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PubMed1997

Physician-assisted suicide and patients with human immunodeficiency virus disease.

BACKGROUND: Data are limited on the attitudes and practices of physicians regarding assisting the suicide of patients with human immunodeficiency virus (HIV) disease. METHODS: Between November 1994 and January 1995, we used an anonymous, self-administered questionnaire to survey all 228 physicians in the Community Consortium, an association of providers of health care to patients infected with HIV in the San Francisco Bay area. The responses were compared with those in a 1990 survey of consortium physicians. Physician-assisted suicide was defined as "a physician providing a sufficient dose of narcotics to enable a patient to kill himself." Respondents were to "assume that the patient is a mentally competent, severely ill individual facing imminent death." RESULTS: One hundred eighteen of the questionnaires were evaluated. Respondents reported a mean of 7.9 "direct" and 13.7 "indirect" requests from patients for assistance. In responses based on a case vignette, 48 percent of the physicians said they would be likely or very likely to grant the request of a patient with the acquired immunodeficiency syndrome (AIDS) for assistance in a suicide, as compared with 28 percent of the respondents in 1990. Asked to estimate the number of times they had granted the request of a patient with AIDS for assistance in committing suicide, 53 percent said they had done so at least once (mean number of times, 4.2; median, 1.0; range, 0 to 100). In a multivariate analysis, factors positively associated with having, in fact, assisted a suicide were having had a higher number of patients with AIDS who had died, a higher number of indirect requests from patients for assistance, a stated gay, lesbian, or bisexual orientation on the part of the physician, and a higher "intention to assist" score (as calculated from the physician's responses to the case vignette). CONCLUSIONS: Within a group of physicians caring for patients with HIV disease, the acceptance of assisted suicide increased between 1990 and 1995. A majority of respondents in 1995 said they had granted a request for assisted suicide from a patient with AIDS at least once.

Acquired Immunodeficiency Syndrome↗
PubMed2002

Familial incidence of urinary incontinence.

OBJECTIVE: The purpose of this study was to evaluate whether urinary incontinence is more common in family members of women with incontinence compared with continent individuals. STUDY DESIGN: Women who were examined at 2 different outpatient facilities over a 2-year period received a questionnaire that covered social, behavioral, and medical issues. They were also asked whether they had a family member who complained of urinary incontinence and, if so, the degree of the relationship. Subjects were excluded for the following reasons: not mentally competent, difficulty understanding the written English language, and a history of bladder cancer or of acquired or congenital neuropathy. Statistical analyses were conducted with chi-squared tests for differences between groups; a probability of <.05 was defined as significant. RESULTS: A total of 833 women received the questionnaire; 667 women answered the question about urinary incontinence in family members. These 667 women were divided into 3 groups: group I, 441 incontinent women from the first facility; group II, 112 continent women from the first facility; and group III, 114 continent women from the second facility. Women with at least 1 relative with urinary incontinence were 34.9% in group I, 16.1% in group II, and 5.3% in group III. This difference was statistically significant. In a comparison of group I and group II, the odds that an incontinent woman had at least 1 relative with incontinence were 2.6 times higher (95% CI, 1.50-4.48); comparing group I and group III, the odds were 9.6 times higher (95% CI, 4.17-22.25). CONCLUSION: In our study population, women with urinary incontinence were more likely to have at least 1 family member also with incontinence when compared with women who were continent.

Chi-Square Distribution↗
PubMed1998

Institutional Review Board issues related to special populations.

The present article begins with an introduction to the role of Institutional Review Boards (IRBs) in research activities in general and proceeds to issues IRBs face with relation to special populations, including children and terminally ill individuals, as well as developmentally disabled and cognitively impaired persons. A historical overview of research with these special populations is included, and the report concludes with a real-world example of how IRB-related issues with developmentally disabled and cognitively impaired individuals are discussed and resolved.

Child↗
PubMed2005

Protecting autonomy as authenticity using Ulysses contracts.

Pre-commitment directives or Ulysses contracts are often defended as instruments that may strengthen the autonomous self-control of episodically disordered psychiatric patients. Autonomy is understood in this context in terms of sovereignty ("governing" or "managing" oneself). After critically analyzing this idea of autonomy in the context of various forms of self-commitment and pre-commitment, we argue that what is at stake in using Ulysses contracts in psychiatry is not autonomy as sovereignty, but autonomy as authenticity. Pre-commitment directives do not function to protect autonomous self-control. They serve in upholding the guidance that is provided by one's deepest identity conferring concerns. We elucidate this concept of autonomy as authenticity, by showing how Ulysses contracts protect the possibility of being "a self."

Advance Directive Adherence↗
PubMed2005

Scandinavian forensic psychiatric practices--an overview and evaluation.

The Scandinavian countries share a social-democratic and humanistic view in that mentally disturbed offenders should not be punished or sentenced to prison if they are considered unaccountable for their actions. The countries differ, however, for example regarding referrals for medico-legal examinations. This article gives: 1) an overview of the Scandinavian forensic psychiatric practices regarding organization, legislation, resources and use of methods, and 2) a study of forensic psychiatric assessment as they are done in the Scandinavian countries. From each country 20 forensic psychiatric court reports concerning male murderers were examined. Each report was scored in five sections: characteristics of the defendant, setting of the observation, acting professions, methods used and premises for the experts' conclusions. Data were summarized with descriptive measures. Danish and Swedish experts had a more frequent use of tests and instruments than Norwegian experts. Swedish experts used the Global Assessment of Functioning Scale (GAF), and they diagnosed the observant according to DSM-IV. The Scandinavian experts rarely referred to the tests they had applied nor did they refer to any kind of theory or literature as a basis for their conclusion. Only a few reports expressed doubt concerning the validity of the conclusion. Stating all the premises of the forensic psychiatric examination might improve the quality of the reports by doing them more explicit and verifiable. More use of standardized actuarial-based methods and more attention to knowledge about clinical judgmental processes is recommended.

Expert Testimony↗
PubMed2001

Empowerment and decision-making for people with dementia: the use of legal interventions in Scotland.

Dementia is associated with a decline in the ability to reason and make judgements thereby affecting a person's ability to make sound decisions. Others are not legally entitled to make these decisions until they have been assigned legal jurisdiction to do so. It is not clear, however, the extent to which people with dementia rely on available legal interventions. The growing emphasis on early diagnosis for people with dementia provides an opportunity for people to plan and control decisions about financial management and welfare and may well lead to an increase in the uptake of these interventions. This paper coincides with a move to reform outdated Scottish Law with the Adults with Incapacity (Scotland) Act 2000. This legislation proposes a more integrated and flexible approach to the legal management of the affairs of people with reduced decision-making capability. The paper reviews of the recent literature on the use of legal interventions for people with dementia and their families, and discusses the empowering or disempowering nature of the interventions.

Decision Making↗
PubMed2003

The use of sections 2 and 3 of the Mental Health Act (1983) with older people: a prospective study.

The use of the UK Mental Health Act (MHA) is under scrutiny with older people, especially in those with dementia and other organic mental disorder. Whilst research into use of the MHA with this group has been sparse, the small body of existing research suggests that the MHA is applied differently to older adults (i.e. those over 65 years). This multi-centre study identified all MHA assessments conducted over a prospective three-month period, and obtained detailed data on the circumstances behind assessment. The findings highlighted that older people assessed under the MHA tend to exhibit different behaviour patterns, circumstances and core characteristics to those under 65; older people were more likely to be detained because of self neglect and physical illness and also more often had a diagnosis of an organic mental disorder. Younger people were unlikely to have a diagnosis of organic mental disorder and were more likely to be judged as a risk to other people. Risk of suicide was particularly highlighted with the under 65 age group. Implications for legislative reform are discussed.

Adult↗
PubMed1996

Autonomy for elderly people in long-term care.

A cross-sectional view of the extent to which residents in long-term care exercise autonomy has been obtained from an audit using the Royal College of Physicians' CARE scheme (Continuous Assessment Review and Evaluation) in 17 long-term care facilities among 298 residents. Most centres have procedures in place to enable residents to exercise choice, on information or services provided and how to complain, but only half provide opportunities to comment on policy and procedures and planned changes. There was a high level of personal care plans but many of these were disappointing in their detailed content; less than half of the residents had a key worker; a series of indicators of choice scored reasonably high in nursing homes but lower in hospitals; independent advocates are in evidence where patients' mental competence is in question. The established use of care plans should provide a foundation for improvements in this aspect of the quality of care. Such audits could form the basis for a national quality system in long-term care.

Aged↗
PubMed2004

BIPP madness; an iatrogenic cause of acute confusion.

An 81-year-old man, admitted under the Ear, Nose and Throat Team with persistent epistaxis, developed an acute confusional state. He was previously physically independent and mentally competent. Immediate investigations did not reveal a cause for his deterioration. He eventually made a full recovery and returned home. Subsequently, his serum bismuth level was noted to be within the toxic range and was felt to have been the cause of his confusional state.

Acute Disease↗
PubMed2001

Are persons with cognitive impairment able to state consistent choices?

PURPOSE: This study examined the decision-making capacity of persons with cognitive impairment with respect to their everyday care preferences and choices. This is the first in a series of articles to report on findings from a larger study that examines choice, decision making, values, preferences, and practices in everyday care for community-dwelling persons with cognitive impairment and their family caregivers. DESIGN AND METHODS: Fifty-one respondent pairs, or dyads, were interviewed, that is, persons with cognitive impairment (n = 51) and their family caregivers (n = 51). All persons with cognitive impairment were interviewed twice within a week using a parallel interview to determine stability and accuracy of responses. The family caregiver was interviewed once. RESULTS: Persons with mild to moderate cognitive impairment (i.e., Mini-Mental State Exam scores 13-26) are able to respond consistently to questions about preferences, choices, and their own involvement in decisions about daily living, and to provide accurate and reliable responses to questions about demographics. IMPLICATIONS: Including the perspective of persons with cognitive impairment in both research and practice has the potential to enhance their autonomy and improve their quality of life.

Activities of Daily Living↗
PubMed2006

Coping with late-life challenges: Development and validation of the care-receiver efficacy scale.

PURPOSE: Measures are lacking that address the challenges that people think they face in their roles as elderly care receivers. However, the development of a sense of efficacy in this role by mentally competent care receivers is critical to successful partnerships between caregivers and care receivers. The purpose of this article is to report the development and psychometric analysis of the Care-Receiver Efficacy Scale (CRES). DESIGN AND METHODS: Content validity, internal consistency reliability, factor structure, and convergent validity were assessed through a pilot study, expert review, and field administration with 177 participants. RESULTS: Results suggest that the CRES comprises five subscales, with strong reliability evidenced for three subscales but marginal reliability for the remaining two. Strong support was found for content validity from expert review and moderate support from the relationship between empirical and expert judgment of item location. Support for validity also was found from correlation with the Geriatric Depression Scale-Short Form and the Philadelphia Geriatric Center Morale Scale. IMPLICATIONS: The CRES may be useful as an outcome measure for psycho-socio-behavioral interventions aimed at increasing the capacity of care receivers to direct and improve their own care. Future measure revision and validation are important to optimize its utility.

Adaptation, Psychological↗
PubMed1995

Multiple perceptions of discharge planning in one urban hospital.

Since the advent of diagnosis-related groups (DRGs), advocacy groups have claimed that although hospital discharge planners perceive the discharge planning process as helpful, elderly patients and their families do not. This article explores how the discharge planning process was perceived by 40 discharge planners and 40 family caregivers. Planners greatly overrated caregiver influence and the amount adequacy of information shared about posthospital health care, choice of discharge to home or nursing home, and time to decide. Caregivers perceived that nursing homes were forced on patients by social workers and physicians. DRGs, physicians, and hospital administrators appeared to pressure social workers to coerce mentally competent patients into nursing homes. Excessive concern by hospital staff about patient safety after discharge may override patients' rights to autonomy and self-determination, violating the NASW Code of Ethics. Implications for practice, policy, and future research are discussed.

Aged↗
PubMed1999

The social worker in the emerging field of home care: Professional activities and ethical concerns.

Although home care is one of the fastest growing segments of the health care delivery system, there is little empirical data on the professional functions or ethical concerns of social workers employed in home care. To provide this information 118 social workers in proprietary and nonprofit agencies in one midwestern and one southern state were surveyed. The results indicated that social workers performed a wider array of professional functions with a more diverse population of patients than had been documented previously. Workers experienced ethical concerns related to self-determination, barriers to access of services, implementing advance directives, and assessment of mental competence most often. Workers in proprietary agencies rated the ethical concern of barriers to access of services as occurring significantly more often than workers in nonprofit agencies.

Adolescent↗