MacArthur Competence Assessment Tool-Treatment Research Articles

Assessment of adolescent decision-making capacity for pharmacy access to hormonal contraception

ObjectivesTo examine adolescents’ decision-making capacity for pharmacsist-prescribed hormonal contraception. Study DesignA subset of 60 females, ages 14–21, were recruited to complete the MacArthur Competence Assessment Tool-Treatment. Overall scores were compared by age and demographic factors and variation examined. ResultsParticipants scored high on the MacArthur Competence Assessment Tool-Treatment with little variation in the scores (18.8 [±1.9]/20 total points). Factors such as chronic illness, health literacy, and family affluence were not associated with of overall scores. ConclusionsAdolescents and young adults have the capacity to make decisions regarding contraception in the pharmacy access settings.

Decisional capacity in young people with first episode psychosis, major depressive disorder and no mental disorder

We aimed to (1) examine decisional capacity for treatment in young people (aged 15 to 25 years) with first-episode psychosis (FEP), Major Depressive Disorder (MDD) and no mental disorder, and (2) determine which theoretically relevant factors are associated with, and predict decisional capacity. We assessed decisional capacity (using MacArthur Competence Assessment Tool-Treatment; MacCAT-T), cognitive abilities, insight and symptom severity in young people with no mental disorder (n = 38), MDD (n = 38) and FEP (n = 18) from inpatient and outpatient services. Most young people with MDD (84.2%) or no mental disorder (86.8%) had adequate decisional capacity to consent to treatment based on recommended cut-off scores, compared with fewer than half of the those with FEP (44.4%). Levels of capacity were not significantly different between young people with MDD and those with no mental disorder (p = .861). However, young people with FEP demonstrated significantly poorer decisional capacity than those with no mental disorder (p = .006) and MDD (p = .009). A hierarchical regression analysis suggested that differences may be better explained by variation in cognitive ability, especially thematic verbal recall. Greater symptom severity and poorer insight were associated with poorer decisional capacity for FEP (p = .008 and p < .001, respectively), but not MDD (p = .050 and p = .805, respectively). Cognitive performance (i.e., predicted IQ, processing speed, mental flexibility and thematic verbal memory) collectively explained 36.6% of the variance in decisional capacity (p < .001). Thematic verbal memory was the strongest predictor of decisional capacity (p < .001). Supports for memory should be implemented to facilitate involvement in treatment decisions during the early course of illness.

Decision-making Capacity for Treatment After Electroconvulsive Therapy for Depression.

Depression can impair decision-making capacity (DMC) for health care decisions. However, it is unclear whether DMC improves after treatments for depression such as electroconvulsive therapy (ECT). There is limited evidence available on DMC for treatment in patients with depression referred for ECT, and it is unknown whether ECT has any impact on DMC. We hypothesized that ECT will improve DMC in severely depressed patients and that this change will be associated with reduced depressive symptom severity. Using the MacArthur Competence Assessment Tool-Treatment, 4 abilities related to DMC were evaluated: Understanding, Appreciation, Reasoning, and Expressing a choice. This prospective study compared DMC abilities, depression severity, and cognition scores in 24 patients hospitalized with a major depressive episode before and 3 to 5 days after a course of ECT. Although Understanding scores significantly improved after ECT (P = 0.004, r = 0.41), there was no change in other abilities related to DMC or cognition scores. As expected, there was a large improvement in mood ratings after ECT, but the change in DMC abilities was not associated with change in depressive symptoms. To our knowledge, this is the first study to provide data on the effects of ECT on DMC in patients with depression. Abilities related to DMC that may be affected in this group before treatment include Understanding and Reasoning. Findings indicate that DMC to consent to treatment mostly does not change after a course of ECT and some aspects can improve in patients with depression.

Competency of aMCI patients to consent to cholinesterase treatment.

In medical practice, a patient's loss of competency is a major obstacle when choosing a treatment and a starting treatment program smoothly. A large number of studies have revealed the lack of medical competency in patients with dementia. However, there have been only a few reports focusing on the capacity of patients with mild cognitive impairment (MCI) to make a medical choice. In this study, we evaluated the competency of 40 patients with amnestic MCI (aMCI) and 33 normal subjects to make a medical choice using the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). We compared the judgement of a team conference using the recorded semi-structured interview with the clinical judgement of a chief clinician. A team conference concluded that 12 aMCI patients had no competency, and the clinical judgement, without any special interview, judged that five aMCI patients had no competency. All subjects in the control groups were judged to be competent to consent to treatment by both clinicians and the team conference. Without supplementary tools such as explanatory documents, not a few patients with aMCI were judged by a team conference to have no competency to consent to therapy even in a relatively simple and easy case. In contrast, clinical physicians tended to evaluate the competency of aMCI patients in a generous manner.

Should capacity assessments be performed routinely prior to discussing advance care planning with older people?

32 older people (mean age = 84.1) with a Mini-Mental State Examination of 24 or above were recruited from two retirement villages in Auckland. Participants also completed Trail Making Test Part A & Part B and Geriatric Depression Scale (GDS-15) before undertaking the two capacity assessments that were video recorded to enable further analysis by four independent old age psychiatrists. Using the MacCAT-T as the gold standard, over half (53.1%) of the participants were considered as lacking in capacity to engage in ACP. Participants struggled with the "Understanding ACP" domain the most. Capacity was not predictable by any of the demographic or cognitive functioning variables. When compared to the gold standard, ACP-CAV was accurate in assessing capacity in 68.8% of the cases. Clinicians should routinely explain ACP to older people and ensure they fully understand it prior to an ACP discussion. If there is any concern about their understanding, further exploration and documentation of their capacity using the capacity assessment framework would be necessary. However, capacity assessment is a complex iterative process that does not easily lend itself to screening methodology and requires a high level of clinical judgment.

Correlation Between Insight and Capacity to Consent to Research in Subjects With Bipolar Disorder Type I and Schizophrenia

IntroductionSchizophrenia and bipolar disorder type I (BD-I) can affect patient autonomy and capacity to consent to participate in research. Other variables associated with the autonomy of patients must be explored in order to improve the quality of the currently available tools. ObjectiveTo evaluate the relationship between insight and the capacity to consent to participate in research in patients with BD-I and schizophrenia. MethodsA cross-sectional and longitudinal study was conducted with 120 subjects (40 subjects with schizophrenia, 40 with BD-I, and 40 healthy controls). The tools used were the Scale Assessment Insight-Expanded (SAI-E) and the MacArthur Competence Assessment Tool-Treatment (MacCAT-CR), which was first adapted culturally, and its validity and reliability assessed. The results obtained on each scale were compared and the association between them were evaluated. ResultsThere is a direct correlation between the capacity to consent to research, measured using the MacCAT-CR tool, and the degree of insight, measured using the SAI-E scale, with an effect size of 1.3 for BD-I and 2.03 for schizophrenia. ConclusionsThe results suggest that there is a correlation between the degree of insight and the capacity to consent to research in subjects with schizophrenia and BD-I. Insight should therefore be included as a relevant variable to assess the capacity to consent, and future studies should include it when researching on or designing new tools which aim at a greater respect of patient autonomy.

Autonomy and Capacity to Consent in Dementia

As the global population ages, the incidence and prevalence of various types of dementia will increase. People with dementia are generally multimorbid and have on average 4–6 major diseases besides dementia (Zubenko, Mulsant, Sweet, Pasternak, & Tu, 1997; Attems, Konig, Huber, Lintner, & Jellinger, 2006). Hence, they are dependent on all sorts of medical treatments. According to generally accepted legal and ethical principles, patients have the right to decide whether or not they wish to accept the offer of a certain treatment. No treatment can be forced upon the patient without the informed consent of a patient who has the capacity to make the decision in question. Medical treatment that is carried out without or on the basis of invalid informed consent may lead to charges of criminal assault or civil battery in the event of bodily harm. One difficulty is that, particularly with regard to patients with a progressive type of dementia, the capacity to consent is always specific to the decision in question – and may change over time depending on context (Katatona et al., 2009). Hence, the attending physician has to assess the capacity to consent of a patient for every single decision for or against a prescribed medical treatment. The problem of how to reliably and validly decide whether a person has the capacity to consent to a specific treatment is not solely a practical problem for the physician, but must be solved interdisciplinarily, by including experts from the fields of (particularly, but not limited to) psychiatry, psychology, law, ethics, sociology, and, in the case of persons with dementia, gerontology and geriatrics (Moye & Marson, 2007). This special issue represents an attempt to integrate these diverse disciplines. The first contribution in this issue studies mental capacity in light of the Convention on the Rights of Persons with Disabilities. Based on the situation in Germany, Thomas Klie and Jorg Leuchtner debate the legal situation in selected other countries (Canada, UK, Spain, and Switzerland). In the second contribution, Jakov Gather and Jochen Vollmann present the clinical case report of a 91-year-old patient with dementia and discuss different aspects in the evaluation of the patient’s will from an ethical point of view. The third contribution presents a substudy that is part of the comprehensive research project EmMa (Promotion of capacity for consent to medical treatment among persons with dementia by means of resource-oriented communication). The EmMa project, funded by the Volkswagen Foundation, aims to enable people with dementia to benefit from their right to self-determination as much as possible. A major step toward achieving this aim was made in the examination of common practice. Mueller, Haberstroh, Knebel, Oswald, and Pantel compare different assessments of capacity to consent to treatment in people with dementia: the initial clinical assessment, the result of the most widely used standardized test for capacity to consent (MacArthur Competence Assessment ToolTreatment; Grisso & Appelbaum, 1998; Appelbaum, 2007), and an interdisciplinary assessment. Results are then discussed from a psychological and a psychiatric point of view. Birgit Panke-Kochinke rounds out this special issue with the sociological perspective. She proposes a decision grid for individualized interventions which promotes the ability of people with dementia to live successfully with their disease. This special issue represents multiand interdisciplinary perspectives on autonomy and the capacity to consent of people with dementia. The hope is to sensitize readers to the problems involved in determining capacity to consent, to the discrimination of people with dementia in questions of self-determination, and to the need for multiand interdisciplinary empirical approaches that promote autonomy in dementia as much as possible and likewise protect the person from harm. According to the UN Convention on the Rights of Persons with Disabilities, the main question should not be whether a person has the capacity to consent, but how we can enable and help the person attain and exercise that autonomy. GeroPsych, 28 (1), 2015, 5–6

Neuropsychological Performance Within-Person Variability Is Associated with Reduced Treatment Consent Capacity

The capacity of older adults to make healthcare decisions is often impaired in dementia and has been linked to performance on specific neuropsychological tasks. Within-person across-test neuropsychological performance variability has been shown to predict future dementia. This study examined the relationship of within-person across-test neuropsychological performance variability to a current construct of treatment decision (consent) capacity. Participants completed a neuropsychological test battery and a standardized capacity assessment. Standard scores were used to compute mean neuropsychological performance and within-person across-test variability. Assessments were performed in the participant's preferred location (e.g., outpatient clinic office, senior center, or home). Participants were recruited from the community with fliers and advertisements and consisted of men (N= 79) and women (N= 80) with (N= 83) or without (N= 76) significant cognitive impairment. Participants completed the MacArthur Competence Assessment Tool-Treatment and 11 neuropsychological tests commonly used in the cognitive assessment of older individuals. Neuropsychological performance and within-person variability were independently associated with continuous and dichotomous measures of capacity, and within-person neuropsychological variability was significantly associated with within-person decisional ability variability. Prevalence of incapacity was greater than expected in participants with and without significant cognitive impairment when decisional abilities were considered separately. These findings are consistent with an emerging construct of consent capacity in which discrete decisional abilities are differentially associated with cognitive processes and indicate that the sensitivity and accuracy of consent capacity assessments can be improved by evaluating decisional abilities separately.

PreliminaryTurkish study of psychiatric in‐patients’ competence to make treatment decisions

Competence is a prerequisite for informed consent. Patients who are found to be competent are entitled to accept or refuse the proposed treatment. In recent years, there has been an increased interest in studies examining competence for treatment in psychiatric patients. In this study, we aimed to investigate the decision-making competencies of inpatients with a range of psychiatric diseases. This study was carried out at the psychiatry clinic of Kocaeli University Hospital in Turkey from June 2007 to February 2008. Decision-making competence was assessed in 83 patients using the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). The study groups consisted of patients with mood (39.8%), psychotic (27.7%) and anxiety disorders (18.1%), and alcohol/substance addiction (14.5%). There was a significant relation between decision-making competence and demographic and clinical characteristics. Appreciation of the given information was more impaired in psychotic disorder patients than in other patients, but understanding and reasoning of the given information was similar in all groups. These results reveal the importance of evaluating decision-making competencies of psychiatric patients before any treatment or intervention is carried out to ascertain their ability to give informed consent to treatment. Institutional and national policies need to be determined and put into practice relating to the assessment and management of competence in patients with psychiatric disorders.

Effects of group metacognitive training (MCT) on mental capacity and functioning in patients with psychosis in a secure forensic psychiatric hospital: a prospective-cohort waiting list controlled study

BackgroundMetacognitive Training (MCT) is a manualised cognitive intervention for psychosis aimed at transferring knowledge of cognitive biases and providing corrective experiences. The aim of MCT is to facilitate symptom reduction and protect against relapse. In a naturalistic audit of clinical effectiveness we examined what effect group MCT has on mental capacity, symptoms of psychosis and global function in patients with a psychotic illness, when compared with a waiting list comparison group.MethodsOf 93 patients detained in a forensic mental health hospital under both forensic and civil mental health legislation, 19 were assessed as suitable for MCT and 11 commenced. These were compared with 8 waiting list patients also deemed suitable for group MCT who did not receive it in the study timeframe. The PANSS, GAF, MacArthur Competence Assessment Tool- Treatment (MacCAT-T) and MacArthur Competence Assessment Tool-Fitness to Plead (MacCAT-FP) were recorded at baseline and repeated after group MCT or following treatment as usual in the waiting list group.ResultsWhen baseline functioning was accounted for, patients that attended MCT improved in capacity to consent to treatment as assessed by the MacCAT-T (p = 0.019). The more sessions attended, the greater the improvements in capacity to consent to treatment, mainly due to improvement in MacCAT-T understanding (p = 0.014) and reasoning . The GAF score improved in patients who attended the MCT group when compared to the waiting list group (p = 0.038) but there were no changes in PANSS scores.ConclusionMeasures of functional mental capacity and global function can be used as outcome measures for MCT. MCT can be used successfully even in psychotic patients detained in a forensic setting. The restoration of elements of decision making capacity such as understanding and reasoning may be a hither-to unrecognised advantage of such treatment. Because pharmacotherapy can be optimised and there is likely to be enough time to complete the course, there are clear opportunities to benefit from such treatment programmes in forensic settings.

Informed Consent in Deep Brain Stimulation – Ethical Considerations in a Stress Field of Pride and Prejudice

Informed Consent in Deep Brain Stimulation – Ethical Considerations in a Stress Field of Pride and Prejudice

Consent to treatment in adolescents with anorexia nervosa

This study examined the ability of adolescents with anorexia nervosa (AN) to make treatment decisions. The MacArthur Competence Assessment Tool-Treatment (MacCAT-T) was used to compare the decision making abilities of 35 adolescents with AN who were receiving inpatient treatment with that of 40 healthy, community-based adolescents. Vignettes of both a medical and psychiatric illness were provided, requiring participants to work through the process of making a hypothetical treatment decision. The MacCAT-T was also administered to participants with AN to examine decision-making about their own illness, which allowed for comparison of competencies across contexts. Group differences were found, with the community group showing superior reasoning skills to the adolescents with AN. The results provide evidence to suggest that adolescents with AN tend toward a thinking disposition that is concrete and lacking in abstract reasoning and reflection, which may negatively affect their ability to reason about treatment options.

Capacity to Make Treatment Decisions in Chinese Older Persons With Very Mild Dementia and Mild Alzheimer Disease

This study aims at assessing mental competence in Chinese patients with mild and very mild dementia with a semistructured assessment method and the impact of repeated presentations of information on patients' mental competence. Subjects with mild and very mild dementia were compared with cognitively intact subjects. Chinese subjects were recruited from local social centers and residential hostels for the elderly in Hong Kong. Sixty-six Chinese community-dwelling older adults (aged from 65 to 87 years) were recruited. Clinical diagnosis was made by experienced geriatric psychiatrists. Subjects were assessed with the Mini-Mental State Examination and the Clinical Dementia Rating (CDR). Mental capacity to consent to treatment was assessed by using the Chinese version of the MacArthur Competence Assessment Tool-Treatment (MacCAT-T) and independent clinician ratings based on the definition in the Mental Capacity Act 2005 of the United Kingdom. Thirty-three (50%) participants were diagnosed with very mild or mild dementia (CDR = 0.5 or 1). In this group, 15 (45.5%) subjects were rated as mentally incompetent in clinician ratings. In the assessment of interrater reliability, the intraclass correlation coefficient of MacCAT-T summary scores among three raters ranged from 0.64 to 0.83. The MacCAT-T summary scores correlated significantly with clinician ratings, years of education, Mini-Mental State Examination score, and CDR. In contrast to the nonimpaired group, repeated presentation of information did not significantly improve capacity in the demented group. Results from this study suggest that even patients with very mild dementia in this population can show substantial deficits in decision-making capacity, and that improved capacity is not likely to result from repeated disclosure of information.

Neuropsychological predictors of decision-making capacity over 9 months in mild-to-moderate dementia

Older adults with dementia may have diminished capacity to make medical treatment decisions. To examine rates and neuropsychological predictors of treatment decision making, or consent capacity, among older adults with dementia over 9 months. Consent capacity was assessed initially and 9 months later in subjects with and without dementia using a longitudinal repeated measures design. Fifty-three older adults with dementia and 53 similarly aged adults without dementia. A standardized measure MacArthur Competence Assessment Tool-Treatment of 4 legal standards for capacity (Understanding, Appreciation, Reasoning, and Expressing a Choice) and a neuropsychological battery. In the dementia group, 9.4% had impaired capacity initially, and 26.4% had impaired capacity at 9 months. Mean scores in the dementia group were impaired relative to controls initially and at 9 months for Understanding (initial t=2.49, P=.01; 9-month t=3.22, P<.01) and Reasoning (initial t=2.18, P=.03; 9-month t=4.77, P<.01). Declining capacity over 9 months was attributable to a further reduction in Reasoning (group x time F=9.44, P=.003). Discriminant function analysis revealed that initial scores on naming, delayed Logical Memory, and Trails B were associated with impaired capacity at 9 months. Some patients with mild-to-moderate dementia develop a clinically relevant impairment of consent capacity within a year. Consent capacity in adults with mild-to-moderate dementia should be reassessed periodically to ensure that it is adequate for each specific informed consent situation. Interventions that maximize Understanding and Reasoning by supporting naming, memory, and flexibility may help to optimize capacity in this patient group.

Decision-Making Capacity of Inpatients With Schizophrenia in Hong Kong

This is a prospective study examining decision-making abilities in Chinese schizophrenia patients in Hong Kong. We interviewed patients before their discharge from hospital after a psychotic relapse, examining their decision regarding whether or not they would take maintenance neuroleptic treatment. Decision-making abilities were assessed by the MacArthur Competence Assessment Tool-Treatment, a semistructured questionnaire. We examined their relationships with demographic, clinical, and cognitive variables, measured by standardized instruments. Eighty-one participants were seen. Weaknesses were noted in a range of relevant decision-making abilities. Positive and negative schizophrenic symptoms, specifically lack of judgment and insight, difficulty in abstract thinking, unusual thought content, and conceptual disorganization, were found to be correlated with performance in decision-making abilities, as were cognitive deficits. Verbal working memory was a moderate predictor of the ability to understand treatment information. Decision-making impairments and negative treatment attitude were related to the decision not to adhere to medication.

The Cognitive Based Approach of Capacity Assessment in Psychiatry: A Philosophical Critique of the MacCAT-T

This article gives a brief introduction to the MacArthur Competence Assessment Tool-Treatment (MacCAT-T) and critically examines its theoretical presuppositions. On the basis of empirical, methodological and ethical critique it is emphasised that the cognitive bias that underlies the MacCAT-T assessment needs to be modified. On the one hand it has to be admitted that the operationalisation of competence in terms of value-free categories, e.g. rational decision abilities, guarantees objectivity to a great extent; but on the other hand it bears severe problems. Firstly, the cognitive focus is in itself a normative convention in the process of anthropological value-attribution. Secondly, it misses the complexity of the decision process in real life. It is therefore suggested that values, emotions and other biographic and context specific aspects should be considered when interpreting the cognitive standards according to the MacArthur model. To fill the gap between cognitive and non-cognitive approaches the phenomenological theory of personal constructs is briefly introduced. In conclusion some main demands for further research to develop a multi-step model of competence assessment are outlined.

Mental competence and neuropsychologic impairments in demented patients

The study aim was to examine if neuropsychological tests and clinical dementia scales identify incompetent patients with dementia. Eighteen demented outpatients (ICD-10: F00-F03) underwent psychiatric examination, neuropsychological testing, and formal (MacArthur Competence Assessment Tool Treatment, Hopkins Competency Assessment Test) and clinical assessment of competence. Clinical dementia scales but not neuropsychological testing correlate with formal and clinical assessment of competence in patients with dementia. Our results do not support a neuropsychological model of competence assessment. However, in cases with poor results in clinical dementia scales, clinicians should assess the patients' competence in more detail. It remains open which is the best and ethically grounded methodology for competence assessment.