Emergencies, general medicine, ‘community treatment orders’, and ‘psychiatric advance statements’

2017 ◽  
Author(s):  
George Szmukler
Keyword(s):  
Decision Making ◽  
Psychiatric Treatment ◽  
Good Practice ◽  
General Medicine ◽  
Mental Illnesses ◽  
Community Treatment ◽  
Best Interests ◽  
Important Place ◽  
Decision Making Capacity ◽  
Advance Statements

The implications of the Fusion Law for general medicine, especially inpatient care when non-consensual and involuntary treatment is being considered, are examined in this chapter. The new burdens posed by regulation can be minimized by making requirements essentially parallel ‘good practice’. Involuntary psychiatric treatment in the community under the ‘decision-making capability–best interests (will and preferences)’ principles of the Fusion Law would be substantially different from the way it is commonly instituted today. The Fusion Law offers an important place for ‘advance statements’ and ‘advance directives’, supporting respect for a patient’s beliefs and values (or ‘will and preferences’). Illnesses that impair decision-making capacity, but that are relapsing-remitting—such as the majority of mental illnesses—are good candidates for such advance planning, yet such measures have rarely been employed to date.

scholarly journals Do Community Treatment Orders in Psychiatry Stand Up to Principalism: Considerations Reflected through the Prism of the Convention on the Rights of Persons with Disabilities

2019 ◽  
Vol 47 (1) ◽  
pp. 126-133 ◽  
Author(s):  
Giles Newton-Howes
Keyword(s):  
Decision Making ◽  
Psychiatric Treatment ◽  
Community Treatment ◽  
Psychiatric Practice ◽  
Individual Autonomy ◽  
Ethical Considerations ◽  
Community Treatment Orders ◽  
Persons With Disabilities ◽  
Medical Interventions ◽  
Modern Context

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.

Is childhood a disability? Using Mental Capacity Tribunals and the Deprivation of Liberty Safeguards to shield children's capacity to consent to and refuse medical treatment

2014 ◽  
Vol 19 (2) ◽  
pp. 96-106 ◽  
Author(s):  
Robin Mackenzie ◽  
John Watts
Keyword(s):  
Mental Health ◽  
Decision Making ◽  
Medical Treatment ◽  
Mental Health Treatment ◽  
Mental Capacity ◽  
Best Interests ◽  
Legal Analysis ◽  
Content Type ◽  
Decision Making Capacity ◽  
The Law

Purpose – The purpose of this paper is to demonstrate that the common and statutory law governing children's capacity or competence to consent to and to refuse medical treatment is unsatisfactory and to suggest solutions. Design/methodology/approach – Critical legal analysis of the law on assessing minors’ decision-making capacity in relation to legal recognition of their consent to and refusal of medical treatment. Findings – Without legal mechanisms which protect both children and their rights, all children and young people are effectively disabled from exercising age and capacity-related autonomy and participation in decisions affecting their lives. Yet in English law, inconsistencies between legal and clinical measures of decision-making capacity, situations where compulsory medical or mental health treatment is lawful, and tensions between rights and duties associated with human rights, autonomy, best interests and protections for the vulnerable create difficulties for clinicians, lawyers and patients. Research limitations/implications – As the paper acknowledges in its recommendations, the views of stakeholders are needed to enrich and inform legal reforms in this area. Originality/value – The paper makes suggestions to amend the law and clinical practice which are original and far reaching. The paper suggests that in order to observe children's rights while protecting them appropriately, the Mental Capacity Act 2005 and Deprivations of Liberty Safeguards should be applied to minors. The paper recommends the establishment of Mental Capacity Tribunals, similar in nature and purpose to Mental Health Tribunals, to provide legal safeguards and mechanisms to foster the supported decision-making envisaged in recent United Nations Conventions.

The early experience of Old Age Psychiatrists in the application of the Mental Capacity Act 2005: a pilot study

2009 ◽  
Vol 22 (1) ◽  
pp. 147-157 ◽  
Author(s):  
Ajit Shah ◽  
Natalie Banner ◽  
Chris Heginbotham ◽  
Bill Fulford
Keyword(s):  
Decision Making ◽  
Old Age ◽  
Social Care ◽  
Mental Capacity ◽  
Best Interests ◽  
Decision Making Capacity ◽  
Mental Capacity Act 2005 ◽  
Old Age Psychiatry ◽  
Mental Capacity Act

ABSTRACTBackground: The Mental Capacity Act 2005 (MCA) was fully implemented in October 2007 in England and Wales.Methods: A pilot questionnaire study examined the experience of consultants in Old Age Psychiatry in the early implementation of the MCA pertaining to local policy and training in the application of the MCA, the assessment of decision-making capacity, the determination of best interests, and the use of the least restrictive option and restraint.Results: Fifty-two (27%) of the 196 consultants in Old Age Psychiatry returned useable questionnaires. Seventy-five percent of them reported that local training on the application of the MCA was available, but less than 50% reported that training was mandatory. The vast majority of assessments of decision-making capacity were conducted by consultants in Old Age Psychiatry. Almost all of them reported using the four-fold specific test of decision-making capacity (DMC) described in the MCA. Restraint was reported to be rarely used.Conclusions: Consultants in Old Age Psychiatry generally reported using the criteria for the assessment of DMC, the determination of best interests and restraint described in the MCA. The findings highlight concern about the workload of clinicians in implementing the MCA and this requires careful monitoring. Consideration should be given to statutory provision of training in the application of the MCA by all healthcare and social care providers for all their healthcare and social care staff.

scholarly journals This Wasn’t a Split-Second Decision”: An Empirical Ethical Analysis of Transgender Youth Capacity, Rights, and Authority to Consent to Hormone Therapy

2021 ◽  
Author(s):  
Beth A. Clark ◽  
Alice Virani
Keyword(s):  
Decision Making ◽  
Hormone Therapy ◽  
Qualitative Content Analysis ◽  
Healthcare Providers ◽  
Best Interests ◽  
Legal Authority ◽  
Capacity To Consent ◽  
Decision Making Capacity ◽  
The Right ◽  
Trans Youth

AbstractInherent in providing healthcare for youth lie tensions among best interests, decision-making capacity, rights, and legal authority. Transgender (trans) youth experience barriers to needed gender-affirming care, often rooted in ethical and legal issues, such as healthcare provider concerns regarding youth capacity and rights to consent to hormone therapy. Even when decision-making capacity is present, youth may lack the legal authority to give consent. The aims of this paper are therefore to provide an empirical analysis of minor trans youth capacity to consent to hormone therapy and to address the normative question of whether there is ethical justification for granting trans youth the authority to consent to this care. Through qualitative content analysis of interviews with trans youth, parents, and healthcare providers, we found that trans youth demonstrated the understandings and abilities characteristic of the capacity to consent to hormone therapy and that they did consent to hormone therapy with positive outcomes. Employing deontological and consequentialist reasoning and drawing on a foundation of empirical evidence, human rights, and best interests we conclude that granting trans youth with decisional capacity both the right and the legal authority to consent to hormone therapy via the informed consent model of care is ethically justified.

Advance Care Planning and Surrogate Decision-Making (DRAFT)

2018 ◽  
Author(s):  
Robert C. Macauley
Keyword(s):  
Decision Making ◽  
Decision Maker ◽  
Patient Autonomy ◽  
Best Interests ◽  
Evidence Based ◽  
Surrogate Decision Maker ◽  
Substituted Judgment ◽  
Decision Making Capacity ◽  
Advance Care ◽  
Surrogate Decision

Adult patients are presumed to possess decision-making capacity, but when they are unable to make their own decisions—which is especially frequent in the context of serious illness—ideally a surrogate decision-maker will be able to determine what the patient would have wanted (i.e., substituted judgment). Only when this is not possible is it necessary to fall back on what seems to be in the patient’s best interests. To foster patient autonomy, goals and values should be identified and documented in advance, such as in an advance directive, as well as a surrogate decision-maker named. This helps guide the medical team in critical and often uncertain times, given the challenges in accurate prognostication (which are lessening with the advent of evidence-based tools).

The Best Interests Standard for Incompetent or Incapacitated Persons of All Ages

2007 ◽  
Vol 35 (1) ◽  
pp. 187-196 ◽  
Author(s):  
Loretta M. Kopelman
Keyword(s):  
Decision Making ◽  
Decision Makers ◽  
Best Interests ◽  
Medical Decisions ◽  
Comfort Care ◽  
Aging Society ◽  
American Academy Of Pediatrics ◽  
Decision Making Capacity ◽  
Baby Doe ◽  
Best Interests Standard

When making decisions for adults lacking decision-making capacity and having no discernable preferences, widespread support exists for using the Best Interests Standard. For example, the President's Council on Bioethics supports this view in its publication, Taking Care: Ethical Caregiving in Our Aging Society. The President's Council maintains that decision-makers should seek the best available care for incapacitated adults, yet clarifies the best care does not always extend biological life for the longest time and advocates careful attention to comfort care and pain control. Their recommendations for making medical decisions for incapacitated adults match guidelines by American Academy of Pediatrics (AAP) committees and by the U.K’.s Nuffield Council on Bioethics report for making medical decisions for children and infants.For reasons of consistency, fairness, and compassion, this guidance should be applied to all people lacking decision-making capacity. Uniform guidelines, however, would be incompatible with a policy for infants based on the Child Abuse Prevention and Treatment Act (CAPTA) amendments, widely known as the “Baby Doe” Rules.

Involuntary hospitalization

2021 ◽  
pp. 279-298
Author(s):  
Christopher James Ryan ◽  
Jane Bartels
Keyword(s):  
Decision Making ◽  
Mental Illness ◽  
Clinical Features ◽  
Real World ◽  
Inpatient Treatment ◽  
Psychiatric Treatment ◽  
Ethical Question ◽  
Involuntary Treatment ◽  
Involuntary Hospitalization ◽  
Decision Making Capacity

The chapter outlines a series of arguments designed to answer possibly the most important ethical question in psychiatry: under what circumstances, if any, is it ethically justifiable to treat people with clinical features of mental illness, despite their objection? We argue that involuntary inpatient treatment is ethically justified, but only in circumstances where: the objection to treatment was made without decision-making capacity; there is no reason to believe that the person would have objected had he or she been competent; the treatment will protect the person from serious harms (when balancing these with any harms associated with the treatment); and involuntary treatment represents the avenue for protection least restrictive of the person’s freedom. Having established a model for ethically justified involuntary inpatient psychiatric treatment, we examine how it can be applied to two real-world cases.

scholarly journals Capacity issues at the front door

2019 ◽  
Vol 80 (9) ◽  
pp. 513-516
Author(s):  
Peter Lepping
Keyword(s):  
Decision Making ◽  
Cognitive Impairment ◽  
Decision Maker ◽  
Acute Infection ◽  
Mental Capacity ◽  
Best Interests ◽  
Decision Making Capacity ◽  
Mental Capacity Act 2005 ◽  
Mental Capacity Act ◽  
Psychiatric Problems

Decision-making capacity is often overestimated by clinicians. An average of one third of patients lack capacity to make complex decisions and clinicians should be alert to such a possibility. Cognitive impairment, acute infection, intoxication and other common medical and psychiatric problems can impair patients' capacity. The Mental Capacity Act 2005 has to be applied when treating patients who lack capacity. The main decision maker for a proposed treatment or investigation is responsible for assessing capacity. However, all clinicians have to consider and assess capacity, and act in a patient's best interests if he/she lacks capacity.

scholarly journals Determining medical decision-making capacity in brain tumor patients: why and how?

2020 ◽  
Vol 7 (6) ◽  
pp. 599-612 ◽  
Author(s):  
Andrea Pace ◽  
Johan A F Koekkoek ◽  
Martin J van den Bent ◽  
Helen J Bulbeck ◽  
Jane Fleming ◽  
...  
Keyword(s):  
Decision Making ◽  
Brain Tumor ◽  
Medical Decision Making ◽  
Clinical Decision Making ◽  
Best Interests ◽  
Medical Decision ◽  
Surrogate Decision Making ◽  
Tumor Patients ◽  
Decision Making Capacity ◽  
Surrogate Decision

Abstract Background Brain tumor patients are at high risk of impaired medical decision-making capacity (MDC), which can be ethically challenging because it limits their ability to give informed consent to medical treatments or participation in research. The European Association of Neuro-Oncology Palliative Care Multidisciplinary Task Force performed a systematic review to identify relevant evidence with respect to MDC that could be used to give recommendations on how to cope with reduced MDC in brain tumor patients. Methods A literature search in several electronic databases was conducted up to September 2019, including studies with brain tumor and other neurological patients. Information related to the following topics was extracted: tools to measure MDC, consent to treatment or research, predictive patient- and treatment-related factors, surrogate decision making, and interventions to improve MDC. Results A total of 138 articles were deemed eligible. Several structured capacity-assessment instruments are available to aid clinical decision making. These instruments revealed a high incidence of impaired MDC both in brain tumors and other neurological diseases for treatment- and research-related decisions. Incapacity appeared to be mostly determined by the level of cognitive impairment. Surrogate decision making should be considered in case a patient lacks capacity, ensuring that the patient’s “best interests” and wishes are guaranteed. Several methods are available that may help to enhance patients’ consent capacity. Conclusions Clinical recommendations on how to detect and manage reduced MDC in brain tumor patients were formulated, reflecting among others the timing of MDC assessments, methods to enhance patients’ consent capacity, and alternative procedures, including surrogate consent.

scholarly journals Providing treatment to prisoners with mental disorders: development of a policy

2003 ◽  
Vol 182 (4) ◽  
pp. 299-302 ◽  
Author(s):  
Mark Earthrowl ◽  
John O'Grady ◽  
Luke Birmingham
Keyword(s):  
Decision Making ◽  
Mental Disorders ◽  
Psychiatric Hospitals ◽  
Treatment Decision ◽  
Case Law ◽  
Care Staff ◽  
Best Interests ◽  
Health Care Staff ◽  
Ethical Implications ◽  
Decision Making Capacity

BackgroundMental disorder is more prevalent among people in prison than in the general population. Prisoners who require transfer to psychiatric hospitals for treatment face long delays. Doctors working in prisons regularly face ethical and legal dilemmas posed by prisoners with mental illness.AimsTo develop a policy for providing treatment under the common law to prisoners with mental disorders who lack treatment decision-making capacity while arrangements are made to transfer them to hospital.MethodThe policy was developed through literature review and consultation with the Faculty of Law at Southampton University and health care staff at Winchester prison in the UK.ResultsThe policy provides guidelines for establishing decision-making capacity standards for documentation, and guidelines for implementation based on the Mental Health Act Code of Practice, other best-practice guidelines and case law.ConclusionsIt can be argued that case law allows more-extensive treatment to be provided in the best interests of the incompetent prisoner, beyond emergency situations. The policy has ethical implications and its use should be carefully monitored.

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