A Prospective Observational Study of Decisional Capacity Determinations in an Academic Medical Center

Kahn, Debra R.; Bourgeois, James A.; Klein, Sally C.; Iosif, Ana‐Maria

doi:10.2190/pm.39.4.e

Cited by 20 publications

(16 citation statements)

References 14 publications

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“…However, the findings of CIPOLD have contributed to the accumulating body of evidence about the importance of the MCA for patients. Studies have reported that 40-70 per cent of medical in-patients (Raymont et al, 2004;Kahn et al, 2009), and 60 per cent of psychiatric inpatients (Owen et al, 2008) do not have capacity to make decisions about their treatment, suggesting that the link identified by CIPOLD between poor understanding of, and adherence to the MCA by health and social care professionals, and premature deaths of people with ID is likely to have wider relevance beyond people with ID. The MCA has been law since 2007 and, despite advice and toolkits for health and social care professionals, there is an apparent widespread practice gap in understanding and using the MCA for people with ID.…”

Section: Discussionmentioning

confidence: 99%

Poor adherence to the mental capacity act and premature death

Heslop

Blair²,

Fleming³

et al. 2014

The Journal of Adult Protection

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Purpose -The purpose of this paper is to report the findings of the Confidential Inquiry into premature deaths of people with intellectual disabilities (CIPOLD) in relation to the Mental Capacity Act (England and Wales) (MCA) 2005. Design/methodology/approach -CIPOLD reviewed the deaths of all known people with intellectual disabilities (ID) aged four years and over who had lived in the study area and died between 2010 and 2012. Findings -The deaths of 234 people with ID aged 16 years and over were reviewed. There were two key issues regarding how the MCA was related to premature deaths of people with ID. The first was of the lack of adherence to aspects of the Act, particularly regarding assessments of capacity and best interests decision-making processes. The second was a lack of understanding of specific aspects of the Act itself, particularly the definition of "serious medical treatment" and in relation to Do Not Attempt Cardiopulmonary Resuscitation guidelines. Research limitations/implications -CIPOLD did not set out to specifically evaluate adherence to the MCA. It may be that there were other aspects relating to the MCA that were of note, but were not directly related to the deaths of individuals. Practical implications -Addressing the findings of the Confidential Inquiry in relation to the understanding of, and adherence to, the MCA requires action at national, local and individual levels. Safeguarding is everyone's responsibility, and in challenging decision-making processes that are not aligned with the MCA, the authors are just as effectively protecting people with ID as are when the authors report wilful neglect or abuse. Originality/value -CIPOLD undertook a retrospective, detailed investigation into the sequence of events leading to the deaths of people with ID. To the authors' knowledge, this is the first time that such research has associated a lack of adherence to the MCA to premature deaths within a safeguarding framework.

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Section: Discussionmentioning

confidence: 99%

Poor adherence to the mental capacity act and premature death

Heslop

Blair²,

Fleming³

et al. 2014

The Journal of Adult Protection

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“…There was no family present at bedside, and he would not provide information to contact them because he "did not want to worry them." The patient's score on the MMSE was 25, which was above the cut-offs of both 21 and 24 described by Kahn et al 4 During his initial evaluation, it was determined that the patient was able to understand his medical situation, manipulate the information, evidence a choice about his treatment plan, and appreciate the situation and its consequences. Given that he was able to meet these standards of capacity, he was found to have the capacity to refuse surgery at that time and to accept intravenous antibiotic treatment to prevent infection (ie, meningitis).…”

Section: Case Descriptionmentioning

confidence: 81%

“…The MMSE is useful in predicting medical decision-making capacity when used in conjunction with other evaluation methods, but it can be misleading when used alone. 4 Kahn et al demonstrated that using an MMSE cut-off score of < 21 is 100% specific and 69% sensitive for identifying patients without capacity, whereas a score of < 24 is only 90% specific and 83% sensitive for identifying patients without capacity. 4 Similar results have been reported elsewhere, 5,6 suggesting that there seems to Illogical thought processes Denial as a defense mechanism Delusions Psychosis Impaired communication skills be a "gray zone" for scores in the middle range of the MMSE that are not predictive of a patient's medical decision-making capacity.…”

Section: The Four Standards Of Capacitymentioning

confidence: 99%

“…4 Kahn et al demonstrated that using an MMSE cut-off score of < 21 is 100% specific and 69% sensitive for identifying patients without capacity, whereas a score of < 24 is only 90% specific and 83% sensitive for identifying patients without capacity. 4 Similar results have been reported elsewhere, 5,6 suggesting that there seems to Illogical thought processes Denial as a defense mechanism Delusions Psychosis Impaired communication skills be a "gray zone" for scores in the middle range of the MMSE that are not predictive of a patient's medical decision-making capacity. Many types of patients will be unable to meet this standard, such as patients with psychosis, delirium, dementia, moderate to severe mental retardation, anxiety, depression, and mania, and therefore would not be found to have decision-making capacity ( Table 1).…”

Section: The Four Standards Of Capacitymentioning

confidence: 99%

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Challenges of the Capacity Evaluation for the Consultation-Liaison Psychiatrist

White

Lofwall

2015

Journal of Psychiatric Practice

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Assessing medical decision-making capacity is a clinical skill required of all medical professionals, but it is particularly essential for consultation- liaison psychiatrists. Medical decision-making capacity, often confused with competency, is evaluated by assessing 4 standards, which include whether a patient (1) can understand his or her medical situation, (2) can manipulate the information, (3) can evidence a choice about the proposed treatment, and (4) can appreciate the situation and its consequences. Multiple myths and pitfalls may be encountered during capacity evaluations; many of these can be avoided by proper education and training. We discuss the case of a 71-year-old man who presented to the emergency department by ambulance and was refusing non-emergent neurosurgery after a self-inflicted gunshot wound to the head. He was evaluated for medical decision-making capacity, specifically on whether he had the capacity to refuse neurosurgery and accept intravenous antibiotic treatment. In discussing this case, which illustrates the elements, challenges, and ethical dilemmas of the capacity evaluation, we review several mental illnesses that may prevent individuals from having medical decision-making capacity. Myths and pitfalls of capacity evaluations and possible methods for avoiding them are proposed. Specifically, we emphasize the importance of communication between the primary team and the consultationliaison psychiatry service and describe possible solutions to common communication problems that may arise between services. It is hoped that this case presentation and review will help educate psychiatry residents and other physicians so that they are well prepared to perform a medical decision-making capacity evaluation.

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“…Thus an assessment of subjects’ decisional capacity may be required prior to completing the informed consent process. A review of the literature surrounding consent of older adults with cognitive limitations suggests using instruments such as, the Mini-Mental Status Exam (MMSE) or the MacArthur Competence Assessment tool for Clinical Research to determine the decisional capacity of an older adult with mild to moderate cognitive impairment (Black et al, 2008; Jefferson et al, 2008; Kahn, Bourgeois, Klein, & Iosif, 2009; Rubright et al, 2010). Furthermore, adding a clinical assessment component can improve prediction of decisional capacity among adults with cognitive disorders (Kahn et al, 2009).…”

Section: Methodological Issuesmentioning

confidence: 99%

Methodological Challenges in Physical Activity Research With Older Adults

Chase

2011

West J Nurs Res

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The aging adult population is growing, as well as the incidence of chronic illness among older adults. Physical activity has been demonstrated in the literature to be a beneficial component of self-management for chronic illnesses commonly found in the older adult population. Health sciences research seeks to develop new knowledge, practices, and policies that may benefit older adults’ management of chronic illness and quality of life. However, research with the older adult population, though beneficial, includes potential methodological challenges specific to this age group. This article discusses common methodological issues in research among older adults, with a focus on physical activity intervention studies. Awareness and understanding of these issues may facilitate future development of research studies devoted to the aging adult population, through appropriate modification and tailoring of sampling techniques, intervention development, and data measures and collection.

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A Prospective Observational Study of Decisional Capacity Determinations in an Academic Medical Center

Cited by 20 publications

References 14 publications

Poor adherence to the mental capacity act and premature death

Poor adherence to the mental capacity act and premature death

Challenges of the Capacity Evaluation for the Consultation-Liaison Psychiatrist

Methodological Challenges in Physical Activity Research With Older Adults

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