scholarly journals Substituted Decision Making and Coercion: The Socially Accepted Problem in Psychiatric Practice and a CRPD-Based Response to Them

2021 ◽  
pp. 4-12
Author(s):  
Giles Newton-Howes ◽  
Leah Kininmonth ◽  
Sarah Gordon
Keyword(s):  
Decision Making ◽  
Models Of Care ◽  
Model Of Care ◽  
Persons With Disabilities ◽  
Decision Making Capacity ◽  
Mental Health Settings ◽  
Psychosocial Disability ◽  
Informal Coercion ◽  
International Conventions ◽  
Reasons For Use

Psychiatry has a long tradition of enforcing ‘care’ within mental health settings, through formal and informal coercion, often with little regard to decision-making capacity. Despite scant evidence for the effectiveness of coercive interventions and the wide variation in their application, indicating structural as opposed to health-driven reasons for use, coercive practices continue to be routinely used internationally. This is notwithstanding the recovery model of care that is endorsed on a national public policy level in many countries. Further, the Convention on the Rights of Persons with Disabilities (CRPD) and its Committee make plain that the use of practices of coercion for those who experience disability, including people who experience psychosocial disability, are unacceptable and in breach of their and other international conventions. The CRPD is interpreted as demanding an end to coercion, primarily through substitute decision-making being replaced with supported decision-making. This critical analysis examines the development of coercive practices in psychiatry, how they have become embedded as both common and socially acceptable, and approaches that may help to reduce their use in light of the CRPD. Models of care where changes have been successful in reducing substitute decision-making and promoting supported decision-making are highlighted to challenge some of the inertia to change.

Psychiatry of the elderly

2021 ◽  
pp. 499-528
Author(s):  
Catherine Oppenheimer ◽  
Julian C. Hughes
Keyword(s):  
Decision Making ◽  
Old Age ◽  
Ethical Issues ◽  
The Elderly ◽  
Predictive Diagnosis ◽  
Truth Telling ◽  
Persons With Disabilities ◽  
Decision Making Capacity ◽  
The Face ◽  
Mental Capacity Act

This chapter describes the ethical issues that arise in the setting of mental illness, and particularly dementia, in old age. It affirms the importance of understanding each older person as an individual, embedded in a unique history and in relationships which sustain their identity even in the face of cognitive decline. Autonomy and paternalism are discussed, and the alternative concept of ‘parentalism’ introduced. Decision-making capacity and competence are extensively analysed from both philosophical and practical viewpoints, with particular reference to the Mental Capacity Act 2005, and to mechanisms for decision-making for noncompetent patients. Topics briefly treated include predictive diagnosis and mild cognitive impairment, end-of-life care, truth telling, sexuality, and the UN Convention on the Rights of Persons with Disabilities. The text is aimed at old age psychiatrists and other practitioners in the field, as well as at those with an interest in ethical issues in old age.

‘Mental disorder’ and public protection

2017 ◽  
Author(s):  
George Szmukler
Keyword(s):  
Decision Making ◽  
Mental Illness ◽  
Mental Disorder ◽  
Treatment Decision ◽  
Persons With Disabilities ◽  
The Public ◽  
Treatment Decision Making ◽  
Decision Making Capacity ◽  
United Nations Convention ◽  
Current Systems

The implications of a Fusion Law for the management and treatment of people with impairments or disturbances in the functioning of mind who have committed offences is examined in this chapter. Concerns about public protection under a Fusion Law have been raised, particularly in relation to serious offences. Fusion Law principles can be applied with fair procedures regarding sentencing and hospitalization for those with a mental illness. The public can be protected on the same basis as for those without a mental illness. Options for extended sentences exist in many countries, equally applicable to all persons. ‘Unfitness to plead’ and ‘not guilty by reason of insanity’ present, under current systems, a problem when a person now has treatment decision-making capacity but is deemed a risk. The implications of the Fusion Law for the treatment of ‘psychopathy’ and the addictions are examined. The United Nations Convention on the Rights of Persons with Disabilities poses dilemmas for which solutions are uncertain.

Evidence or Clinicians or the Person

2016 ◽  
Vol 30 (1) ◽  
pp. 17-20 ◽  
Author(s):  
Kristine L. Florczak
Keyword(s):  
Decision Making ◽  
Evidence Based Practice ◽  
Models Of Care ◽  
Evidence Based ◽  
Healthcare Decision ◽  
Model Of Care ◽  
Healthcare Decision Making ◽  
Proposed Model ◽  
Practice Models

In this column, the issue of who should drive healthcare decision-making will be considered. To that end, evidence-based practice and evidence-informed practice models of care will be discussed. Problems with the use of each of these models will be brought to light followed by a presentation of a proposed model of care that puts the person at the center of healthcare decision- making.

Community psychiatry

2021 ◽  
pp. 555-580
Author(s):  
George Szmukler
Keyword(s):  
Community Psychiatry ◽  
Ethical Dilemmas ◽  
Models Of Care ◽  
Community Treatment ◽  
Ethical Challenges ◽  
Persons With Disabilities ◽  
Crisis Plans ◽  
Decision Making Capacity ◽  
The Social ◽  
Harm To Others

Ethical dilemmas in community psychiatry are not novel, but they present in sufficiently different guises to warrant reconsideration in a new context. The models of care and the social climate in which they have developed are reviewed, as well as the key ethical challenges that have emerged. These include concerns about privacy, confidentiality, coercive practices (the range of treatment pressures, ‘involuntary outpatient commitment’ or ‘community treatment orders’), and conflicts of duty to the patient versus others. Approaches to dealing with these issues are presented. These include increasing patients’ involvement in their care (e.g., ‘crisis cards’, ‘joint crisis plans’, and advance directives), clarifying grounds for coercive interventions in the health interests of the patient (e.g., a decision-making-capacity-based approach, the influence of the UN Convention on the Rights of Persons with Disabilities), and considerations concerning the risk of harm to others, including duties to carers.

scholarly journals Can the World Health Organisation’s ‘QualityRights’ initiative help reduce coercive practices in psychiatry in Ireland?

2020 ◽  
pp. 1-4
Author(s):  
R. M. Duffy ◽  
B. D. Kelly
Keyword(s):  
Decision Making ◽  
Paradigm Shift ◽  
Training Programme ◽  
World Health ◽  
Legal Capacity ◽  
Persons With Disabilities ◽  
Decision Making Capacity ◽  
The World ◽  
Advance Planning ◽  
The Right

The treatment of mental illness is undergoing a paradigm shift, moving away from involuntary treatments towards rights-based, patient-centred care. However, rates of seclusion and restraint in Ireland are on the rise. The World Health Organisation’s QualityRights initiative aims to remove coercion from the practice of mental health care, in order to concord with the Convention on the Rights of Persons with Disabilities. The QualityRights initiative has recently published a training programme, with eight modules designed to be delivered as workshops. Conducting these workshops may reduce coercive practices, and four of the modules may be of particular relevance for Ireland. The ‘Supported decision-making and advance planning’ and the ‘Legal capacity and the right to decide’ modules highlight the need to implement the Assisted Decision-Making (Capacity) Act, 2015, while the ‘Freedom from coercion, violence and abuse’ and ‘Strategies to end seclusion and restraint’ modules describe practical alternatives to some current involuntary treatments.

scholarly journals Decision-making capacity and the Victorian Mental Health Tribunal

2018 ◽  
Vol 2017 (24) ◽  
pp. 87
Author(s):  
Christopher Maylea ◽  
Christopher James Ryan
Keyword(s):  
Mental Health ◽  
Decision Making ◽  
Mentally Ill ◽  
Empirical Studies ◽  
Relevant Information ◽  
Involuntary Treatment ◽  
Persons With Disabilities ◽  
Decision Making Capacity ◽  
Mental Health Legislation ◽  
Health Legislation

<p>The United Nations Convention on the Rights of Persons with Disabilities (CRPD) has led to a re-thinking of traditional mental health law around the world. Since Australia’s ratification of the CRPD, all but one of its eight jurisdictions have introduced reforms to mental health legislation. These are aimed, in part, towards compliance with the Conventions articles. This paper examines the meaning and operation of the reforms introduced in Australia’s second most populous state – Victoria.</p><p><br />We first describe the criteria for involuntary treatment set out in the new <em>Mental Health Act 2014</em> (Vic) (Austl.) (the Act). We then argue that when making an order for Involuntary Treatment, the Victorian Mental Health Tribunal (the Tribunal) is obliged to carefully consider a person’s decision-making capacity as part of ensuring that treatment is provided in the least restrictive way, and to only authorise the involuntary treatment over a person’s competent objection in very limited circumstances.</p><p><br />Having established the way in which the Act <em>should</em> operate, we then present two empirical studies which analyse the decisions of the Statements of Reasons of the Tribunal to gain some appreciation of how the Act is working. These indicate that seldom does the Tribunal consider the decision-making capacity of people brought before it, and that, even when this is considered, the relevant information is not being used protectively so as to uphold a right to competently refuse treatment. Instead, the Tribunal uses the presence or absence of decision-making capacity, insight or poor judgement, to determine if a person is mentally ill or if treatment is required to prevent serious harm. We conclude that the Tribunal’s practice is inconsistent with the principles of the Act and consequently the intention of Parliament.</p>

Theorising and Critiquing ‘Best Interests’: A Systematic Review

2021 ◽  
Vol 66 (Special Issue) ◽  
pp. 36-36
Author(s):  
Giles Birchley ◽  
◽  
Keyword(s):  
Systematic Review ◽  
Decision Making ◽  
English Language ◽  
Best Interests ◽  
Medical Decision ◽  
Early 19Th Century ◽  
Persons With Disabilities ◽  
The United Kingdom ◽  
Decision Making Capacity ◽  
Best Interests Standard

"The ‘best interests’ standard is a key part of international law and bioethics, governing the medical treatment of children and adults who lack decision-making capacity. While the concept is used in various circumstances, ‘best interests’ has a long association with medical decision-making, appearing in English language medical journals from at least the early-19th century. Despite its history, the concept of ‘best interests’ has been fiercely criticised within bioethics and law. Critics argue that ‘best interests’ is vague and lacks specificity, and because of this, is an unchallengeable repository of medical power, and an affront to patient autonomy or parental rights. These critiques have fuelled recent calls to replace or radically reform the ‘best interests’ standard from international bodies (the Committee on the Rights of Persons with Disabilities), and national campaign groups (the Charlie Gard Foundation in the United Kingdom). This paper, undertaken as part the BABEL Wellcome Trust Collaborative Award, presents a systematic review of fifty-three theoretically rich analyses of best interests from the 1970s to the present. The discussions consider best interests primarily in clinical situations, such as withdrawal of treatment, dementia, organ donation and circumcision. They reveal a range of theories that underlie best interests including objectivism, paternalism, patient rights, pragmatism and utilitarianism. We discuss what this multiplicity of theoretical bases can reveal about the coherence of current critiques as well as the fundamental structure, and prospects of survival, of the ‘best interests’ standard. "

Issues of Capacity and Decision-Making in the Context of Delirium

2015 ◽  
Vol 24 (4) ◽  
pp. 140-145
Author(s):  
Kevin R. Patterson
Keyword(s):  
Decision Making ◽  
Patient Autonomy ◽  
Care Setting ◽  
Cognitive Change ◽  
Treatment Team ◽  
Precipitating Factors ◽  
Term Care ◽  
Decision Making Capacity ◽  
Fundamental Consideration

Decision-making capacity is a fundamental consideration in working with patients in a clinical setting. One of the most common conditions affecting decision-making capacity in patients in the inpatient or long-term care setting is a form of acute, transient cognitive change known as delirium. A thorough understanding of delirium — how it can present, its predisposing and precipitating factors, and how it can be managed — will improve a speech-language pathologist's (SLPs) ability to make treatment recommendations, and to advise the treatment team on issues related to communication and patient autonomy.

scholarly journals Taking advantage of Covid-19 to improve hospital models of care: are we moving in the right direction?

2021 ◽  
pp. 1-7
Author(s):  
Raffaella Gualandi ◽  
Anna De Benedictis
Keyword(s):  
Hospital Management ◽  
Models Of Care ◽  
Patient Needs ◽  
Model Of Care ◽  
Letter To The Editor ◽  
Rapid Changes ◽  
Improve Hospital ◽  
The Right ◽  
Shed Light

Abstract In this letter to the Editor, we shed light on the rapid changes the Covid-19 virus has generated in hospital management. Recent experiences in the field aim to reorganizing hospital processes and policies. In this new scenario, new patient needs emerge, and a change in the hospital model of care should include them.

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