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Autonomy and the psychiatric patient.
The aim of this paper is to consider possible justifications for the denial of the right to refuse treatment in the case of certain kinds of psychiatric patients. The basis of this right in general is first considered: arguments based on Kantian conceptions of autonomy are rejected as confused, and preference is given to Millian arguments based on the right to make decisions about one's own life, however irrational, as long as they do not harm others. In light of this discussion, it is argued that mentally disordered people cannot be denied this right on grounds of their 'irrationality', which is anyway a vague concept with several meanings. In conclusion, it is argued that there may be a case for such a denial in those sorts of mental disorder which involve a 'disturbance of personal identity'.
Documenting the cognitive status of hip fracture patients using the Short Portable Mental Status Questionnaire.
AIMS AND OBJECTIVES: The aim of this study was to describe how nurses document their subjective assessment of the patients' cognitive status in the patients' records and to compare this documentation with an assessment made using a validated evaluation instrument in older patients with a hip fracture. BACKGROUND: There are indications that older people with a hip fracture and impaired cognitive ability do not receive optimal care and that they suffer from a disproportionately high number of complications. Preventing and rapidly detecting confusion is probably an effective strategy for improving care for these patients. To be able to prevent care-related complications and plan for future nursing and medical care, it is necessary to identify patients with impaired cognitive ability. DESIGN: Clinical trial including 362 patients. METHODS: The patients' cognitive function was assessed by a research nurse using a validated instrument, the Short Portable Mental Status Questionnaire, and an independent subjective assessment was made by a ward nurse. The agreement between these assessments was analysed. RESULTS: An assessment of cognitive function by the ward nurse was lacking in 12% of the patients. The assessment made by the nurses did not correspond to the level of orientation according to Short Portable Mental Status Questionnaire in 24% of the patients. In the vast of majority of these cases, the patients were documented as being cognitively alert although they were cognitively impaired according to the Short Portable Mental Status Questionnaire. Among the patients who were cognitively oriented according to the Short Portable Mental Status Questionnaire, the nurses' assessment identified 97% as oriented, but among the patients with impaired cognitive ability according to the Short Portable Mental Status Questionnaire, only 58% were identified as being cognitively impaired by the ward nurses. CONCLUSIONS: An assessment of cognitive function is still lacking in nursing records for a substantial number of older people with a hip fracture and cognitive dysfunction is frequently underdiagnosed in routine health care. RELEVANCE TO CLINICAL PRACTICE: Patient care could be improved if the patients' cognitive function was assessed regularly and objectively by means of a validated evaluation instrument.
Healthy participants in phase I clinical trials: the quality of their decision to take part.
AIMS AND OBJECTIVE: This study was set out to test the quality of the decision-making process of healthy volunteers in clinical trials. BACKGROUND: Researchers fear that the decision to volunteer for clinical trials is taken inadequately and that the signature on the consent forms, meant to affirm that consent was 'informed', is actually insubstantial. DESIGN: The study design was quasi-experimental, using a convenience quota sample. METHODS: Over a period of a year, candidates were approached during their screening process for a proposed clinical trial, after concluding the required 'Informed Consent' procedure. In all, 100 participants in phase I trials filled out questionnaires based ultimately on the Janis and Mann model of vigilant information processing, during their stay in the research centre. RESULTS: Only 35% of the participants reached a 'quality decision'. There is a definite correlation between information processing and quality decision-making. However, many of the healthy research volunteers (58%) do not seek out information nor check alternatives before making a decision. CONCLUSIONS: Full disclosure is essential to a valid informed consent procedure but not sufficient; emphasis must be put on having the information understood and assimilated. Research nurses play a central role in achieving this objective.
Factors influencing nurses' judgements about self-neglect cases.
From the perspective of the practising nurse self-neglect may best be understood in terms of a set of complex and often poorly defined clinical problems in which two key clinical issues are "how do I judge whether this person has the capacity to make decisions about their lifestyle?" and "do we need to treat this person using mental health legislation?" These are taxing questions as judging if a patient has the capacity to make decisions about their lifestyle choices is difficult for even the most experienced clinicians. Such determinations require nurses to form a judgement as to mental capacity of the patient. We do not know what patient characteristics and in what combination nurses use these when making these judgements. This factorial survey aimed to identify which patient characteristics influenced Registered Nurses' judgements on decision-making capacity and decisions on the use of interventions which require statutory interventions in cases of self-neglect. Judgements on decision-making capacity were overwhelmingly predicted by information of the patients' mental health status. Nurses place patients in one of three broad categories of no mental illness, minor mental illness and severe mental illness. This categorization appears to operate as a fast and frugal heuristic indicating that nurses may use mental status as a cognitive screen to work from in judging self-neglect. Although there is a correlation between the severity of mental illness and the capacity for making decisions they are not the same. This study shows the continued work that needs done in educating nurses not only about self-neglect but also about the role a patient's mental status may have in assessment of problems.
Duty of care in the emergency department.
This paper explores issues that relate to the management of deliberate self-harm in the emergency department (ED) from a New South Wales perspective. A scenario that is typical to the ED is presented to illustrate the dilemma that nurses face and the implications for clinical practice. Confusion and concern regarding the treatment and detention of this type of patient in the ED can often result in the inappropriate use of the Mental Health Act. It is preferable for clinicians to be aware of the treatment options they have under duty of care rather than relying on the unfounded reassurance provided by scheduling a patient under the Mental Health Act. Communication and negotiation skills are highlighted as attributes that clinicians must develop and enhance to effectively manage difficult presentations to the ED.
Gender differences in signs and symptoms presentation and treatment of Jordanian myocardial infarction patients.
Heart disease is the number one killer in the USA. In Jordan, cardiovascular disease is the leading cause of death, and about 34.5% of women die of cardiovascular disease as compared with 44.25% of men. The differences between men and women in heart disease, such as signs and symptoms presentation, diagnostic and therapeutic interventions, are becoming more apparent in the literature. There is a dearth of research regarding gender differences among Jordanian myocardial infarction (MI) patients. Therefore, the purpose of this study was to explore the differences between Jordanian men and women in signs and symptoms presentation of MI and follow-up care. A convenience sample of 83 patients (26 women and 57 men) who were diagnosed with MI, mentally competent and haemodynamically stable were used to explore the research questions. An interview guide and chart audit were used to elicit information about initial and associated signs and symptoms and treatment plan of MI patients. Chest pain was the most common initial symptom in both men and women. The four most common associated signs and symptoms reported by both men and women were general weakness, sweating, nausea and fatigue. However, women experienced more general weakness and sweating compared with men. Women were less likely to receive intravenous nitroglycerin, heparin and thrombolytic therapy for the treatment of MI. Chest pain was the initial symptom of MI reported by men and women. Although similarities exist in the associated sings and symptoms, women might experience different associated signs and symptoms from men. Despite these similarities, women are still less likely than men to receive the therapeutic regimen used for men.
Criminal policy for offenders with mental disorder in Japan.
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The treatment of mentally disordered offenders in Japanese medical prisons.
The author outlines the general trends of crime and the treatment of criminals in Japan, and trends of mentally disordered offenders in Japanese penal institutions. Further, he explains the treatment of the mentally disordered offenders in Japanese medical prisons. The author analyzes the Hachioji Medical Prison's treatment record, particularly in regards to the reincarceration rate, which markedly decreases when family support and psychiatric treatment are properly present after release. Finally, the author stresses the value of correctional psychiatric treatment in the medical prison; it is expected to play an important role in contributing to the rehabilitation of mentally disordered offenders and "patients difficult to treat," and bringing about more open and innovative community-centered mental health services.
A conversation: challenging the relevance and wisdom of separate mental health legislation.
This paper explores the dilemmas encountered by mental health nurses when working with mental health legislation. The concerns and considerations of an expert mental health nurse, complemented by the opinion of an expert in health-care and legal issues are presented. It is argued that there is currently a distorted perception with regard to the function and sentiment of mental health legislation, and this paper aims to restore balance in interpreting and working with such law. Viewing mental health legislation primarily as a mechanism for involuntary hospitalization effectively removes any power or recourse given to mental health consumers by the law. Principles of mental health care and legislation are examined as well as the relationship the law has with dangerousness to self or others and mental ill health. A dialogue is established between the two authors to assist the exploration of these legal and clinical issues. The continued relevance of specific mental health legislation is brought into question. It is proposed that the existence of such legislation constitutes discrimination and contributes to stigma associated with mental illness. An alternative legislation for all circumstances where an individual is deemed incompetent is proposed as the most significant step towards mainstreaming of mental health care and an end to discrimination.
"There but for the grace of God": moral responsibility and mental illness.
Setting the terms of praise- and blameworthiness has long dominated philosophers' discussions of responsibility. Analytic philosophy has most often looked to reason and the abstract relations between individual rational judgements and actions to advance the discourse on moral responsibility. Those whose capacity for reasoned judgement is impaired are deeply problematic. Is it proper to morally appraise "the mentally ill"? The philosopher T.M. Scanlon discusses moral responsibility as a precondition of moral appraisal and contends that it is not appropriate to appraise a person as (morally) praise- or blameworthy if that person cannot be held responsible for the action(s) for which he is being praised or blamed. What are the conditions, then, under which one can properly be said to be responsible for one's actions? Can one hold "the mentally ill" responsible for their actions? If not, can it in any way be reasonable to expect them to "take responsibility" for their actions and/or characters? The expectation that "the mentally ill" will attempt to control, i.e. take responsibility for their behaviour despite the fact of their mental illness is a pervasive feature of psychiatric approaches to the care and treatment of "the mentally ill". It would seem that such treatment approaches are coherent only to the degree "the mentally ill" can be considered responsible moral agents. This paper explores these issues with regard to that form of mental illness categorized as the personality disorders. It describes the morally and clinically relevant features of personality disorder, explains how they do not fit traditional analytic paradigms of "mental illness" and elaborates the argument that persons with this category of mental illness are fully moral persons who are rightly subject to praise and blame.
Physician assisted suicide: new developments in the Netherlands.
Until recently, physician assisted suicide was dealt with on the same basis as active voluntary euthanasia in the Netherlands. Over the last years, several cases relating to assistance in suicide of mental patients did raise specific issues, not addressed so far in the debate on euthanasia. One of these cases resulted in a Supreme Court decision. The paper summarizes this decision and comments on it from a legal point of view.
Ulysses contracts.
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Amputees by choice: body integrity identity disorder and the ethics of amputation.
Should surgeons be permitted to amputate healthy limbs if patients request such operations? We argue that if such patients are experiencing significant distress as a consequence of the rare psychological disorder named Body Integrity Identity Disorder (BIID), such operations might be permissible. We examine rival accounts of the origins of the desire for healthy limb amputations and argue that none are as plausible as the BIID hypothesis. We then turn to the moral arguments against such operations, and argue that on the evidence available, none is compelling. BIID sufferers meet reasonable standards for rationality and autonomy: so as long as no other effective treatment for their disorder is available, surgeons ought to be allowed to accede to their requests.
Children as witnesses--legal and psychological perspectives.
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Development and application of medical guidelines for drivers in the state of Maine.
In 1984, the Medical Advisory Board for the state of Maine realized that uniform criteria with regard to physical, emotional, and mental competence to operate a motor vehicle were nonexistent. This resulted in confusion and inevitable inequities. The burden of determining one's ability to operate a motor vehicle safely was left with the individual physician, who often had to defend a stand without adequate guidelines. In addition, the impaired driver was frequently not reported because of fear of liability and breach of confidentiality. Being aware of these deficiencies, the Medical Advisory Board (MAB) decided to develop a reasonable uniform standard to be applied in the state. The first step was to draft nonliability legislation. The second step was to draft Driver Impairment Profiles. Care has been taken to insure that functionally impaired drivers are granted driving privileges consistent with the fullest extent of their ability to operate a motor vehicle safely. The guidelines identify impairments that post unacceptable driving risks. Most important, the decision to allow operation of a motor vehicle is now shifted to the Division of Motor Vehicles (DMV), with the physician supplying the pertinent medical information on the reporting form.
Getting meaningful informed consent from older adults: a structured literature review of empirical research.
OBJECTIVES: To perform a structured literature review of the published empirical research on informed consent with older adults in order to make recommendations to improve the informed consent process and to highlight areas needing further examination. DESIGN: Relevant literature was identified by searching electronic databases (AGELINE, BIOETHICSLINE, CancerLit, Ethics Index, Health, LegalTrac, MEDLINE, PAIS International, PsycInfo, and Sociofile). Studies were included if they were reports of primary research data about informed consent and, if patients or other subjects were used, older subjects were included in the sample. Data related to the aspect of informed consent under study (recruitment, decision-making capacity, voluntariness, disclosure of information, understanding of information, consent forms, authorization, and policies and procedures) were abstracted and entered into a specially designed database. MEASUREMENTS: Characterization of the population, age of subjects, setting, whether informed consent was being studied in the context of research or treatment, study design, the nature of outcome or dependent variables, independent variables (e.g., experimental conditions in a randomized controlled trial or patient/subject characteristics in a nonrandomized comparison), and results according to the aspect of informed consent under study. RESULTS: A total of 99 articles met all the inclusion criteria and posed 289 unique research questions covering a wide range of aspects of informed consent: recruitment (60); decision making capacity (21); voluntariness (6); disclosure (30); understanding (139); consent forms (7); authorization (11); policies (13); and other (2). In the secondary analyses of numerous studies, diminished understanding of informed consent information was associated with older age and fewer years of education. Older age was also sometimes associated with decreased participation in research. Studies of disclosure of informed consent information suggest strategies to improve understanding and include a variety of novel formats (e.g., simplified, storybook, video) and procedures (e.g., use of health educators, quizzing subjects, multiple disclosure sessions). CONCLUSIONS: A systematic review of the published literature on informed consent reveals evidence for impaired understanding of informed consent information in older subjects and those with less formal education. Effective strategies to improve the understanding of informed consent information should be considered when designing materials, forms, policies, and procedures for obtaining informed consent. Other than empirical research that has investigated disclosure and understanding of informed consent information, little systematic research has examined other aspects of the informed consent process. This deficit should be rectified to ensure that the rights and interests of patients and of human subjects who participate in research are adequately protected.
Decision-making capacity to execute a health care proxy: development and testing of guidelines.
OBJECTIVE: To evaluate the reliability and validity of guidelines to determine the capacity of nursing home residents to execute a health care proxy (HCP). DESIGN: A cross-sectional study. SETTING: A 750-bed not-for-profit nursing home located in New York City. PARTICIPANTS: A random sample of 200 nursing home residents: average age, 87; 99% white; 83% female; average length of stay, 3.05 years; mean Mini-Mental State Exam (MMSE) score, 15.9. MEASUREMENTS: Demographic characteristics (Minimum Data Set (MDS)); function and cognitive status (Institutional Comprehensive Assessment and Referral Evaluation (INCARE)); Reisberg Dementia Staging; MMSE; Minimum Data Set-Cognitive Performance Scale (MDS-COGS)); an investigator-developed measure of a nursing home resident's capacity to execute a health care proxy (Health Care Proxy (HCP) Guidelines.) RESULTS: The internal consistency of the decision-making scales in the HCP Guidelines, paraphrased recall and recognition, reached acceptable levels, alphas of .85 and .73, respectively. Interrater reliability estimates were .92 and .94, respectively, for the recall and recognition scales; test-retest reliability estimates were .83 and .90. The discriminant validity of these scales is promising. For example, the MMSE correlation was .51 with the Recall scale and .57 with the Recognition scale. Of residents with severe cognitive impairment (MMSE < 10), 71% completed 50% or more of the scaled items in the HCP guidelines and 95% consistently named a proxy. CONCLUSIONS: Seventy-three percent of testable residents, approximately three-quarters of whom were cognitively impaired, evidenced sufficient capacity to execute an HCP. Of residents with severe cognitive impairment, the HCP guidelines are potentially useful in identifying those with the capacity to execute a HCP. The guidelines are more predictive than the MMSE in identifying residents able to execute a HCP.