Decision-making capacity for treatment in psychiatric and medical in-patients: Cross-sectional, comparative study

Abstract

BackgroundIs the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients?AimsTo compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice.MethodA secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool - Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability.ResultsMost people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P = 0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better ‘test’ of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P = 0.02).ConclusionsAmong those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting.

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

“…The study integrated clinical and phenomenological approaches with standard techniques from qualitative interview research. Further details on the method are reported elsewhere (Owen et al, 2013). Essentially, a series of open-structured interviews was used in order to gain insight into the patient's experience of making decisions under conditions of neuropsychiatric disorder.…”

“…Reflecting the decision-specific nature of the concept, the international literature is increasingly using the term “decision-making capacity” (DMC) and we use this term here. Clinical-ethical research has started to clarify how DMC relates to the type of psychiatric or neurological disorder (Kim, 2010; Owen, Freyenhagen, Hotopf, & Martin, 2015; Owen et al, 2013; Tan, Hope, Widdershoven, McMillan, & van der Scheer, 2008). …”

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

“…Some individuals may be able to understand key information but lack insight and ability to appreciate that a psychiatric condition is present (Appelbaum 2007;Owen et al 2013). Other individuals may have unrecognized cognitive impairment that results in poor adherence or unwillingness to consider treatment.…”

Misevaluating the Future: Affective Disorder and Decision-Making Capacity for Treatment – A Temporal Understanding

“…This appreciation ability is helpful for assessing DMC for treatment in cases of psychosis where delusions may be impacting upon decision-making [9], although even in this context, potential problems surround the judgement that irrational beliefs, arising from a mental disorder, are underpinning refusal. In the case of affective disorders, however, where delusions may not be present, or overt, or where consent may be as controversial as refusal (e.g., electroconvulsive therapy), this operationalisation of appreciation is far more problematic and returns us to the problem of “outcome bias.” For even if appreciation helps us with the “cognitive bias” problem, how might it help avoid the difficulties of outcome-based assessments?…”