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At least 109 records · Page 6Linked to original sources
PubMed1992

The do-not-resuscitate order in a nursing home: patient's choice or staff's decision.

An 86-year-old woman in a residential health care facility suffered a massive stroke; immediate intubation was performed, she was transferred to a nearby hospital where she died two months later. Within 48 hours of this event, three mentally competent residents and one family member on the unit requested a do-not-resuscitate order. They, along with the seven other mentally competent and non-terminal residents on the unit, participated in a questionnaire survey, the purpose of which was to elicit information on DNR attitudes. Only one respondent requested cardiopulmonary resuscitation. All insisted that do-not-resuscitate decisions were theirs alone to make. A staff questionnaire was given to 81 employees having many years of health care experience. Most had witnessed death and cardiopulmonary resuscitation and knew of its poor outcome. However, 51% were very willing to participate in cardiopulmonary resuscitation, and 65% thought cardiopulmonary resuscitation was worthwhile in residential health care facilities. Furthermore, 56.8% thought that families should participate in the decision. The dichotomy between residents' wishes and staff perceptions merits recognition and further study.

Aged↗
PubMed1979

Development of articulatory competence in mentally retarded children.

Mentally retarded children participated in a verbal stimulation program developed at the Institute for Psychophysiological and Speech Disorders, Belgrade, Yugoslavia. Intensive home therapy was associated with an increase in articulatory competence in both moderately and profoundly retarded children. The development of articulation differed between retardate groups as well as with the sequence of normal phonological production. The results suggest that the order in which wounds are introduced into the therapeutic program may be a critical factor in the over-all development of competent articulation.

Child↗
PubMed1998

Appreciation and emotion: theoretical reflections on the MacArthur Treatment Competence Study.

When emotions are mentioned in the literature on mental competence, it is generally because they are thought to influence competence negatively; that is, they are thought to impede or compromise the cognitive capacities that are taken to underlie competence. The purpose of the present discussion is to explore the possibility that emotions might play a more positive role in the determination of competence. Using the MacArthur Treatment Competence Study as an example, it is argued that appreciation, a central theoretical concept in many contemporary approaches to competence, has important emotive components that are seldom sufficiently recognized or acknowledged. If true, this means that some leading contemporary accounts of competence need to be revised in order to make more adequate provision for the positive contribution of emotion.

Cognition↗
PubMed1977

False belief and the refusal of medical treatment.

May a doctor treat a patient, despite that patient's refusal, when in his professional opinion treatment is necessary? This is the dilemma which must from time to time confront most physicians. An examination of the validity of such a refusal is provided by the present authors who use the case history of a patient refusing treatment, for cancer as well as for a fractured hip, to evaluate the grounds for intervention in such circumstances. In such a situation the patient is said to have a 'false belief' and it is the doctor's duty to try to change that belief in the patient's interest. The false belief is considered here in terms of the liberty principle, the patient's mental competence and on what is called the 'harm principle' (harm to other individuals or to society). Finally the concept of paternalism is examined. The authors conclude that the doctor must attempt to change a false belief, and if this fails he must examine the patient's mental competence to make the decision to refuse treatment. But in the last analysis the doctor may be under an obligation to respect the patient's refusal. Readers might like to look at (or read again) the papers on 'Liberty' and 'Conscience' published in this Journal under the heading Analysis.

Attitude to Health↗
PubMed1992

[A project on eating disorders. Increasing of competence within mental health services in treating severe eating disorders].

We describe a two-year education programme for health workers treating patients with eating disorders. The intention of the programme was partly to increase the knowledge and ability of the participants themselves, and partly to spread this knowledge to other health workers not directly involved in the programme. The programme attracted 66 participants. It was composed of theoretical lectures, group supervision, clinical work with patients with eating disorders and individual supervision as needed. Evaluation at the end of the programme showed a greater feeling of competence and more positive attitudes towards treating these particular patients. More than 80% of the participants had supervised other health workers outside the programme, and nearly 50% had held lectures on the treatment of eating disorders.

Clinical Competence↗
PubMed2004

[Conscious refusal of food and fluids by Dutch nursing home patients in order to hasten death: a matter regarding patient and physician?].

Refusal of food and/or fluids frequently occurs in nursing home patients. If the patient's decision to stop eating and drinking has been taken consciously and with due consideration of the consequences, it is referred to in Dutch as 'versterven'. A mentally competent, 73-year-old male nursing home patient suffering from progressive supranuclear palsy wished, in order to prevent further suffering, to end his life by taking sleeping tablets that he had saved up and by refusing artificial food and liquids. This wish met with a lot of legal and moral objections from the board of directors of the nursing home as well from experts consulted by the nursing home physician. Closer examination afterwards, however, showed that the patient would have been spared a lot of uncertainty if all parties concerned had been better informed as to the legal and moral framework. There are no legal objections as long as the doctors assess the refusal of food and drink with regard to voluntariness, deliberateness and permanence. If we as a society accept that mentally competent patients who are fully aware of the consequences and of possible alternative methods of treatment may take this road, then there would seem to be no moral obstacles either.

Aged↗
PubMed1997

Informed consent and psychiatric research.

The general problem with research is that its purpose does not necessarily benefit an individual patient now. In psychiatry the specific problem is that psychiatric patients may have a reduced mental competence, because of their illness. Thus the specific clinical problems of the research subjects may impede the ethical requirements of the research. To try to solve this conundrum, we may need to move away from a vision of psychiatric ethics which is rights and individual based, and find another, which understand that ethical decision are made in the context of relationship: psychiatrist-patient, patient-society, analyst-patient, psychiatrist-society.

Altruism↗
PubMed2005

Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years.

BACKGROUND: Recent randomized, controlled trials performed at two years postoperatively have shown that a primary total hip replacement is superior to internal fixation for the treatment of a displaced femoral neck fracture in a relatively healthy, mentally competent, elderly patient. The primary aim of the present study was to evaluate the outcomes at four years. METHODS: One hundred and two patients (mean age, eighty years) who had an acute displaced femoral neck fracture were randomly allocated to be treated with total hip replacement or internal fixation. The inclusion criteria were an age of at least seventy years, absence of severe cognitive dysfunction, an independent living status, and the ability to walk independently. The main outcome measurements were hip complications, reoperations, hip function, and health-related quality of life. RESULTS: The mortality rate was 25% in both groups. At the forty-eight-month follow-up evaluation, the rate of hip complications was 4% in the patients treated with total hip replacement and 42% in those treated with internal fixation (p < 0.001) and the reoperation rates were 4% and 47%, respectively (p < 0.001). The arthroplasty group had no additional hip complications or reoperations between the twenty-four and forty-eight-month follow-up visits. In the fixation group, the percentage of hip complications increased from 36% to 42% and the percentage of reoperations increased from 42% to 47% during the same period. The hip function was significantly better and the decline in health-related quality of life was less pronounced in the arthroplasty group than it was in the fixation group at the four, twelve, and twenty-four-month follow-up evaluations. Ninety-seven percent of the patients in the arthroplasty group and 57% of the patients in the fixation group who were available for follow-up at forty-eight months had no hip complications (p < 0.001). CONCLUSIONS: Compared with internal fixation, primary total hip replacement provides a better outcome for mentally competent elderly patients with a displaced femoral neck fracture. The complication and reoperation rates were significantly lower and hip function and health-related quality of life were at least as good at four years after the surgery.

Aged↗
PubMed1986

Assessing the employment-related interpersonal competence of mildly mentally retarded workers.

Interpersonal competence has been identified as a key variable in the vocational success of mentally retarded adolescents and adults. Unfortunately, few tests are available that address this critical skill area. The purpose of this article is to describe the Test of Interpersonal Competence for Employment (TICE), a measure designed to assess mildly retarded worker's knowledge of interpersonal skills in the employment setting. This test was developed using the Behavioral-Analytic Model of Test Development (Goldfried & D'Zurilla, 1969). This procedure called for the detailed analysis of the problems that mildly retarded workers experience in the vocational setting and the identification of correct responses to those problems by competitive employers. The TICE was standardized on both high school and workshop populations. Overall, the initial psychometric properties of the test are uniformly adequate and encouraging.

Adolescent↗
PubMed2000

Permitting suicide of competent clients in counseling: legal and moral considerations.

State statutes, case law, and professional codes of ethics in the mental health professions typically stress either a duty or the permissibility of disclosing confidential information in order to prevent clients from seriously harming themselves. These sources are intended to address cases where clients are deemed to be suffering from cognitive dysfunction for which paternalistic intervention, including involuntary hospitalization, is considered necessary to prevent self-destructive behavior. The counselor's moral and legal responsibility is less apparent when mentally competent clients desire suicide as release from irremediable suffering due to severe physical illness, and this desire is defensible within these clients' value systems. This paper will explore moral and legal dimensions of a counselor's decision not to intervene in such cases. The concept of permitted suicide will be introduced and defined, and guidelines for its application developed.

Commitment of Persons with Psychiatric Disorders↗
PubMed1994

The psychometric properties of the Competency Interview Schedule.

One of the most contentious issues in medical and legal practice is how to reliably assess the mental competence of individuals who consent or refuse psychiatric treatment. Current legislation does not provide clear definitions of what constitutes competence or incompetence to make a treatment decision. As a preliminary attempt to operationalize the concept of competency, we have developed a 15 item questionnaire. The present study reports on the psychometric properties of the instrument. Test-retest and interrater reliability results were good. The instrument was internally consistent and discriminated between individuals found competent and incompetent by the treating physician.

Adult↗
PubMed2000

Misguided guidelines.

The proposed guidelines would require detailed, probing inquiry into motivation for choosing assisted suicide. This is an appropriate requirement in principle. In practice, it will be virtually impossible to carry out this inquiry within likely statutory time limits. Evaluators most likely will either reject the guidelines as impractical or give them merely perfunctory observance. There is, moreover, an inherent tension in the evaluator's relationship with the patient between empathy and impersonal distancing that the guidelines do not adequately acknowledge; this tension necessarily compromises the evaluator's ability to apply the guidelines in the probing, detailed manner they envision. The guidelines provide false comfort that physician-assisted suicide can be carried out with adequately sensitive monitoring of voluntariness and mental competence.

Decision Making↗
PubMed2005

[Study of rating scale of mentally prisoner's competency to serve a sentence].

OBJECTIVE: To create an instrument to determine the mental prisoners' competency to serve a sentence, which is according with the Chinese legal system. METHODS: Integrating the Chinese criminal jurisprudence and the authors' forensic psychiatric experience, the research team created an instrument which called Competency to serve a sentence Rating scale firstly, then used the instrument retrospectively, in the end the validity and reliability of the instrument were inspected and, through an diagnostic test, the feasibility of the instrument was evaluated. RESULTS: Homogeneity reliability of the instrument is 0.8779, the correspondence of the conclusion between the instrument and the expertise is 0.909, except the positive likelihood ratio is 0.0683, the other diagnostic index are better. CONCLUSION: The Competency to serve a sentence Rating Scale is feasible.

Adult↗
PubMed1997

Caring about risks. Are severely depressed patients competent to consent to research?

Depressed patients are often asked to take part in clinical research studies that carry risk. These patients are generally assumed to be mentally competent to consent to research, since depression often leaves a patient's cognitive abilities intact. In this article, it is argued that many severely depressed patients may not be competent to consent because they cannot be considered accountable for their decisions. The article presents 2 arguments: first, that it is unclear whether the decisions of some severely depressed patients are authentically theirs, and second, that some severely depressed patients may not have the appropriate minimal degree of concern for their own well-being. It is argued that assessments of competence must take account of emotional factors, and that, if severely depressed patients are incompetent to consent, research studies involving a poor risk-benefit ratio will be much more difficult to justify.

Depressive Disorder↗
PubMed1994

Depression, competence, and the right to refuse lifesaving medical treatment.

OBJECTIVE: The authors explore the possibility that psychiatrists inappropriately extend their views on suicide by the medically well to refusal of lifesaving treatment by the seriously medically ill. METHOD: The legal and bioethics literature on competence to refuse lifesaving treatment and the possible impact of depression on this refusal is reviewed. RESULTS: Over the past 20 years, the burden of proof concerning the mental competence of seriously medically ill patients who refuse lifesaving treatment has shifted to the persons who seek to override these refusals. However, in psychiatry a patient's desire to die is generally considered to be evidence of an impaired capacity to make decisions about lifesaving treatment. This contrast between ethical traditions is brought into clinical focus during the evaluation and treatment of medically ill patients with depression who refuse lifesaving treatment. The clinical evaluation of the effect of depression on a patient's capacity to make medical decisions is difficult for several reasons: 1) depression is easily seen as a "reasonable" response to serious medical illness, 2) depression produces more subtle distortions of decision making than delirium or psychosis (i.e., preserving the understanding of medical facts while impairing the appreciation of their personal importance), and 3) a diagnosis of major depression is neither necessary nor sufficient for determining that the patient's medical decision making is impaired. CONCLUSIONS: Depression can be diagnosed and treated in patients with serious medical illness. But after optimizing medical and psychiatric treatment and determining that the patient is competent to make medical decisions, it may be appropriate to honor the patient's desire to die.

Attitude to Health↗
PubMed2001

On risk and decisional capacity.

Limits to paternalism are, in the liberal democracies, partially defined by the concepts of decision-making capacity/incapacity (mental competence/incompetence). The paper is a response to Ian Wilks's (1997) recent attempt to defend the idea that the standards for decisional capacity ought to vary with the degree of risk incurred by certain choices. Wilks's defense is based on a direct appeal to the logical features of examples and analogies, thus attempting to by-pass earlier criticisms (e.g., Culver & Gert, 1990) of risk-based standards. Wilks's argument is found wanting on the grounds that he misconstrues the logic of such capacity, especially in accounting for conceptual and pragmatic ties with issues of decisional authority. A diagnosis is offered as to the source of Wilks's error (the assumption that mental competence is a species of wider genus of "competence"), and an alternative way of accounting for risk within the predominant contemporary legal framework is sketched.

Choice Behavior↗