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M Silberfeld

Publications and source records attributed to M Silberfeld.

At least 19 recordsLinked to original sources
PubMed1999

Assessment of patient capacity to consent to treatment.

OBJECTIVE: To compare results of a specific capacity assessment administered by the treating clinician, and a Standardized Mini-Mental Status Examination (SMMSE), with the results of expert assessments of patient capacity to consent to treatment. DESIGN: Cross-sectional study with independent comparison to expert capacity assessments. SETTING: Inpatient medical wards at an academic secondary and tertiary referral hospital. PARTICIPANTS: One hundred consecutive inpatients facing a decision about a major medical treatment or an invasive medical procedure. Participants either were refusing treatment, or were accepting treatment but were not clearly capable according to the treating clinician. MEASUREMENTS AND MAIN RESULTS: The treating clinician (medical resident or student) conducted a specific capacity assessment on each participant, using a decisional aid called the Aid to Capacity Evaluation. A specific capacity assessment is a semistructured evaluation of the participant's ability to understand relevant information and appreciate reasonably foreseeable consequences with regard to the specific treatment decision. Participants also received a SMMSE administered by a research nurse. Participants then had two independent expert assessments of capacity. If the two expert assessments disagreed, then an independent adjudication panel resolved the disagreement after reviewing videotapes of both expert assessments. Using the two expert assessments and the adjudication panel as the reference standard, we calculated areas under the receiver-operating characteristic curves and likelihood ratios. The areas under the receiver-operating characteristic curves were 0.90 for specific capacity assessment by treating clinician and 0.93 for SMMSE score (2p =.48). For the treating clinician's specific capacity assessment, likelihood ratios for detecting incapacity were as follows: definitely incapable, 20 (95% confidence interval [CI] 3. 6, 120); probably incapable, 6.1 (95% CI 2.6, 15); probably capable, 0.39 (95% CI 0.18, 0.81); and definitely capable, 0.05 (95% CI 0.01, 0.29). For the SMMSE, a score of 0 to 16 had a likelihood ratio of 15 (95% CI 5.3, 44), a score of 17 to 23 had a likelihood ratio of 0. 68 (95% CI 0.35, 1.2), and a score of 24 to 30 had a likelihood ratio of 0.05 (95% CI 0.01, 0.26). CONCLUSIONS: Specific capacity assessments by the treating clinician and SMMSE scores agree closely with results of expert assessments of capacity. Clinicians can use these practical, flexible, and evaluated measures as the initial step in the assessment of patient capacity to consent to treatment.

Aged↗
PubMed1996

Mental competence and the question of beneficent intervention.

The authors examine recent arguments purporting to show that mental incompetence (lack of decision-making capacity) is not a necessary condition for intervention in a person's best interests without consent. It is concluded that these arguments fail to show that competent wishes could justifiably be overturned. Nonetheless, it remains an open question whether accounts of decision-making capacity based solely on the notion of understanding and appreciation can adequately deal with various complexities. Different possible ways of resolving these complexities are outlined, all of which need further exploration.

Beneficence↗
PubMed1996

Competency and practical judgment.

At least four different frameworks--psychiatric, cognitive, functional and decision-making--are used in the evaluation of competence, all of which remain more or less unrelated in the literature. In the first section of this paper we consider various meanings of "competence," in order to arrive at a definition of the term relevant to the medical and legal setting. Patient or client "competence," we conclude, refers to the practical abilities that individuals employ in pursuing their own autonomous goals in life. We then show how a systematic categorization of these practical abilities--which we call a taxonomy of practical judgment--allows us to show when the traditional frameworks for the evaluation of competence may or may not be useful in the evaluation of a particular competence. In the final section we explore some of the normative considerations underlying the taxonomy. For instance, competence is not only related to intrinsic abilities but to resources available in the community. Here we touch on questions related to the fair distribution of community resources.

Aged↗
PubMed1996

Family and physicians' views of surrogate decision-making: the roles and how to choose.

Physicians and family members were compared on the roles played in surrogate decision-making and their views as to how choices should be made by surrogate decision-makers. Thirty-six family members of patients with Alzheimer's disease, 35 family members of patients with schizophrenia, and 34 physicians from a diversity of specialties were the respondents. There was general agreement that shared decision-making was preferred. Physicians seem to make surrogate decisions in accordance with contemporary views about their roles. Families believed they had a strong subjective appreciation of the patient's overall good. The burden of decision-making was greater for families, but that depended to some degree on the diagnosis of the patient.

Activities of Daily Living↗
PubMed1996

Measuring capacity to complete an advance directive.

OBJECTIVE: To validate reference standards for the assessment of capacity to complete an advance directive and to develop and test three simple screening instruments. METHODS: We administered five measures of capacity to 96 older subjects from nursing homes, retirement homes, and homes for the aged. The measures included two reference standard evaluations: an assessment by a specially trained nurse in collaboration with a multidisciplinary team (Competency Clinic assessment) and geriatrician assessment using a decisional aid. Three screening instruments were also included: a Generic Instrument designed for any advance directive, a Specific Instrument designed for the "Let Me Decide" advance directive, and the Standardized Mini-Mental Status Examination (SMMSE). The screening instruments and the geriatrician's assessment were administered twice to half of the respondents to determine interrater agreement. RESULTS: The chance-corrected agreement for the assessment by two geriatricians was 0.78, and for agreement between the geriatricians and Competency Clinic assessments it was 0.82. Agreement for the Generic and Specific screening instrument assessments by two observers was 0.77 and 0.90, respectively. The areas under the Receiver Operating Characteristic curve relating the results of the three screening instruments to the Competency Clinic assessment were 0.82 for the Generic Instrument, 0.90 for the Specific Instrument, and 0.94 for the SMMSE; chance is an unlikely explanation for the difference between these three values (P < or = .01). CONCLUSIONS: Using rigorous methods, health workers can make reproducible and valid assessments of capacity to complete an advance directive. The SMMSE accurately differentiates people who can learn about and ultimately complete advance directives from those who cannot.

Advance Directives↗
PubMed1996

Competency assessments: perceptions at follow-up.

OBJECTIVES: To report on the perceptions of assessment of competency and its consequences on a group of clients and significant others at follow-up. METHODS: Ninety-five interviews were conducted using a carefully developed semistructured telephone interview of 24 clients and 71 family/caregivers, representing the perceptions of about 80 clients. RESULTS: There was general satisfaction in the competency assessment process. There was a perception that interests and rights were protected. Clients were seen to be less involved in all spheres of decision making regardless of capacity outcome. Clients and families were satisfied with how decisions were made. CONCLUSIONS: Follow-up study of competency assessment does not support the conclusions previously drawn based on court record studies that assessments are deleterious and frequently result in violations of rights.

Adolescent↗
PubMed1996

Permissible errors in managing property: an approach to the threshold of capacity.

OBJECTIVE: To demonstrate a practical approach to describing the threshold of mental capacity. METHOD: A retrospective analysis of 62 cases of assessments for capacity to manage property was carried out to record the type and frequency of errors. RESULTS: For items on the Mini-Mental State Examination (MMSE), there was no clear demarcation of items associated with a judgement of capable. On the clinical criteria, several items almost completely distinguished capable from incapable subjects. CONCLUSIONS: The permissible error approach makes the threshold of capacity explicit. It is well suited to the emphasis put on functional performance in the evaluation of mental capacity.

Canada↗
PubMed1996

Bathing incompetent patients.

Bathing incompetent patients can be a difficult experience, both for the patient and the nurse. When incompetent patients express a wish not to be bathed, or actively resist being bathed, it is even more stressful.

Baths↗
PubMed1995

Reflections on segregating and assessing areas of competence.

Various complexities that arise in the application of legal and/or clinical criteria to the actual assessment of competence/capacity are discussed, and a particular way of understanding the nature of such criteria is recommended.

Activities of Daily Living↗
PubMed1995

Agreement between professions on ethical decisions: an empirical demonstration.

The decisions of a multidisciplinary competency panel at the Baycrest Centre for Geriatric Care, Toronto, Canada, were studied to try to explain the high level of agreement on individual cases when determining mental capacity. The panel assessed its own judgments on a standardized form developed to capture the process of coming to a capacity determination. Though the relative weights given to decision-making variables varied with discipline, there was agreement on a group of criteria most relevant to capacity. Three alternative explanations are given for these results.

Aged↗
PubMed1994

Presumptions respecting mental competence.

This paper addresses the role(s) played by presumptions regarding mental competence in the context of clinical assessment of decision-making capacity. In particular, the issue of whether or not the usual common law presumption of competence is appropriate and applicable in cases of reassessment of persons previously found incompetent is discussed. Arguments can be made for either retaining a presumption of competence or adopting a presumption of incompetence in reassessment cases. In addressing the issue and the arguments, the authors conclude that the question is really a public policy issue which requires legislative resolution. In writing this paper, the authors have drawn on their joint clinical experience at the Baycrest Competency Clinic. Though the authors' jurisdiction is the province of Ontario, their intent is to raise awareness and to prompt consideration of this issue both inside and outside Ontario.

Commitment of Persons with Psychiatric Disorders↗
PubMed1993

A randomized trial of a decisional aid for mental capacity assessments.

The objective of this study was to evaluate the clinical utility of a decisional aid for mental capacity assessments which was developed using a group judgment methodology. This was carried out by a randomized, controlled trial. The subjects comprised 64 University of Toronto psychiatry residents in postgraduate years 1 through 4. Residents were randomized to carry out mental capacity assessments on simulated cases with, or without, the use of the decisional aid. The main outcome measure was the extent of agreement between the mental capacity determinations of residents and those of experts. There was no difference between the intervention and control groups with respect to the overall mean level of agreement with experts (0.87 vs 0.86, p = 0.88; 95% confidence interval for the difference between the study groups, -0.07 to +0.08). A logistic regression analysis, which adjusted for imbalances between the groups, also revealed no difference between the groups in their agreement with experts. The mean time per competency assessment was significantly longer in the intervention group (19.1 vs 10.8 min; p < 0.001). It was concluded that the decisional aid did not improve the ability of the psychiatry residents to make mental capacity assessments on simulated cases. Despite relatively limited formal training, the psychiatry residents had a high level of agreement with experts.

Adult↗