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Retrospective views of psychiatric in-patients regaining mental capacity

  • Gareth S. Owen (a1), Anthony S. David (a1), Peter Hayward (a2), Genevra Richardson (a3), George Szmukler (a4) and Matthew Hotopf (a5)...
Abstract
Background

An individual's right to self-determination in treatment decisions is a central principle of modern medical ethics and law, and is upheld except under conditions of mental incapacity. When doctors, particularly psychiatrists, override the treatment wishes of individuals, they risk conflicting with this principle. Few data are available on the views of people regaining capacity who had their treatment wishes overridden.

Aims

To investigate individuals' views on treatment decisions after they had regained capacity.

Method

One hundred and fifteen people who lacked capacity to make treatment decisions were recruited from a sample of consecutively admitted patients to a large psychiatric hospital. After 1 month of treatment we asked the individuals for their views on the surrogate treatment decisions they received.

Results

Eighty-three per cent (95% CI 66–93) of people who regained capacity gave retrospective approval. Approval was no different between those admitted informally or involuntarily using Mental Health Act powers (χ2 = 1.52, P = 0.47). Individuals were more likely to give retrospective approval if they regained capacity (χ2 = 14.2, P = 0.001).

Conclusions

Most people who regain capacity following psychiatric treatment indicate retrospective approval. This is the case even if initial treatment wishes are overridden. These findings moderate concerns both about surrogate decision-making by psychiatrists and advance decision-making by people with mental illness.

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Copyright
Corresponding author
Gareth S. Owen, Department of Psychological Medicine, Institute of Psychiatry, Weston Education Centre, Cutcombe Road, London SE5 9RS, UK. Email: g.owen@iop.kcl.ac.uk
Footnotes
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This study was funded by the Wellcome Trust (grant no. 075712). M.H. and A.S.D. are supported by the South London Maudsley NHS Foundation Trust/Institute of Psychiatry, King's College London, National Institute of Health Research Specialist Biomedical Research Centre.

Declaration of interest

None.

Footnotes
References
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1 Beauchamp, TL, Childress, JF. Principles of Biomedical Ethics. Oxford University Press, 2001.
2 Owen, GS, Freyenhagen, F, Richardson, G, Hotopf, M. Mental capacity and decisional autonomy: an interdisciplinary challenge. Inquiry 2009; 52: 79107.
3 Owen, GS, Szmukler, 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.
4 Stone, AA. Mental Health and Law: A System in Transition. National Institute of Mental Health, 1975.
5 Stone, AA. The right to refuse treatment. Arch Gen Psychiatry 1981; 38: 358–62.
6 Gardner, W, Lidz, CW, Hoge, SK, Monahan, J, Eisenberg, MM, Bennett, NS, et al. Patients' revisions of their beliefs about the need for hospitalization. Am J Psychiatry 1999; 156: 1385–91.
7 Kane, JM, Quitkin, F, Rifkin, A, Wegner, J, Rosenberg, G, Borenstein, M. Attitudinal changes of involuntarily committed patients following treatment. Arch Gen Psychiatry 1983; 40: 374–7.
8 Priebe, S, Katsakou, C, Amos, T, Leese, M, Morriss, R, Rose, D, et al. Patients' views and readmissions 1 year after involuntary hospitalisation. Br J Psychiatry 2009; 194: 4954.
9 Owen, G, Richardson, G, David, A, Szmuker, G, Hayward, P, Hotopf, M. Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: a cross sectional study. BMJ 2008; 337: 448.
10 World Health Organization. The ICD–10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, 1992.
11 Grisso, T, Appelbaum, PS, Hill-Fotouhi, C. The MacCAT-T: a clinical tool to assess patients' capacities to make treatment decisions. Psychiatr Serv 1997; 48: 1415–9.
12 Appelbaum, PS. Assessment of patient's competence to consent to treatment. N Engl J Med 2007; 357: 1834–40.
13 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.
14 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.
15 Raymont, V, Bingley, W, Buchanan, A, David, AS, Hayward, P, Wessely, S, et al. Prevalence of mental incapacity in medical in-patients and associated risk factors: cross-sectional study. Lancet 2004; 364: 1421–7.
16 Owen, GS, David, AS, Richardson, G, Szmukler, G, Hayward, P, Hotopf, M. Mental capacity, diagnosis and insight. Psychol Med 2008; 22: 122.
17 Schwartz, HI, Vingiano, W, Perez, CB. Autonomy and the right to refuse treatment: patients' attitudes after involuntary medication. Hosp Community Psychiatry 1988; 39: 1049–54.
18 Henderson, C, Flood, C, Leese, M, Thornicroft, G, Sutherby, K, Szmukler, G. Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ 2004; 329: 136.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Supplementary Table S1

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Retrospective views of psychiatric in-patients regaining mental capacity

  • Gareth S. Owen (a1), Anthony S. David (a1), Peter Hayward (a2), Genevra Richardson (a3), George Szmukler (a4) and Matthew Hotopf (a5)...
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eLetters

MENTAL HEALTH ACT AND MENTAL CAPACITY ACT: OVERLAPS OR OXYMORONS?

Massimo Lanzaro, Consultant Psychiatrist
09 February 2011

The finding that clinicians tend to underestimate lack of capacity (especially when patients are accepting treatment) is very interesting andallows however to speculate about issues of overlap between the legal frameworks, which are encountered daily in the clinical practice.

The Mental Health Act is a formal set of procedures to use in acute mental health situations, the MCA a way of ensuring that people's best interests and wishes are taken into account when making decisions about their care when it is deemed they no longer lack the capacity to make someor all of these decisions themselves.

The Mental Health Act instructs the formal processes of Mental HealthCare - detaining etc, the Mental Capacity Act deals more with the human rights side of things - best interests and liberty decisions, sometimes asa follow on or precursor to decisions that are made under the MHA (e.g. detaining someone under the mental health act and then ensuring under the MCA DOLs framework that this continues to be a justified intervention).

It is not therefore in our opinion a case of either or (as some courts already ruled) but of the MCA complimenting the MHA. The mental health act covers most of what the mental capacity act also does but does so as part of a formal framework. The mental capacity act provides a more 'informal' framework for those who may lack the capacity to make some or all decisions but do not fall within the remit of need under the mental health act. Jurisdictions that maintain these separate frameworks need to manage the interface and probably further guidance is needed.
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Conflict of interest: None Declared

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Advance decisions - ethical dilemmas

Balamurugan Ganesan, Specialty Registrar in Old Age Psychiatry
04 January 2010

Dear Sir/Madam

I read with interest the study on ‘Retrospective views of psychiatricin-patients regaining mental capacity’. It is good to know that majority (80-90%) of the individuals who regained decisional capacity thought theirdoctors had taken the right kind of decisions during their recent admission. This can very well be utilised to draw up care plans for the future thereby promoting ‘autonomy’ of the patients.

The remaining (10-20%) who thought that the treatment they received was not of the right kind after having regained decisional capacity pose more difficult problems. Advance decisions to refuse treatment (previously‘living wills’ or ‘advance directives’) gives them the opportunity to makea legally binding statement refusing the treatments which probably helped them regain their decisional capacity in the first place. Advance decisions to refuse treatment can pose serious ethical dilemmas as exemplified in a recent case where a young woman with a diagnosis of borderline personality disorder was allowed to die as she had made a legally binding advanced decision refusing treatment should the circumstances arise (1). Though it is clear in law that the presence of mental illness in itself is not evidence of lack of capacity practically it can be very difficult to assess how much the mental illness influences the decision making process. Also the law does state that advance decisions cannot be used to refuse basic nursing care required to keep a person comfortable (2). Does it mean if the person starts to become uncomfortable a decision can be made to over ride their advance decisions to refuse a treatment? These are difficult questions and I am sure there will always be a case both for and against.

References

(1)Sheila MacLean on advance directives and the case of Kerrie Wooltorton – BMJ group blogs, 1 October 2009.

(2)Advance decisions to refuse treatment: a guide - http://www.adrtnhs.co.uk/pdf/ADRT_a_guide_May_2009.pdf
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