Clinical assessment of decision-making capacity in acquired brain injury with personality change

Abstract

Assessment of decision-making capacity (DMC) can be difficult in acquired brain injury (ABI) particularly with the syndrome of organic personality disorder (OPD) (the “frontal lobe syndrome”). Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of deficit and thinking about psychological states can be present. However, the awareness of deficit may not be “online” and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: (1) necessary for DMC, (2) threatened by ABI , and (3) assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined.

The Mental Capacity Act: 10 years on – the key learning areas for healthcare professionals

“…However, it is suggested that these findings are transferrable on a wider global scale where the assessment of mental capacity takes place. As has been seen in this piece of work, example studies from America and Australia have echoed some of the findings of UK-based studies, [13][14][15][16][17]24 confirming that assessing a person's mental ability to make a decision about their care can sometimes be a complex task.…”

“…13 Conversely, it is appreciated that the assessment of mental capacity with a person whose lucidity and understanding can be changeable can be a difficult task in itself. 17 Furthermore, impulsive behavior may be misconstrued as a lack of understanding, which also may not be the case. These findings are supported by Emmett et al 16 who found that mental capacity assessments could be outcome driven, rather than based on a person supported to make a personal decision.…”

Traumatic Brain Injury with Personality Change: a Challenge to Mental Capacity Law in England and Wales

“…In a number of recent works, Gareth Owen and colleagues explore what might be amiss in cases of brain-injured people who are susceptible to making impulsive decisions (Owen et al 2015, Owen et al 2018a. From their observations of patients with acquired brain injury, the authors identify three abilities that they take to be involved in being able to use and weigh information relevant to the decision at hand.…”

Manic temporality

“…We employed the technique of “second-person phenomenology” on which we have reported in earlier work (Owen, Freyenhagen, Hotopf, & Martin, 2015; Owen, Freyenhagen, & Martin, 2018; Owen, Freyenhagen, Martin, & David, 2017). We approached the research participants as collaborators, and as informants as to the character of their own manic experience.…”