Ten myths about decision-making capacity.

Ten Myths About Decision-Making Capacity

Understanding the Breadth and Depth of C-L Psychiatry: Decisional Capacity Assessments

Healthcare professionals (HCPs) have a responsibility to conduct assessments of decision-making capacity that comply with the Mental Capacity Act 2005 (MCA). Current best-practice guidance, such as the Mental Capacity Code of Practice and National Institute for Health and Care Excellence decision-making and mental capacity guidance, does not stipulate how to accomplish this in practice, for example, what questions should be asked, how options and information should be provided. In addition, HCPs struggle to assess the capacity of individuals with communication difficulties. This study was a service evaluation that aimed to objectively analyse, using Conversation Analysis (CA), how real-life capacity assessments were conducted in a hospital setting with patients with acquired brain injury (ABI)-related communication difficulties. A second aim was to establish the feasibility of using CA to advance knowledge of the conduct of capacity assessment. Four naturally occurring capacity assessments were video-recorded. Recordings involved speech and language therapists, occupational therapists, neuropsychologists and patients with communication difficulties as a result of ABI. The methods and findings of CA were used to investigate the interactional behaviours of HCPs and patients during assessments of decision-making capacity. The analysis was informed by our knowledge of the MCA best practice guidance. An overall structure of capacity assessment that enacted some of the best-practice MCA guidance was identified in one recording, consisting of six phases: (i) opening, (ii) preparation, (iii) option-listing, (iv) test, (v) decision, and (vi) close. The preparation phase consisted of two sub-components: information gathering and information giving. Variation from this structure was observed across the dataset, notably in the way in which options were (or were not) presented. CA is a feasible empirical method for exploring the structure and conduct of capacity assessments. CA identifies and provides ways of describing interactional behaviours that align with and diverge from best-practice MCA guidance. Future CA studies including a wider range of health and social care professionals and patients have the potential to inform evidence based training for HCPs who conduct assessments of decision-making capacity. What is already known on this subject The Mental Capacity Act (MCA) is poorly implemented in practice. Healthcare professionals (HCPs) find it challenging to assess the decision-making capacity of individuals with communication difficulties, and people with communication difficulties are often excluded from or insufficiently supported during capacity assessment. Research is limited to self-report methods. Observational studies of capacity assessment are required. What this study adds This is the first study to use Conversation Analysis (CA) to explore how capacity assessments are conducted in a hospital setting by HCPs with people with communication difficulties as a result of acquired brain injury. One video-recorded capacity assessment was structured in six phases that aligned with best practice MCA guidance. However, other capacity assessments deviated from this structure. One phase, option listing, varied in practice and options were not always presented. What are the clinical implications of this work? CA revealed interactional behaviours that align with and diverge from best-practice MCA guidance. Future CA studies are warranted to inform training for health and social care professionals who conduct capacity assessments.

As the population of the United States ages, chronic diseases increase and treatment options become technologically more complicated. As such, patients' autonomy, or the right of patients to accept or refuse a medical treatment, may become a more pressing and complicated issue. This autonomy rests upon a patient's capacity to make a decision. As more older, cognitively and functionally impaired individuals enter healthcare systems, quality assessments of decision-making capacity must be made. These assessments should be done in a time-efficient manner at a patient's bedside by the patient's own physician. Thus, a clinically practical tool to assist in decision-making capacity assessments could help guide physicians in making more accurate judgments. To create a clinically relevant Bedside Capacity Assessment Tool (BCAT) to help physicians make timely and accurate clinical assessments of a patient's decision-making capacity for a specific decision. The Department of Medicine, Division of Geriatrics and Palliative Medicine, Zucker School of Medicine at Hofstra/Northwell . Geriatric medicine fellows, palliative medicine fellows, and internal medicine residents (n = 30). Subjects used the BCAT to assess the decision-making capacity of patients described in 10 written, clinically complex capacity assessment vignettes. Subjects' conclusions were compared to those of experts. The subjects' and experts' assessments of capacity had a 76.1 percent rate of agreement, with a range of 50 percent to 100 percent. With removal of three complex outlier vignettes, the agreement rate reached 83.2 percent. The strong correlation between the two groups-one of physicians in training utilizing the BCAT and the other of specialists in this area-suggests that the BCAT may be a useful adjunct for clinicians who assess decision-making capacity in routine practice. The range indicates that further refinement and testing of this tool is necessary. The potential exists for this tool to improve capacity assessment skills for physicians in clinical practice.

(Waisel) Attending Anesthesiologist, Wilford Hall Medical Center.(Truog) Director, Multidisciplinary Intensive Care Unit, Children's Hospital, Boston, Associate Professor of Anaesthesiology & Pediatrics, Harvard Medical School.Received from the Department of Anesthesiology, Wilford Hall Medical Center, Lackland Air Force Base, Texas, and from the Department of Anesthesiology, Children's Hospital, Harvard Medical School, Boston, Massachusetts. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or other Departments of the US Government. Submitted for publication October 10, 1995. Accepted for publication April 10, 1997.Address reprint requests to Dr. Waisel: 59th MDW/MKAA, 2200 Bergquist Drive, Suite 1, Lackland Air Force Base, Texas. Address electronic mail: waisel@texas.net.Anesthesiologists have a tendency to frame conflicts in terms of either medical or legal judgments, without fully appreciating the ethical dimensions of the issues. The goal of the previous papers in this series was to heighten the sensitivity of anesthesiologists to these ethical dimensions and to discuss potential avenues for resolving these conflicts. Many of the ideas presented can be difficult to implement in practice, however, particularly if an anesthesiologist is not experienced in these matters. For example, determining if a patient retains sufficient decision-making capacity after receiving midazolam is not easy. Nor is it always clear how to delineate the obligations owed to the patient who wishes to retain do-not-resuscitate (DNR) status during surgery. Matters that involve other professionals may be more complex. How does one resolve an operating room disagreement about when to transfuse blood?Although education in ethics may help anesthesiologists recognize ethical dilemmas, they may still be unable to define and articulate the issues authoritatively. Ethics consultants help resolve dilemmas by providing a structured way of thinking about problems, clarifying the positions of individuals with a moral interest in the decision, and simplifying communication. After consultations, clinicians feel greater satisfaction in managing cases with ethical conflicts, not only because of their awareness of the expert consulting services available but also because of their increased knowledge and comfort in dealing with these issues. [1–3] One study found that after the conclusion of an ethics consultation, more than 95% of physicians would request another. [4]There are at least two levels of ethics consultations available for anesthesiologists: institutional ethics committees and national professional ethics committees, such as the American Society of Anesthesiologists Committee on Ethics.During the earliest years after the introduction of ethics committees into hospital practice, they were sometimes considered the vehicle for ensuring that the physician's choice of clinical options was the one offering the least legal risk. These ethics committees tended to be bureaucratic organizations with “all the right answers.” In recent years, however, ethics committees and the process of ethical consultations have evolved into a constructive service that benefits the clinician and patient. An ethics service should not view itself as the sole arbiter of right and wrong. Rather, the goals of the ethics consultation should be, simply, to “assist the primary physician, the patient and the family to reach a right and good clinical decision.”[5] The usefulness of such a process has been recognized by The Joint Commission on Accreditation for Healthcare Organization, whose guidelines require hospitals to have “a functioning process to address ethical issues.”* Ethics committees and their consultation services fulfill this requirement.Institutional ethics committees are usually hospital-based and can help with ethical dilemmas involving individuals, departments, and third-parties such as managed care organizations. Traditionally, cases presented for consultation centered on individual patients and physicians and involved questions about resuscitation status, informed consent, decision-making capacity, confidentiality, and withdrawing and withholding care. [4,6,7] Given the dramatic way health care and reimbursement changes have intruded on the patient-physician relationship, ethics committees have started to take a broader role in participating in difficulties involving institutions. Anesthesiologists may find ethics consultation useful in any of these situations.Take, for example, the patient with early Alzheimer's disease who arrives in the preoperative holding area and needs to give informed consent. The anesthesiologist recognizes that the patient's decision-making capacity is not at a usual level, but may not feel adept in determining if it is adequate. The ethics consultant establishes the necessary framework for resolving this problem, beginning, perhaps, by establishing the needed extent of the patient's decision-making capacity. For example, a patient may need more capacity when making one decision (thoracic epidural) compared with another decision (arterial pressure monitoring). The consultant then helps ascertain the patient's decision-making capacity, in part by looking for articulation of a cohesive expression of preferences using consistent and rational logic. After a decision about the patient's capacity is made, it is natural for the anesthesiologist to feel some discomfort. This may be a result of limited experience with ethical dilemmas, the lack of absolute certainty in making these determinations, or the recognition that he or she may be intentionally or unintentionally influenced by production pressures. The consultant's support allows the anesthesiologist to feel more confident in his or her decision to proceed or, alternately, to provide an anchor for the anesthesiologist battling internal or external production pressures. [8]This consultant is acting mostly in the role of an expert, similar to the manner of a traditional medical consultant who interviews and examines the patient, researches the situation and options, and supplies a specific recommendation supported by ethical and legal opinions. [9,10] This role presumes the ethics consultant has extensive knowledge in bioethics, institutional requirements, and proper documentation. This role also appreciates the consultant's greater experience in resolving ethical dilemmas. For example, a consultant who frequently helps patients reevaluate their desires for resuscitation in the operating room is more likely to be aware of potential pitfalls and to navigate a more successful course. Ethics consultants also act as facilitators. The use of facilitation presupposes that if the participants in the case can communicate, most issues can be resolved. Conventional wisdom suggests that the majority of ethics consultations are more about improving communications than about abstract theoretical concepts. Most of the work of those who do clinical ethics “turns on trying to get the facts straight, clearing up misconceptions and misunderstandings, [and] trying to overcome emotional confusion…”[11] The consultant clarifies considerations and therapeutic goals and brings together those who have a moral interest in the case. Successful facilitations seek to attain an ethically acceptable resolution consistent with the patient's well-considered goals rather than a specific solution. The consultant can usually achieve such because he or she is usually perceived as an unbiased newcomer to the disagreement who is unaffected by rancor or prejudice.For the most part, ethics consultants function as an expert and as a facilitator. Consider a surrogate who insists on general anesthesia for the debridement of leg ulcers for her father who has severe chronic obstructive pulmonary disease. The anesthesiologist believes the patient would be better served with a spinal anesthetic. The ethics consultant can assist in resolving this dilemma by helping the anesthesiologist clarify his or her concerns about general anesthesia for this patient. For example, is the harm to the patient substantial, minor, or unclear?[12] On what kind of information is this opinion based?[13–15] The consultant then facilitates discussion between the surrogate and the anesthesiologist. For example, the consultant may find that the patient had always expressed disdain for spinal anesthetics after his brother received one during World War II and returned home paraplegic. The consultant and anesthesiologist can then address the differences between spinal anesthesia then and now and elucidate for the surrogate the true risks and benefits of each procedure. This explanation gives the surrogate psychological permission to go against her father's previous statements by understanding that her father was rejecting an uninformed view of spinal anesthesia. The consultant may ask the surrogate to imagine what her father would do with the new information. If the surrogate chooses in the end to act contrary to the anesthesiologist's advice, the consultant can help the anesthesiologist clarify where the choice lies on the continuum from choices that are acceptable but undesirable to those that constitute abuse. If there is a need to pursue other channels, the consultant can provide direction.Ethics consultants can help facilitate disagreements within professional relationships, too. Consider the problem of a surgeon who demands the administration of a blood transfusion when the anesthesiologist does not believe one is indicated. It is difficult to fruitfully address this disagreement in the middle of an operation if a working relationship is not already established. As such, the ethics consultant may use preventative ethics, which centers on resolving conflicts before they happen, particularly if they can be identified as being repetitive. [16,17] In this case, the ethics consultant's goals are to clarify and evaluate blood transfusion practices and to maintain professional relationships.To accomplish the first goal, the consultant would encourage the participants to discuss each physician's transfusion practices in light of published recommendations and the practices of trusted colleagues. Equally important is the second goal, which is for the anesthesiologist and surgeon to develop a working relationship capable of successfully addressing differences of opinion. Preserving or developing this kind of relationship benefits patients who deserve to receive the expertise of both physicians. The consultant may also be able to recognize that common ground cannot be reached and that the participants should seek to work with colleagues who have more similar transfusion practices.Similarly, “turf battles” between departments can be addressed. For instance, the departments of anesthesiology and emergency medicine may bicker about who manages the trauma patient's airway. Several advantages may allow the ethics consultant to broker a successful compromise. The consultant is presumably free from financial considerations, peer pressures, and the antagonism that has developed between the physicians in the two departments. This fresh view allows the ethics consultant to separate and define the individual issues, often a first and necessary step toward resolution. In this case, issues may include residency training needs, financial considerations, and hubris, all of which may have resulted in a failure to communicate. The consultant can refocus the discussion toward the priority of patient care, while acknowledging substantial ancillary issues of finances and resident training. He or she may also be able to temper the discussion. This alone may allow the principals to communicate with each other to the point of amicably devising an agreement that satisfies both departments.Ethics consultation and hospital ethics committees can also assist departments and hospitals in establishing workable policies for complex issues. [18] Consider an obstetric department that wants to provide increased services to Jehovah's Witnesses. Part of their preparation would include gaining support with the department of anesthesiology. Up to this point, only a few of the 20 anesthesiologists have been providing anesthesia for Jehovah's Witnesses, and this care has been primarily for elective procedures. The ethics consultant can educate the caregivers about the pertinent issues, and in doing so can help them clarify their beliefs and their ability to deliver agreed-on care. The ethics consultant may identify two mechanisms that are necessary to honor the patients' treatment preferences while also protecting the integrity of the caregivers. The first is to design a preoperative consultation that sufficiently discusses and clearly documents the desires of patients to the satisfaction of the caregivers. The second is to develop a system to allow certain anesthesiologists not to provide care. This may be a difficult task for the mostly unscheduled and occasionally emergent needs of an obstetric service, particularly in a department in which all the anesthesiologists usually provide obstetric anesthesia at night and on weekends. The ethics consultant would, like other consultants, follow the implementation of the proposals and suggest adjustments and help resolve differences as needed.This is just one example of how ethics committees fulfill an obligation to coordinate continuing education in ethics. Many ethics committees invite speakers, hold conferences, and even present didactic sessions to acquaint colleagues with significant issues. Some ethics committees organize educational programs to inform the community about relevant ethical issues such as completing advance directives. Anesthesiologists should be aware that most ethics committees are pleased to provide focused education to any group, such as a department, that requests it.Ethics consultations involving difficulties with administrators and third-party payers are likely to become more prominent given that 90% of privately insured Americans undergo some sort of utilization review for their medical care. [19]“Significant anecdotal evidence suggests that doctors perceive managed care regulations as preventing them from behaving in an ethical manner.”[20] Concerns about third-party payers may center on policies for patients and policies pitting patient care against physician finances. [21–23] Caregivers are often frustrated by health care plans that appear to be penny wise and pound foolish. [20,24]Prominent disputes between physicians and third-party payers have included pressure on physicians to discharge patients from the hospital quickly and to limit consultations. [20] Anesthesiologists are not unaffected by these disagreements. For example, anesthesiologists may be faced with pressure to perform anesthesia for a postpartum tubal ligation several hours after delivery instead of the next day. If an anesthesiologist's normal practice is to wait until the next day, should he or she provide care earlier? Such a delay may cause the patient to stay in the hospital an additional day. This is particularly difficult because there is no clear consensus in the literature on this situation, and the anesthesiologist may have difficulty responding to an administrator's request to show that this practice is unsafe. [25–27] Or, consider a child with multiple congenital anomalies who needs bilateral myringotomy and tubes and tonsillectomy. Because it is only “tubes and tonsils,” the managed care organization refuses to authorize the otolaryngologist to do the procedure at the more expensive children's hospital and requires the procedure to be done at the local community hospital. The anesthesiologist may believe such a case is “slightly” out of his or her reach. How does an anesthesiologist determine if a case is too difficult? And how should an anesthesiologist approach such an issue, particularly if the hospital administration is not sympathetic?Other questions may arise as anesthesiologists are held more accountable for costs. [19,23,28] How should an anesthesia group respond to a health plan that refuses to authorize postoperative epidural analgesia? Should an anesthesiology group not use more expensive and possibly more effective drugs in the patient with capitated reimbursement?[26] Such policies may be dangerous. Consider a third-party payer that will not authorize anesthesia for gastrointestinal endoscopies. Anesthesiologists may then be placed in the undesirable position of having to provide otherwise avoidable emergent airway management for oversedation, for example, and such emergencies may cause patients harm.An ethics consultation can provide a sounding board for the appropriateness of the anesthesiologist's discomfort with the system and can help determine whether to appeal the third-party's position. [12] The same experience that benefits the ethics consultant when dealing with difficult situations involving patients and physicians can help in dealing with third parties. Ethics committees may be able to give a voice to the anesthesiologists so that they can “participate in political give-and-take with nonphysicians.”[29] This may allow anesthesiologists to put research in the proper light and not let it be used in an inappropriate way to limit the therapeutic options of anesthesiologists. [29] Because chairs of ethics committees often command respect, they tend to have significant unofficial authority with hospital administrations and other third parties and thus may be more successful in addressing certain policy issues. Third-party payers may also have their own ethics committees that may provide another avenue toward affecting is to for a consultation than a As such, suggest anesthesiologists become with their institutional ethics before help in a an ethics consultation is than a medical Anesthesiologists are to ask a specific when a clinical consultation, such as this patient's pulmonary status be better before this general and rather than clear this patient for Anesthesiologists may not have the necessary to ask for a specific recommendation from an ethics ethics consultants are with Part of their is to help define the of ethics consultations can Some hospitals allow any involved with the patient, family and to an ethics require the physician to the consultation, and most require the physician to at least to the of the physician is The relationship is the of medical care, and this relationship should not be intruded without the physician's ethics committees are for the most part and the consultation with an relationship with the physician is It is important for the anesthesiologist to that by of for a patient he or she is one of the patient's physicians and has the right and to ethics consultations when cases the consultant will be a physician who is with medical and the hospital physician also has a greater of being as an authority by other physicians. For these some all consultants should be physicians. Because the of dilemmas and helping patients and clinicians these concerns are not limited to hold that clinical consultation should be to other professionals such as and For example, may have with their patients than do physicians. not all ethics consultations at the physician level, and some ethical dilemmas center primarily on and also have become effective ethics consultants, because of their ability to issues from a of the medical of for ethics Ethics consultation may be by an individual or by who may with a group providing some Some have these differences by having an more ethics and a more ethics consultation service to provide clinical consultation has developed in a manner similar to new clinical as consultants in medical ethics take and in As a no process for ethics consultants and patients are not from who lack expertise in clinical ethics but who may as individual consultation services have their own and mechanisms to define are in the It is to a more process in the committees and ethics consultation services should include a of hospital such as and with either an interest or some expertise in patients often a useful and to the with a interest in may be more to the than an institutional whose is to the This presumes that ethical views are influenced by and thus committees should include individuals from a of It is for this to be fully even with to include in the may be to the of one the to and the to pursue or to have for example, that sometimes will at a consensus decision that no individual in a group would such as when who positions to a compromise. Because committees work may and the views of their colleagues. committees for of that consensus itself is that the decision is This consensus may be unintentionally of these issues may help committees such of preventing these are to the so can to have the ethics evaluate pertinent issues, or to have an evaluate the and provide One problem with having the ethics review the consultant's work is that as one of the more of the the consultant usually has a of unofficial authority that may the review ethics consultants and committees may provide One is the to frequently as a result of or committees are always with no authority the ability to This the of the relationship between the physician and the patient and is to the recommendations by other however, does not the are without An opinion from an effective ethics with a of moral authority that is difficult to If of the ethics believe so is that they are to then the the proper ethics committees can provide an to the they do not the The have or ethics and the use of an ethics does not legal The lack of a process in the ability of committees to and or in the of does not ethics committees to function on the of the Some have that ethics committees need to greater to the of For example, not all ethics committees require that the patient or family be of the and not all that the patient or surrogate has the to with the that involve only the and of the caregivers the of being and even ethics committees should not be perceived as to certain of is necessary for them to perform and for an ethics consultation Ethics committees should their in the for several to communicate, to to facilitate most to the consultant to be in his or her the of the consultation and may the of clinicians in the of the The of the consultation may An ethics consultation may either a clinical consultation, and or provide a introduction to the clinical situation by a more discussion of the ethical issues. This discussion should include questions by the of the consultation, pertinent issues, ethical of the issues, and to the if Because ethical dilemmas are it may be difficult to always the same and to case. In any given case, common hospital policy or be the the benefits of ethics consultation are in part because of the goals of ethics consultations. this the goals of ethics consultation as to “assist the primary physician, the patient and the family to reach a right and good clinical this is not as to as clinical One problem may be that the of a by situation, and How is the of or of a and good clinical Most on satisfaction and knowledge that at a of and about is difficult to the of the patient, or An of The of on a more such as ethical it is that these will tend to into a process and but that is not always a in a of has been to and to to this undesirable often for the anesthesiologist is the American Society of Anesthesiologists Committee on The on ethics primary The first is policy and which most has included a policy on in the operating room and an of the for the of These policies provide a substantial for anesthesiologists to to when faced with ethical for the Care of with or that was by the American Society of Anesthesiologists of in October of This was the first of a professional to the now practice of having patients reevaluate instead of their to limit resuscitation when receiving anesthesia and surgery. After Society the Committee on Ethics with the American of to have them a similar This patient care by providing a common of practice for and other most recent of the for the of was by the of in October of 1995. It of bioethics, in recognition that may be specific in which the guidelines may not and may be were addressing the ethical of anesthesiologists to and to anesthesiologists to in the management of their health care and to be in financial second function of the Committee on Ethics is The educational at the such issues as the ethics of care, care, and what to do with the anesthesiologist. The of the in other educational such as and and most function for the clinician is to respond to questions and by anesthesiologists or other professionals involved in the delivery of health care. The of the one or two each have included the appropriateness of a surgeon and anesthesiologist working of anesthesiologists the operating room certain more of certain The Committee on Ethics may to more concerns to their For example, the is the of ethics, and medical ethics, particularly as it to For example, at what point is a in an anesthesiology group of a because of an of Or, is the by as as participants are with Anesthesiologists should view the as an to any concerns to the practice of increased health care and in find it more difficult than to clinical ethical patients' preferences is even more difficult when choices contrary to those of may communicate in a manner from their care in Caregivers who are to consider of when determining patient treatment may have difficulty more and in health care for the and in the of a of patients hospital ethics committees will to have an important role in the of the hospital. In these and anesthesiologists would be to the use of ethics consultation to provide the care they to give and their patients to Commission on Accreditation of Healthcare Accreditation for Society of for the Care of with or that care, American Society of Anesthesiologists of American Society of in the medical ethics and American Society of Anesthesiologists Society of for the of Anesthesiology, American Society of Anesthesiologists of American Society of

Decisional and Dispositional Capacity Determinations: Neuropsychiatric Illness and an Integrated Clinical Paradigm

Preface Acknowledgments I. Curriculum for Ethics Committees 1. Ethical Foundations of Clinical Practice The Role of Ethics in Clinical Medicine Ethics Committees in the Health Care Setting Fundamental Ethical Principles Principlism and Alternative Approaches The Role of Culture, Race, and Ethnicity in Health Care Conflicting Obligations and Ethical Dilemmas 2. Decision Making and Decisional Capacity in Adults Health Care Decisions and Decision Making Decision-Making Capacity Assessment and Determination of Capacity Deciding for Patients without Capacity 3. Informed Consent and Refusal Evolution of the Doctrine of Informed Consent Elements of Informed Consent and Refusal The Nature of Informed Consent Exceptions to the Consent Requirement 4. Truth Telling Justifications Disclosure Disclosure of Adverse Outcomes and Medical Error Privacy and Confidentiality Genomic Testing and Control of Information 5. Special Decision-Making Concerns of Minors Decisional Capacity and Minors Consent for and by Minors Confidentiality and Disclosure Special Problems of Functionally Alone Adolescents 6. Ethical Issues in Reproduction The Ethics and Politics of Reproductive Choice Assisted Reproductive Technologies Surrogacy and Gestational Carriers Termination of Pregnancy Maternal-Fetal Issues Prenatal/Newborn Genetic Testing and Genomic Newborn Screening Special Decision-Making Concerns of the Elderly The Other Side of the Mountain Diminishing Autonomy and Decisional Capacity Promise that you won't ever put me in a nursing home Independence, Dependence, and Role Reversals Prior Wishes and Current Needs Intimacy and Security Transition from Hospital to Home or Nursing Home 8. Ethical Issues in the Care of Disabled Persons Disability and Its Place in Bioethics Defining Disability The Medical and Social Models of Disability The Disability Rights Critique of Prenatal Genetic Testing Special Challenges in the Care of Persons with Severe Cognitive Impairment Medical Decision Making and the Disabled 9. End-of-Life Issues Decision Making at the End of Life Defining Death Organ Donation Advance Health Care Planning Honoring Patients' End-of-Life Decisions Goals of Care at the End of Life Forgoing Life-Sustaining Treatment Protecting Patients from Treatment Rejection of Recommended Treatment and Requests to Do Everything Medical Futility 10. Palliation From Caring to Curing and Back Again The Experience of and Response to Pain The Moral Imperative to Relieve Pain Assisted and Permitted Dying Pediatric Palliative Care Palliative Care and Hospice Palliative Care 11. Justice, Health, and Access to Health Care Access to Health Care in the United States Justice and Health Disparities Health Care as a Requirement of Justice Health Care and Health Theories of Justice Rationing Health Care Reform 12. Organizational Ethics From Bioethics to Health Care Organizational Ethics Moral Responsibilities of Health Care Organizations Organizational Ethics and Compliance Ethics and the Allocation of Resources Ethics Committees and Organizational Issues Developing an Organizational Ethics Service II. The Creation, Nature, and Functioning of Ethics Committees 13. Profile of Ethics Committees Origins Committee Functions Membership Expertise in Ethics Leadership Securing a Foothold Clinical Ethics Consultation Overview of Ethics Consultation Three Models of Clinical Ethics Consultation Services Building an Ethics Consultation Service Credentialing and Privileging Clinical Ethics Consultants Analytic Approaches to Clinical Ethics Consultation Selecting the Best Clinical Ethics Consultation Service Model for Your Institution Access to Clinical Ethics Consultation Policies 15. Ethics Education Brown Bag Lunches Journal Clubs Case Conferences Ethics Grand Rounds Ethics Modules in Residency Training and Medical School Programs Ethics Symposia White Papers, Memoranda, Guidelines, and Protocols Additional Education Opportunities 16. Sample Clinical Cases Adolescent Decision Making Advance Directives Autonomy in Tension with Best Interest Confidentiality Decisional Capacity Disclosure and Truth Telling End-of-Life Care Forgoing Life-Sustaining Treatment Goals of Care Informed Consent and Refusal Medical Futility Parental Decision Making Surrogate Decision Making 17. Sample Policies and Procedures III. Organizational Codes of Ethics Regional Medical Center Code of Conduct Metropolitan Medical Center Code of Ethics University Health Network Code of Ethics IV. Key Legal Cases Informed Consent Privacy Confidentiality Health Care Decision Making Medical Decision Making for Minors Reproductive Rights State Action to Protect Public Health State Action to Control What Practitioners Must or Must Not Discuss with Their Patients Health Care Reimbursement V. An Ethics Committee Meeting Index

Healthcare practitioners have a legal, ethical and professional obligation to obtain patient consent for all healthcare treatments. There is increasing evidence which suggests dissonance and variation in practice in assessment of decision-making capacity and consent processes. This study explores healthcare practitioners' knowledge and practices of assessing decision-making capacity and obtaining patient consent to treatment in the acute generalist setting. An exploratory descriptive cross-sectional survey design, using an online questionnaire, method was employed with all professional groups invited via email to participate. Data were collected over 3 months from July to September 2015. Survey content and format was reviewed by the liaison psychiatry team and subsequently contained five sections (demographics, general knowledge and practice, delirium context, legal aspects and education/training). Descriptive, univariate and bivariate analysis of quantitative data and qualitative content analysis of qualitative data were undertaken. The study was approved by the institutional Human Research and Ethics Committee and informed consent was taken to be provided by participants upon completion and submission of the de-identified survey. In total, 86 participants engaged the survey with n = 24, exiting at the first consent question. Almost two-thirds of respondents indicated that all treatments required patient consent. Knowledge of consent and decision-making capacity as legal constructs was deficient. Decision-making capacity was primarily assessed using professional judgement and perceived predominantly as the responsibility of medical and psychology staff. A range of patient psychological and behavioural symptoms were identified as indicators requiring assessment of decision-making capacity. Despite this, many patients with delirium have their decision-making capacity assessed and documented only sometimes. Uncertain knowledge and inconsistent application of legislative frameworks are evident. Many participants were unsure of the legal mechanisms for obtaining substitute consent in patients with impaired decision-making capacity and refusing treatment. The legal context of decision-making capacity and consent to treatment appears complex for healthcare practitioners. Professional, ethical and legal standards of care in this context can benefit from structured education programmes and supportive governance processes. An understanding of why 'duty of care' is being used as a framework within the context of impaired decision-making capacity is warranted, alongside a review of the context of Duty of Care within health policy, guidance and faculty teaching.

Assessment of Decision-Making Capacity: Views and Experiences of Consultation Psychiatrists

Purpose: This paper explores the clinical implications of acquired communication disorders in decisional capacity. Discipline-specific contributions are discussed in a multidisciplinary context, with a specific focus on the role of speech and language pathologists (SLPs). Method: Key rehabilitation issues in determining decisional capacity are identified. The impact of communication impairment on capacity is discussed in light of the research literature relating to supportive communication and collaborative practice that respects human rights. Results: Guidelines are presented for professionals involved in the assessment of the decisional capacity of individuals with communication disorders of neurological origin. They guide an assessor through: assessing cognition, language and speech; determining preferred communication domains; and practical strategies and considerations for maximising communication. Conclusion: There is a dearth of guidelines available that deal with augmenting and supporting communication of individuals with acquired communication disorders of neurological origin when it comes to assessing legal decision-making capacity. Capacity assessment is a multidisciplinary realm, and the involvement of SLPs is key to maximising the decision-making capacity of these individuals.Implications for rehabilitationAll clinicians have an obligation to maximise client autonomy and participation in decision-making.Assessments of capacity should involve a general cognitive ability assessment, followed by a decision-specific assessment tool or question set for the decision facing the patient.The involvement of speech and language pathologists (SLPs) is key to assess and facilitate capacity determinations in instances of cognitive-communication disorder.Impairments in different aspects of auditory comprehension require different accommodations.

ObjectiveIn Belgium, people with an incurable psychiatric disorder can file a request for euthanasia claiming unbearable psychic suffering. For the request to be accepted, it has to meet stringent legal...

Annals for Educators - 5 March 2019.

PurposeIn Ireland, the Assisted Decision Making (Capacity) Act 2015 provides a statutory framework to adults who are experiencing difficulties with decision-making. This legislation has significant implications for all who work in health and social care. Increasing age and life expectancy, alongside the rising incidence of chronic health conditions and dementia-related diseases, indicates that more individuals are likely to experience challenges regarding decision-making capacity. Therefore, the need for more consistent, best-practice processes to assess decision-making capacity is likely to increase. To ensure occupational therapists are responsible in their contributions, and to ensure those with disabilities are supported, clinicians must be well-informed of the principles underscoring the Act. The purpose of this paper is to provide an overview of this multidisciplinary issue, including recent legislation, and consider how occupational therapy can contribute.Design/methodology/approachThe authors reviewed current literature and considered occupational therapy’s role in decision-making capacity assessment.FindingsOccupational therapists have potential to play a key role in multi-disciplinary assessments of decision-making capacity for clients. Further research is required to explore professional issues, identify clinical best practices and determine training and resource needs.Originality/valueThis paper seeks to provoke consideration of how occupational therapists can contribute to capacity assessment from a client-centred, occupation-based perspective that is mindful of ethical and legislative considerations.

Voluntarism in Consultation Psychiatry: The Forgotten Capacity

Brain Response Correlates of Decisional Capacity in Schizophrenia: A Preliminary fMRI Study