Skip to main content
×
×
Home

Decision-making capacity for treatment in psychiatric and medical in-patients: Cross-sectional, comparative study

  • Gareth S. Owen (a1), George Szmukler (a2), Genevra Richardson (a3), Anthony S. David (a1), Vanessa Raymont (a4), Fabian Freyenhagen (a5), Wayne Martin (a5) and Matthew Hotopf (a1)...
Abstract
Background

Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients?

Aims

To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice.

Method

A secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool – Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability.

Results

Most people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P=0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better ‘test’ of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P=0.02).

Conclusions

Among those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Decision-making capacity for treatment in psychiatric and medical in-patients: Cross-sectional, comparative study
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Decision-making capacity for treatment in psychiatric and medical in-patients: Cross-sectional, comparative study
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Decision-making capacity for treatment in psychiatric and medical in-patients: Cross-sectional, comparative study
      Available formats
      ×
Copyright
Royal College of Psychiatrists, This paper accords with the Wellcome Trust Open Access policy and is governed by the licence available at http://www.rcpsych.ac.uk/pdf/Wellcome%20Trust%20licence.pdf
Corresponding author
Gareth S. Owen, Department of Psychological Medicine, King's College London, Institute of Psychiatry, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK. Email: gareth.1.owen@kcl.ac.uk
Footnotes
Hide All

See editorial, pp. 403–405, this issue.

Declaration of interest

None.

Footnotes
References
Hide All
1 Hale, B. Mental Health Law, 5th edn. Sweet & Maxwell, 2010.
2 Berg, JW, Appelbaum, PS, Grisso, T. Constructing competence: formulating standards of legal competence to make medical decisions. Rutgers Law Rev 1996; 48: 345–96.
3 Re C (Adult: Refusal of Treatment) [1994] 1 WLR 290.
4 Appelbaum, PS. Almost a Revolution: Mental Health Law and the Limits of Change. Oxford University Press, 1995.
5 Stone, AA. The right to refuse treatment. Arch Gen Psychiatry 1981; 38: 358–62.
6 Roth, LH. A committment law for patients, doctors, and lawyers. Am J Psychiatry 1979; 136: 1121–7.
7 Appelbaum, PS, Grisso, T. The MacArthur Treatment Competence Study. I: mental illness and competence to consent to treatment. Law Human Behav 1995; 19: 105–26.
8 Tan, J, Hope, T. Treatment refusal in anorexia nervosa: a challenge to current concepts of capacity. In Empirical Ethics in Psychiatry (eds Widdershoven, G, McMillan, J, van der Scheer, L, Hope, T): 187210. Oxford University Press, 2008.
9 Fulford, KM. Invited commentaries on: mental health legislation is now a harmful anachronism. Psychiatr Bull 1998; 22: 666–8.
10 Owen, GS, Szmuker, G, Richardson, G, David, AS, Hayward, P, Rucker, J, et al Mental capacity and psychiatric in-patients: implications for the new mental health law in England and Wales. Br J Psychiatry 2009; 195: 257–63.
11 Owen, GS, David, AS, Richardson, G, Szmuker, G, Hayward, P, Hotopf, M. Mental capacity, diagnosis and insight. Psychol Med 2008; 22: 122.
12 Owen, GS, Richardson, G, David, AS, Szmukler, G, Hayward, P, Hotopf, M. Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study. BMJ 2008; 337: a448.
13 Raymont, V, Bingley, W, Buchanan, A, David, AS, Hayward, P, Wessely, S, et al Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study. Lancet 2004; 364: 1421–7.
14 Hatch, SL, Frissa, S, Verdecchia, M, Stewart, S, Fear, NT, Reichenberg, A, et al Identifying socio-demographic and socio-economic determinants of health inequalities in a diverse London community: the South East London Community Health (SELCoH) study. BMC Public Health 2011; 11: 861.
15 Okai, D, Owen, G, McGuire, H, Singh, S, Churchill, R, Hotopf, M. Mental capacity in psychiatric patients. Systematic review. Br J Psychiatry 2007; 191: 291–7.
16 Raymont, V, Buchanan, A, David, AS, Hayward, P, Wessely, S, Hotopf, M. The inter-rater reliability of mental capacity assessments. Int J Law Psychiatry 2007; 30: 112–7.
17 Cairns, R, Maddock, C, Buchanan, A, David, AS, Hayward, P, Richardson, G, et al Reliability of mental capacity assessments in psychiatric in-patients. Br J Psychiatry 2005; 187: 372–8.
18 World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, 1992.
19 Folstein, MF, Folstein, SE, McHugh, PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–98.
20 Kim, SYH. Evaluation of Capacity to Consent to Treatment and Research. Oxford University Press, 2010.
21 Kapp, MB, Mossman, D. Measuring decisional capacity: cautions on the construction of a “capacimeter”. Psychol Public Pol L 1996; 2: 7395.
22 Grisso, T, Applebaum, PS. Assessing Competence to Consent to Treatment. Oxford University Press, 1998.
23 Grisso, T, Appelbaum, PS. Comparison of standards for assessing patients' capacities to make treatment decisions. Am J Psychiatry 1995; 152: 1033–7.
24 Vollmann, J, Bauer, A, Danker-Hopfe, H, Helmchen, H. Competence of mentally ill patients: a comparative empirical study. Psychol Med 2003; 33: 1463–71.
25 Kim, SY, Karlawish, JH, Caine, ED. Current state of research on decision-making competence of cognitively impaired elderly persons. Am J Geriatr Psychiatry 2002; 10: 151–65.
26 Marson, DC, Cody, HA, Ingram, KK, Harrell, LE. Neuropsychologic predictors of competency in Alzheimer's disease using a rational reasons legal standard. Arch Neurol 1995; 52: 955–9.
27 Anderson, J. Autonomielueken als soziale pathologie. Ideologiekritik jenseits des paternalismus (Autonomy Gaps as Social Pathology: Ideologiekritik without Paternalism). In Sozialphilosophie und Kritik [Social Philosophy and Criticism] (eds Forst, R, Hartmann, M, Jaeggi, R, Saar, M): 433–53. Suhrkamp, 2009.
28 United Nations. Convention on the Rights of Persons with Disabilities. United Nations, 2006.
29 Bartlett, P. The United Nations Convention on the Rights of Persons with Disabilities and the future of mental health law. Psychiatry 2009; 19: 496–8.
30 Department of Constitutional Affairs. Mental Capacity Act 2005 Code of Practice. TSO (The Stationery Office), 2007.
31 Saks, E, Behnke, SH. Competency to decide on treatment and research: MacArthur and beyond. J Contemp Legal Issues 1999; 10: 103–29.
32 Saks, ER, Dunn, LB, Marshall, BJ, Nayak, GV, Golshan, S, Jeste, DV. The California Scale of Appreciation: a new instrument to measure the appreciation component of capacity to consent to research. Am J Geriatr Psychiatry 2002; 10: 166–74.
33 Sutherland, S. Irrationality: Penguin, 1992.
34 Owen, GS, Cutting, J, David, AS. Are people with schizophrenia more logical than healthy volunteers? Br J Psychiatry 2007; 191: 453–4.
35 Grisso, T, Appelbaum, PS. Appreciating anorexia: decisional capacity and the role of values. Philos Psychiatry Psychol 2007; 13: 293301.
36 Freyenhagen, F, O'Shea, T. Hidden substance: mental disorder as a challenge to normatively neutral accounts of autonomy. Int J Law Context 2013; 9: 5370.
37 Hansard, . House of Lords Debate 25 Jan 2005: columns 1226–7.
38 Tan, J, Stewart, A, Hope, T. Decision-making as a broader concept. Philos Psychiatry Psychol 2009; 16: 345–49.
39 Kim, SYH, Caine, ED, Currier, GW, Leibovici, A, Ryan, JM. Do clinicians follow a risk-sensitive model of capacity determination? An experimental video study. Psychosomatics 2001; 47: 325–9.
40 Gadamer, H-G. Truth and Method, 2nd edn. Continuum, 1989.
41 Martin, W, Hickerson, R. Mental capacity and applied phenomenology of judgement. Phenomenol Cogn Sci 2013; 12: 195214.
42 Owen, GS, Freyenhagen, F, Richardson, G, Hotopf, M. Mental capacity and decisional autonomy: an interdisciplinary challenge. Inquiry 2009; 52: 79107.
43 Banner, N. Unreasonable reasons: normative judgement in the assessment of mental capacity. J Eval Clin Pract 2012; 18: 1038–44.
44 Rabone & Anor v. Pennine Care NHS Trust [2012] UKSC.
45 Fassassi, S, Bianchi, Y, Stiefel, F, Waeber, G. Assessment of the capacity to consent to treatment in patients admitted to acute medical wards. BMC Med Ethics 2009; 10: 15.
46 Richardson, G (ed.) A model law fusing incapacity and mental Health legislation – is it viable; is it advisable? J Ment Health Law 2010; 20 (special issue): 1140.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Decision-making capacity for treatment in psychiatric and medical in-patients: Cross-sectional, comparative study

  • Gareth S. Owen (a1), George Szmukler (a2), Genevra Richardson (a3), Anthony S. David (a1), Vanessa Raymont (a4), Fabian Freyenhagen (a5), Wayne Martin (a5) and Matthew Hotopf (a1)...
Submit a response

eLetters

Capacity Assessment- A Challenging Task

Devender Singh Yadav, Specialty Doctor in Rehabilitation Psychiatry
07 March 2014

Although capacity is a legal concept, healthcare professionals are frequently asked to assess capacity. In my article, I highlight on the fact that, because, we work in an increasing complex healthcare system, itis everyone's business to familiarise themselves in the assessment of capacity [1].

Research has shown that mental incapacity is commonly found in clinical practice (median 29%); that capacity assessment can be done reliably and clinical rather than socio-demographic factors have the greatest impact on likelihood of incapacity [2].

Capacity assessment is decision specific and time specific.

Clinical experience suggests that capacity assessment done over a period of time, is possibly more reliable (indicating the stability of thepatients decision), than, say, if the assessment of capacity is done only once (unless of course, an urgent decision needs to be taken, for example in an emergency in which the patient's life is in danger); this could be one of the shortcoming of the study-the researchers did not comment on thetime frame; this could be addressed in future research.

Also, each dimensional component of capacity (say for example the dimensional component of understanding) is also a composite effect of various other components/variables; namely attention, orientation, environmental and socio-demographic variables; how these variables are interlinked, need further exploration in future research; qualitative analysis, in my view will offer a better understanding of a person's ability or inability, by placing the patient's decision making capacity inclinical context by considering the risks and benefits that such decisionspose; not only to themselves, but also to the health care professionals involved in the patients care.

No wonder, clinicians find assessment of capacity in clinical practice quite challenging.

References:

[1]: Yadav DS, Torne G. Patient Management; Capacity -Everyone's business. Foundation Years Journal 2011; 5 (10): 19-22.

[2]: Okai D, Owen G, Mcguire H, Singh S, et al. Mental capacity in psychiatric patients-Systematic review. BJP 2007; 191: 291-297.

... More

Conflict of interest: None declared

Write a reply

Decision-making capacity for treatment in psychiatric and medical in-patients

Rohit Verma, Assistant Professor
06 January 2014

This is an interesting article by Owen et al. comparing treatment decision-making capacity (DMC) in medical and psychiatric patients and addresses an important aspect of patient care.

The current study communicates that majorly reasoning and to a significant extent understanding contributes as a critical variable for DMC in either group. We also raise the issue of belief and attitude of thepatient towards his/her illness modifying the DMC and creating bias in thefindings. We recently studied attitude and belief of hundred caregivers comparing psychiatric and medical patients and found the attitude towards former to be more negativistic. Such a negative approach decapitates hope and pushes towards Earl Howe's description of the way that depression can threaten DMC.

Physicians assess the DMC of their patients at every clinical encounter. Patients requiring careful assessment are usually identified through directed clinical interview or the use of a formal assessment toolsuch as Aid to Capacity Evaluation (ACE) and the MacArthur Competence Assessment Tool (MacCAT). If the patient lacks the DMC, a determination ofsurrogacy is necessary. In the best-case scenario, the patient may have previously appointed an agent; in the worst-case scenario, the court may need to become involved. The appropriateness of decisions made by surrogates must also be examined.

Because of the complexity of evaluating DMC, physicians should encourage patients to complete advance directives as part of routine care before serious illnesses and capacity questions arise. The Mental Health Care Bill proposed in India is coming forth with this newer avenue of advanced directives is a welcomed step towards feasibility of such an approach [1].

Reference

1.Kala A. Time to face new realities; mental health care bill-2013. Indian J Psychiatry 2013;55:216-9.

... More

Conflict of interest: None declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *