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Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients?
To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice.
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.
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).
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.
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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.
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Conflict of interest: None declared
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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.
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Conflict of interest: None declared
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