessed using the Aid to Capacity Evaluation (ACE) tool. RESULTS: There was a prevalence of 58.5% capacity. There was an association between ability and independence for activities of daily living (odds ratio (OR): 12.214; Confidence interval 95% (95% CI): 3.90 to 32.29, P <.0001) and function intellectual intact (OR: 282.750, 95% CI 34.0 to 2351.2, P <.0001). Numeric variables associated with the capacity for decision-making that had a more important effect size were the Barthel index (d: -1.398) and Pfeiffer index (d: 3.084). CONCLUSIONS: The prevalence of incapacity to make decisions about their health in elderly patients who are cared for in their homes is high. The level of dependence in activities of daily living and the deterioration of intellectual function are factors associated with the presence of this capacity.

Consentimento informado em cirurgia plástica: avaliação da transferência de informação / Model of informed consent in plastic surgery with evaluation and attestation of the transferred information

Informed consent is an indispensable tool in the doctorpatient relationship. Aims broadly and unrestrictedly clarify the patient about the procedure, which he/she will be submitted, including all stages of treatment and possible complications. As for the professional who will perform the procedure it's importance goes beyond the precise information to the patient, and also relevance in the legal scope for any grievances that may arise from the committed act. However for the purpose of consent is reached, one should do it in a way in which the physician has the conviction that his informations and explanations about all stages of treatment were in fact understood by the patient. Method: In order to confirm the transfer of information for the informed consent in an objective manner the authors have developed a method using a test administered to the patient after the clarification on the procedure Results: We observed a greater satisfaction by patients regarding explanations because they felt more secure about the treatment's knowledge to be carried out, taking the chance of further clarification if necessary. Conclusions: This model of consent present itself as evidence that the information about the procedure was conveyed unequivocally, ensuring tranquility and safety for the patient and the professional...

O consentimento informado é uma ferramenta indispensável na relação médico-paciente. Tem como objetivo o esclarecimento amplo e irrestrito pelo paciente a respeito do procedimento ao qual será submetido, incluindo todas as etapas do tratamento, bem como as possíveis complicações. Já para o profissional que executará o procedimento, sua importância vai além da informação precisa ao paciente, tendo também relevância no escopo jurídico por eventuais insatisfações que possam advir do ato praticado. Contudo, para que o objetivo do consentimento seja atingido, há de se fazê-lo de uma forma na qual o médico tenha convicção de que suas informações e explicações sobre todas as etapas do tratamento foram de fato compreendidas pelo paciente. Método: Com o objetivo de confirmar a transferência de informação do consentimento informado de forma objetiva, os autores desenvolveramum método que utiliza um teste aplicado ao paciente após os esclarecimentos sobre o procedimento. Resultados: Foi observada satisfação maior pelos pacientes, pois, estes se sentiram mais seguros quanto ao entendimento das explicações realizadas pelo médico, tendo a chance de novos esclarecimentos caso necessário, eliminando a alegação de desconhecimento do ato a ser praticado, inclusive provando de forma objetiva, na possibilidade de demanda judicial, a transferência inequívoca de informação. Conclusão: Este modelo de consentimento é uma opção mais didática no esclarecimento de dúvidas pelos pacientes, além de eliminar a dúvida do profissional em relação à compreensão que o paciente teve de suas explicações sobre o procedimento a ser realizado...

Aspectos bioéticos de la evaluación de la capacidad mental en psiquiatría / Bioethical aspects in the evaluation of mental capacity in psychiatry

Introducción: La capacidad mental se entiende como un constructo multidimensional que alude a la capacidad de los individuos para tomar decisiones autónomas. La competencia mental es la habilidad para realizar una tarea y la capacidad de una persona para actuar o comportarse adecuadamente en ciertas situaciones, con clara referencia a los aspectos legales. Sin embargo, la tendencia es asimilar ambos conceptos. Objetivo: Mostrar cómo evaluar la capacidad mental de forma estructurada, a fin de evitar su inadecuada evaluación, vulnerar los derechos humanos de los pacientes y generar un dilema bioético, al darle más relevancia al principio de la beneficencia que al de la autonomía. Método: Se reseñan varios instrumentos que permiten realizar una evaluación válida y confiable de la capacidad mental, por lo que resulta conveniente que los médicos se entrenen en la aplicación e interpretación de los resultados. Conclusión: En América Latina se requieren más estudios sobre el tema...

Introduction: Mental capacity is understood as a multidimensional construct that alludes to the capacity of individuals of making autonomous decisions. Mental competency is the ability to perform a task and the ability of a person to act or behave appropriately in certain circumstances, with a clear reference to legal aspects. However, there is a tendency to assimilate both concepts. Objective: To show how mental capacity can be evaluated in a structured way avoiding inadequate assessments, violations of patients’ human rights, and the generation of a bioethical dilemma when the principle of beneficence is given more relevance than the principle of autonomy. Method: Various instruments that allow a valid and trustworthy evaluation of mental capacity are reviewed. It is convenient that physicians train in their application and interpretation of results. Conclusion: More studies on the subject are required in Latin America...

Dignidade, autonomia do paciente e doença mental / Dignity, patient's autonomy and mental illness

A dignidade humana, intrinsecamente vinculada à autonomia, fica comprometida em situações de distúrbio mental grave, quer para participação em pesquisas médicas quer para opinar sobre as prescrições de caráter terapêutico. O artigo discute o conceito de dignidade, o princípio da autonomia e o consentimento informado e, com base em revisão da literatura, preconiza que o agir ético é o constante exercício de identificar quando e como é mais fácil desrespeitar a dignidade e evitar fazê-lo. Conclui asseverando que negar autonomia a outrem, porque simplesmente se está em posição que assim permite, é desrespeitar-lhe a dignidade. Deve-se atentar para o fato de que paternalismo e beneficência nem sempre são boas soluções para o doente mental.