scholarly journals Perceived Burdensomeness and the Wish for Hastened Death in Persons With Severe and Persistent Mental Illness

2021 ◽  
Vol 11 ◽  
Author(s):  
Julia Stoll ◽  
Christopher James Ryan ◽  
Manuel Trachsel
Keyword(s):  
Decision Making ◽  
Mental Illness ◽  
Worth Living ◽  
Perceived Burdensomeness ◽  
Medical Assistance In Dying ◽  
Persistent Mental Illness ◽  
Decision Making Capacity ◽  
Capacity Uncertainty ◽  
Hastened Death ◽  
The Individual

Background: In several European countries, medical assistance in dying (MAID) is no longer confined to persons with a terminal prognosis but is also available to those suffering from persistent and unbearable mental illness. To date, scholarly discourse on MAID in this population has been dominated by issues such as decision-making capacity, uncertainty as to when a disease is incurable, stigmatization, isolation, and loneliness. However, the issue of perceived burdensomeness has received little attention.Objective: The study explores the possible impact of perceived burdensomeness on requests for MAID among persons with severe and persistent mental illness (SPMI).Method: Using the method of ethical argumentation, we discuss the issue of access to MAID for persons with SPMI and perceived burdensomeness.Conclusion: Perceived burdensomeness may be a contributing factor in the wish for hastened death among persons with SPMI. MAID is ethically unsupportable if SPMI causes the individual to make an unrealistic assessment of burdensomeness, indicating a lack of decision-making capacity in the context of that request. However, the possibility that some individuals with SPMI may perceive burdensomeness does not mean that they should be routinely excluded from MAID. For SPMI patients with intact decision-making capacity who feel their life is not worth living, perceived burdensomeness as a component of this intolerable suffering is not a sufficient reason to deny access to MAID.

scholarly journals Compulsory Interventions in Severe and Persistent Mental Illness: A Survey on Attitudes Among Psychiatrists in Switzerland

2021 ◽  
Vol 12 ◽  
Author(s):  
Julia Stoll ◽  
Martina A. Hodel ◽  
Florian Riese ◽  
Scott A. Irwin ◽  
Paul Hoff ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Decision Making ◽  
Mental Illness ◽  
Anorexia Nervosa ◽  
Cross Sectional Survey ◽  
Persistent Mental Illness ◽  
Decision Making Capacity ◽  
Case Vignettes ◽  
Persistent Depression

Background: Some psychiatric patients develop severe and persistent mental illness (SPMI), which, for a variety of reasons, can be therapy-refractory. Sometimes, treatment is not considered helpful by the patients themselves and does not improve their subjective quality of life. Furthermore, many SPMI patients experience compulsory interventions such as seclusion, restraint, or treatment against their will, which can cause harm.Methods: In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about the care of SPMI patients in general, and about their attitudes with regard to compulsory interventions in particular, using three case vignettes of patients with severe and persistent anorexia nervosa, schizophrenia and depression.Results: Out of 1,311 contacted psychiatrists, 457 (34.9%) returned the completed survey. In general, 91.0% found it important or very important to respect SPMI patients' autonomy in decision making. However, based on three different clinical case vignettes, 36.8% of psychiatrists would act against the wishes of the patient with severe and persistent schizophrenia, 34.1% against the wishes of the patient with severe and persistent depression, and 21.1% against the wishes of the patient with severe and persistent anorexia nervosa, although all patients were stated to have preserved decision-making capacity. With regard to the case vignettes, 41.1% considered compulsory interventions leading to a temporary reduction of quality of life acceptable in the patient with severe and persistent schizophrenia, 39.4% in the patient with severe and persistent depression, and 25.6% in the patient with severe and persistent anorexia nervosa, although it was stated in all three case vignettes that two independent experts ascribed the patients decision-making capacity regarding their illness and further treatment.Conclusions: Many psychiatrists in our sample found themselves in an ethical dilemma between autonomy and the provision of medical care. While most respondents respect the autonomy of SPMI patients, many saw the need to perform compulsory interventions even though it was clearly and prominently stated that two independent psychiatrists had ascribed the patients in the case vignettes decision-making capacity. Further examination of these conflicting views is warranted, perhaps along with the development of guidelines for such situations.

The capacity to designate a surrogate is distinct from decisional capacity: normative and empirical considerations

2021 ◽  
pp. medethics-2020-107078
Author(s):  
Mark Navin ◽  
Jason Adam Wasserman ◽  
Devan Stahl ◽  
Tom Tomlinson
Keyword(s):  
Decision Making ◽  
Mental Illness ◽  
Medical Decision Making ◽  
Medical Decision ◽  
Decisional Capacity ◽  
Risks And Benefits ◽  
Relative Risks ◽  
Decision Making Capacity ◽  
Cognitive Diseases ◽  
Surrogate Selection

The capacity to designate a surrogate (CDS) is not simply another kind of medical decision-making capacity (DMC). A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients who lack DMC for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases (eg, Alzheimer’s disease). That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions.

scholarly journals Decision Making Capacity or How to Accept Patient’s Refusal for Orthodontic Treatment

2021 ◽  
Vol 2 (4) ◽  
pp. 1-5
Author(s):  
Yulia Bogdanova Peeva
Keyword(s):  
Decision Making ◽  
Case Report ◽  
Orthodontic Treatment ◽  
Treatment Options ◽  
Healthcare Providers ◽  
Treatment Protocol ◽  
Class Iii ◽  
Decision Making Capacity ◽  
Sharing Responsibility ◽  
The Individual

Introduction: Communication in dentistry is bilateral process which usually is based on response (understanding) by the person. That’s why the Oral Healthcare Providers (OHP) should be convinced the consent given by the patient is valid. It means that at the beginning of the treatment the orthodontist will ask a lot of questions and have expectations to receive appropriate answers. There is a specific lack of awareness about the first orthodontic consultation at 7y of age, occurrence and prevention of most of the common tooth jaw discrepancies which affect the oral health, self-confidence and overall development of the child. A variety of socio-demographic, educational, personal and other factors mostly divided into objective and subjective factors influences the perception of facial attractiveness. The orthodontic treatment lays down on the personal desire and attitudes, depends from the motivation but is not without a risk for the patient. The aim of the current research is to present the most objective and subjective factors identifying the patient’s refusal. Material and methods: It’s a case report based on preliminary discussion and orthodontic consultation over the cephalometric analysis and cast models. Orthodontic treatment protocol was followed and given informed consent by the individual was received. Results and discussions: An electronic search was conducted using the Medline database (PubMed), Science Direct, and Scopus. In this case report were described the treatment options for Class III malocclusion with an emphasis on maxillary protraction and existing impacted canine 13. The decision making capacity was evaluated and also what are the objective and subjective factors and how to proceed with patient refusal. Conclusions: Despite the orthodontist’s efforts to improve the management of the dental practice and to attract new patients, these challenges should never been from the first importance. Contemporary dentistry requires that the patient’s right to refuse should be respected and this refusal must be accepted. Because orthodontic treatment is expensive, the process of returning money or sharing responsibility for the treatment depend on the socio-cultural characteristics of both the patient and the doctor. The whole situation requires a very delicate approach, as it affects the image of the dental community in society at whole.

scholarly journals 458 - End-of-life decision-making capacity in an elderly patient with schizophrenia and terminal cancer

2020 ◽  
Vol 32 (S1) ◽  
pp. 179-179
Author(s):  
C Kotzé ◽  
JL Roos
Keyword(s):  
Decision Making ◽  
Mental Illness ◽  
End Of Life ◽  
Serious Mental Illness ◽  
End Of Life Care ◽  
Care Planning ◽  
Life Care ◽  
Decision Making Capacity ◽  
Advance Care ◽  
End Of Life Decision

Medical practitioners are confronted on a daily basis with decisions about patients’ capacity to consent to interventions. To address some of the pertinent issues with these assessments, the end -of-life decision-making capacity in a 72-year old lady with treatment resistant schizophrenia and terminal cancer will be discussed.In the case discussed there were differences in opinion about the patients decision-making capacity. In light of this, the role of the treating clinician and importance of health-related values in capacity assessment are highlighted. It is recommended that the focus of these assessments can rather be on practical outcomes, especially when capacity issues arise. This implies that the decision-making capacity of the patient is only practically important when the treatment team is willing to proceed against the patient’s wishes. This shifts the focus from a potentially difficult assessment to the simpler question of whether the patient’s capacity will change the treatment approach.Compared to the general population, people with serious mental illness have higher rates of physical illness and die at a younger age, but they do not commonly access palliative care services and are rarely engaged in end-of-life care discussions. Older people with serious mental illness can engage in advance care planning. Conversations about end -of-life care can occur without fear that a person’s psychiatric symptoms or related vulnerabilities will undermine the process. Clinicians are also advised to attend to any possible underlying issues, instead of focusing strictly on capacity. Routine documentation of end-of-life care preferences can support future decision making for family and clinicians at a time when patients are unable to express their decisions.More research about palliative care and advance care planning for people with serious mental illness is needed. This is even more urgent in light of the COVID-2019 pandemic, as there are potential needs for rationing of health care in the context of scarce resources. Health services should consider recommendations that advanced care planning should be routinely implemented. These recommendations should not only focus on the general population and should include patients with serious mental illness.

scholarly journals Ethics of Clinical Research Involving Adults with Impaired Decision-Making Capacity

2016 ◽  
Vol 7 (1) ◽  
pp. 17-26
Author(s):  
Tonmoy Biswas
Keyword(s):  
Decision Making ◽  
Informed Consent ◽  
Psychiatric Hospitals ◽  
Assessment System ◽  
Assessment Tools ◽  
Autonomous Agent ◽  
Extensive Literature ◽  
Decision Making Capacity ◽  
Four Levels ◽  
The Individual

Background: Proper decision making capacity, adequate disclosure and voluntary decisions are basic constituents of informed consent which is required in surgical procedures, any interventions, any tissue collection, or any research involving the human participants. But, it becomes more hectic if the participants or patients are physically or mentally impaired for proper understanding or rational decision making. Time has gone by assembling or regulating effective laws for research involving persons with impaired decision making capacity. Still, question arises, is it ethical to enroll an incompetent person who is not physically or mentally fit to make a decision in risky research or interventional trials? If it is, how the informed consent and ethical measures can be taken? Method: Extensive literature review was done in Google scholar, PubMed and national or institutional websites with the corresponding keywords to summarize the cases of impaired decision making and regulation of informed consent and ethical measures in those cases. Results: Decision making capacity requires three level of capacities and four levels of abilities. If a person has factual understanding, implies a certain level of rational belief, knows to manipulate information to arrive at a choice and remains stable on the choice, is known to be capacitated in decision making. Impaired decision making capacity is more common in Alzheimer’s disease and schizophrenia research. Although a definite line between decisional capacity and incapacity is still in question, many assessment tools are available to conclude it. Moreover, decisional incapacity has been found as a significant ratio in general or psychiatric hospitals and nursing homes regarding psychological disorders or critically ill conditions. But, these conditions should not prevent anyone from understanding, choosing, or accepting any intervention as sometimes they may have some preserved abilities too. As per accepted ethics, respect for persons incorporates at least two ethical convictions. First, the individual should be treated as an autonomous agent and second, the person with diminished autonomy is entitled to protection. That’s why, in case of severe psychiatric diseases and Alzheimer’s diseases, surrogate consent is recommended. But surrogacy should be reviewed by the institutional review board (IRB). Multimedia consent process, advanced consent directives, rational consent waiver and many other processes are practiced in case of ethical research involving decisional incapacitate persons which are discussed in the paper.  Conclusion: It should be clarified by the IRB whether involvement of impaired subjects has beneficial scientific aim or not. Capacity assessment system should be in an organized and systemic way. Threshold for capacity and recognition of persons able to conduct this process should be fixed. Role of surrogacy and involvement of IRB to align it in a proper manner is always a matter of concern. Consideration of risk management, subjects’ autonomy and assent-dissent issues should be clarified in research.

An Advance Request: The Accessibility of Medical Assistance in Dying (MAID) for Patients Who Loose Decision-Making Capacity

2021 ◽  
Vol 10 (2) ◽  
Author(s):  
Natasha Harris
Keyword(s):  
Decision Making ◽  
Assisted Suicide ◽  
Physician Assisted Suicide ◽  
Medical Assistance ◽  
Waiting Period ◽  
Medical Assistance In Dying ◽  
Decision Making Capacity

Since the legalization of Medical Assistance in Dying (MAID) in Canada in 2016, there have been discussions regarding the extension of this service to patients who lose decision-making capacity but have made a prior advance request for physician-assisted suicide. Both caregivers and physicians have shown some support for allowing patients to make advance requests for MAID. The proposed changes to the legislation would remove the mandatory 10 day waiting period and include a waiver of final consent for those who loose decision-making capacity following their MAID request.

‘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.

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