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PubMed2003

Competence of mentally ill patients: a comparative empirical study.

BACKGROUND: This study investigates the competence of patients with dementia, depression and schizophrenia to make treatment decisions. The outcome of an objective test instrument is presented and compared with clinical assessment of competence by the attending physician. METHOD: The MacArthur Competence Assessment Tool-Treatment (MacCAT-T), a test instrument to assess abilities in different standards of competence, was administered to patients with diagnoses of dementia (N = 31), depression (N = 35) and schizophrenia (N = 43). Statistical significance of group differences in the MacCAT-T results were tested with the chi-square test. The concordance of the test and clinical assessment of competence by the attending physician were evaluated by Cohen's kappa coefficient. RESULTS: Patients with dementia, as a group, showed significantly more often impaired performance than those with schizophrenia who were still more impaired than depressed patients. Patients were classified as impaired or not depending on the standards used. By combination of all standards substantially more patients were classified as impaired than by clinical assessment (67.7 v. 48.4% of patients with dementia, 20.0 v. 2.9% of patients with depression, 53.5 v. 18.4% of patients with schizophrenia). CONCLUSIONS: Using different standards of competence the study showed substantial differences among patients with dementia, depression and schizophrenia. The high proportion of patients identified as incompetent raises several ethical questions, in particular, those referring to the selection of standards or the definition of cut-offs for incompetence. The discrepancy between clinical and formal evaluations points out the influence of the used procedure on competence judgements.

Adult↗
PubMed2000

Abortion: a psychiatric patient's right to choose.

1. Competent mentally ill patients should be allowed to terminate pregnancy. 2. It is the responsibility of the staff to provide the patient with a safe, supportive, and respectful environment. 3. Early and frequent staff processing opportunities should be offered to clarify any underlying issues.

Abortion, Legal↗
PubMed2005

A competencies-based mental health training model for health professionals in low and middle income countries.

This paper describes a competencies-based training model specifically created to teach needed mental health skills to health professionals in low and middle income countries (LMICs). The model combines a mental health training needs assessment with the delivery of mental health training modules aligned with national/regional mental health priorities and designed to be used by all health professionals at various levels of the health care system. The model also defines a sustainability framework that involves the creation of a multidisciplinary training team embedded in the national/regional health system. The training program consists of a number of modules, each one designed to enhance specific mental health competencies for a variety of health care workers. These modules are linked to a number of clinically useful tools that facilitate knowledge transfer into clinical care while concurrently addressing health equity issues. This model may provide an efficient and cost-effective alternative to traditional profession-based mental health training approaches, which have to date not been successful at meeting mental health delivery needs and mental health service priorities in LMICs.

Journal Article↗
PubMed1994

Homeless mentally disordered defendants: competency to stand trial and mental status findings.

This study examines relationships between homelessness and findings of incompetency to stand trial in a sample of mentally disordered offenders. All 263 defendants referred for competency evaluation over a six-month period by the Criminal and Supreme Courts in Manhattan were studied. Each defendant was evaluated by two forensic psychiatrists using a structured interview protocol. After removing "false-positive" referrals, 42 percent of the mentally disordered defendants referred to this setting were found to have been homeless at the time of their instant offense, making them more than 40 times more likely to be homeless than the general population and 21 times more likely to be homeless than the rest of the city's mentally ill population. Homeless mentally disordered defendants were significantly more likely to be found incompetent to stand trial than domiciled defendants (p < .007) but also presented with significantly higher levels of psychopathology. Examination of mental status findings revealed that homeless defendants were more likely to be psychotic, including a higher incidence of formal thought disorder and ideas of reference. The relationship between homelessness and incompetency seems to be mediated by psychotic symptoms, suggesting that these defendants are not being found incompetent because they are homeless, but that homeless defendants are more likely to be psychotic and to exhibit a greater degree of psychopathology. The clinical and public policy implications of these findings are discussed.

Adolescent↗
PubMed1984

Mental status tests and the capacity for self-care.

To test the hypothesis that self-care capacity can be predicted by tests of mental functioning, the performances of patients in a long-term care institution on a Self-Care Scale were compared with their scores on the Short Portable Mental Status Questionnaire (SPMSQ) and a Mental Competence Scale. The Self-Care Scale measures ability to perform activities of daily living; the SPMSQ assesses memory, orientation, and calculation; and the Mental Competence Scale measures ability to respond sensibly to interview questions and to judge the environment. Many people who had poor scores on the SPMSQ were able to perform activities of daily living in the nursing home setting, but none whose scores on the Mental Competence Scale were fair or poor were independent in activities of daily living. Despite the fact that both the Self-Care Scale and the Mental Competence Scale are still in the developmental stages, the author concludes that the SPMSQ is not an adequate predictor of capacity for self-care. Moreover, the ability to respond appropriately to an interview may be more relevant for daily functioning than are tests of mental status. The three methods of assessment used in this study measure distinct yet complementary components of functioning that need to be considered in evaluating a mentally impaired elderly person.

Activities of Daily Living↗
PubMed2004

Competence in mental health care: a hermeneutic perspective.

In this paper we develop a hermeneutic approach to the concept of competence. Patient competence, according to a hermeneutic approach, is not primarily a matter of being able to reason, but of being able to interpret the world and respond to it. Capacity should then not be seen as theoretical, but as practical. From the perspective of practical rationality, competence and capacity are two sides of the same coin. If a person has the capacity to understand the world and give meaning to the situation, he or she is able to make decisions, and is thus competent. People can fail in the area of practical rationality. They can feel ill at ease, uncomfortable or not at home in the situation. Under such conditions, they appear as incompetent, and urge caregivers to respond in such a way that their competence can be raised. The issue is not how to measure their incompetence, but how to help them to become more competent, that is to get a practical grip on their situation and to be able to live out their lives in such a way that they develop their identity in relations with others. From a hermeneutic point of view, assessing a patient's capacity implies focusing on the patient's way of meaning making and regarding her behavior from the perspective of practical rationality. The focus should not be on the assessment as a matter of fact, but on improving capacity. This requires allowing the patient to experience the world meaningfully and affording her, in the context of a supportive and trustful institutional environment, the possibility of developing a personal narrative where her choices are expressed verbally or non-verbally.

Adult↗
PubMed1997

The debate over risk-related standards of competence.

This discussion paper continues the debate over risk-related standards of mental competence which appears in Bioethics 5. Dan Brock there defends an approach to mental competence in patients which defines it as being relative to differing standards, more or less rigorous depending on the degree of risk involved in proposed treatment. But Mark Wicclair raises a problem for this approach: if significantly different levels of risk attach, respectively, to accepting and refusing the same treatment, then it is possible, on this account, for a patient to be considered competent to accept, but not refuse, the treatment, or vice versa. I argue that this puzzle does not constitute a genuine problem for a risk-related standard. To this end I focus on the situation where, of two mutually exclusive options, one is riskier, but offering more pronounced benefit, while the other is safer, but offering less benefit. I argue for this proposition: it can take far less insight to know that the safe option is good than to know that the risky option is better. Now say one is actually informed enough to know that the safe option is good, but not enough to know whether the risky option is better; in such a case one is competent to say yes to that first option (the safe one), but not to say yes to the other. (I argue in passing that Pascal's Wager can be interpreted as having precisely this deliberative structure.) I thus conclude that cases do indeed exist where one can be competent to say yes but not no, or vice versa; and that it is thus not an anomaly in the risk-related standard that it entails the existence of such cases.

Coercion↗
PubMed2005

Older immigrants: language competencies and mental health.

Later-life immigration and a lack of dominant language competency present many challenges to mental health for older adults. English as a Second Language (ESL) classes for seniors, often regarded as the sole domain of ESL teachers, offer mental health professionals opportunities for mental health promotion and education. This paper examines some of the mental health issues that emerged from stories written by older adults in an ESL for Seniors program. The program is presented as an example of best practices in an ESL for Seniors program because of its specific development to meet the needs of ESL older persons.

Aged↗
PubMed2002

[Competence to make decisions: the psychology of deliberate decision making].

This paper examines the psychological structure of mental competence, conceived of as competence in deliberate decision making. Analysis of that structure may be useful in understanding mental incompetence, as it occurs among some elderly persons. Mental competence not only depends on a number of cognitive abilities, such as foreseeing consequences, but also on the intactness of emotions, insight in one's own emotions, and abilities for emotion regulation.

Aged↗
PubMed1994

Hip arthroplasty in mentally impaired patients.

The outcome of elective hip arthroplasty in 11 mentally impaired patients was compared with a cohort of 244 mentally competent patients. The impaired patients had a diagnosis of cerebral palsy, schizophrenia, or Down's syndrome, and were unable to give their own surgical consent. Major complications requiring additional surgery occurred in 5 of the mentally impaired patients. Three patients sustained fractures of the femur below the stem and were treated with plating, 1 developed a deep infection requiring prosthesis removal, and 1 developed a thoracic decubiti with bone involvement requiring debridement and rotation flap coverage. Three of these patients also developed urinary tract infections. Of the other 6 mentally impaired patients, 3 developed urinary tract infections, and 1 had a deep venous thrombosis. Functional independence was improved after surgery in the mentally impaired patients. However, the average cost of hospitalization, length of stay, and complication rate were significantly higher (p < 0.05) than those of the mentally competent patients.

Activities of Daily Living↗
PubMed1998

Advance directives, competency evaluation, and surrogate management in elderly patients.

As patients age, their capacities for memory, judgment, reasoning, planning, and decision-making may erode. Preparing for the time when these losses occur involves three important strategies: advance directives, competency evaluation, and surrogate management. Advance directives allow currently competent patients to record the kind of medical procedures they desire if they become incompetent in the future. Competency evaluations determine the mental competence of a patient and require special training for the physician. The need for surrogate management increases as a patient's cognitive deficits worsen and often requires involvement of the legal system. This paper addresses these important strategies in detail.

Advance Directives↗
PubMed2003

Development of the Competency Assessment Tool-Mental Health, an instrument to assess core competencies for mental health care workers.

As the focus on accountability in health care increases, there has been a corresponding emphasis on establishing core competencies for health care workers. This article discusses the development of an instrument to establish core competencies for workers in inpatient mental health settings. Twenty-six competencies were identified and rated by mental health care personnel on two subscales: the importance of the competency and how much behavioral health care workers could benefit from training on the competency. The reliability of the scale and its contributions to the training, retention and recruitment of direct care workers for behavioral health are discussed.

Employee Performance Appraisal↗
PubMed2002

Cynthia's dilemma: consenting to heroin prescription.

Heroin prescription involves the medical provision of heroin in the treatment of heroin addiction. Rudimentary clinical trials on that treatment modality have been carried out and others are currently underway or in development. However, it is questionable whether subjects considered for such trials are mentally competent to consent to them. The problem has not been sufficiently appreciated in ethical and clinical discussions of the topic. The challenges involved throw new light on the role of value and accountability in contemporary discussions of mental competence.

Clinical Trials as Topic↗
PubMed1998

Towards an ethical protocol in mental health informatics.

Application of informatics to mental health has the potential to benefit a disadvantaged yet important patient group. At the same time, difficult issues are raised with regard to data protection and ethics because many patients are not able to express informed and rational views, and this increases their vulnerability. However, developments in this field are limited, and there is little literature. Generic data protection legislation and guidance assumes that data subjects are mentally competent adults. This paper distils key ethical issues and principles in mental health informatics, and describes a process which has initiated the identification of "reasonable" practice.

Adult↗
PubMedDate not supplied

Assessment of parental competence to consent to treatment for their child.

The admission of a child to the intensive care unit (ICU) represents a traumatic experience for parents. They may feel bombarded with information, loss of control and subject to enormous stress. The psychological stress of their child being admitted to ICU may render parents incapable of rational decision-making. Parents may receive frequent requests for consent at a time when their mental competence to do so may be questioned. Parental competence is affected by: information giving, effective communication and the perception of the person evaluating. The purpose of assessment of mental competence is to ensure that informed consent takes place and the best interests of the child are protected.

Adult↗
PubMed2002

Evaluation of do not resuscitate orders (DNR) in a Swiss community hospital.

OBJECTIVE: To evaluate the effect of an intervention on the understanding and use of DNR orders by physicians; to assess the impact of understanding the importance of involving competent patients in DNR decisions. DESIGN: Prospective clinical interventional study. SETTING: Internal medicine department (70 beds) of the hospital of La Chaux-de-Fonds, Switzerland. PARTICIPANTS: Nine junior physicians in postgraduate training. INTERVENTION: Information on the ethics of DNR and implementation of new DNR orders. MEASUREMENTS AND MAIN RESULTS: Accurate understanding, interpretation, and use of DNR orders, especially with respect to the patients' involvement in the decision were measured. Junior doctors writing DNR orders had an extremely poor understanding of what DNR orders mean. The correct understanding of the definition of a DNR order increased from 31 to 93% (p<0.01) after the intervention and the patients' involvement went from 17% to 48% (p<0.01). Physicians estimated that 75% of their DNR patients were mentally competent at the time of the decision. CONCLUSION: An intervention aimed at explaining the ethical principles and the definition of DNR orders improves understanding of them, and their implementation, as well as patient participation. Specific efforts are needed to increase the involvement of mentally competent patients in the decision.

Aged↗
PubMed2004

How to improve mental health competency in general practice training?--a SWOT analysis.

It is quite evident there is room for improvement in the primary care management of common mental health problems. Patients respond positively when GPs adopt a more proactive role in this respect. The Dutch general practice curriculum is currently being renewed. The topics discussed here include the Strengths, Weaknesses, Opportunities and Threats (SWOT) of present primary mental healthcare teaching. What works well and what needs improving? Integrated teaching packages are needed to help general practice trainees manage various presentations of psychological distress. Such packages comprise training videotapes, in which models such as problem-solving treatment (PST) are demonstrated, as well as roleplaying material for new skills, self-report questionnaires for patients, and small-group video feedback of consultations. While GP trainees can effectively master such skills, it is important to query the level of proficiency required by registrars. Are these skills of use only to connoisseur GPs, or to all? More room for specialisation and differentiation among trainees may be the way forward. We have just developed a new curriculum for the obligatory three-month psychiatry housemanship. It is competency oriented, self-directed and assignment driven. This new curriculum will be evaluated in due course.

Curriculum↗