Sunday, October 17, 2004

Lancet looks at mental capacity....

on medical wards, and finds that patients are often more impaired than we think. Often, ill patients nod their consent to us. "Sure, doc, your plan sounds good to me." But how many are really comprehending us? Impairments are more likely to be noticed when a patient is refusing tests, or resisting treatment. Then we get a call. "Is this person competent?" Right off, we ask: competent for what? Impairments can vary, and sometimes fluctuate. They can be general and total, or they can be quite specific. And the processes patients use to make decisions can be mysterious.

At the Institute of Psychiatry in London, researchers interviewed 159 patients on acute medical wards. The article states that thirty-one percent showed impaired ability to make valid judgments. But staff recognition was low: "... only a quarter of patients identified by the investigators as not having mental capacity were identified by clinicians."

"Professor Hotopf comments: “A substantial proportion of inpatients in any general medical ward do not have capacity to make informed treatment decisions, a situation that is rarely recognised by doctors. If a legal approach to solve this problem is too heavy-handed-eg, requiring patients to be more explicitly identified and protected-then people who would be affected by such legislation could be adversely affected.

"However, to accept the passive acquiescence of such patients as evidence of true consent would be dangerous when important and irreversible decisions need to be made. Before making such decisions, the clinician should have considered the possibility that the patient is unable to give valid consent”.

"In an accompanying commentary (p 1383), Jason Karlawish (Institute on Ageing, Philadelphia, USA) concludes: “The critical issue is how we use these data to regulate the freedom to decide, especially in elderly people with mild stages of cognitive impairments. Data are not available but are urgently needed to answer the following questions: What information do raters use, how do they use it, and what are the consequences of these differences? Do experts, clinicians, and families still disagree on capacity judgments, even with the same information and judgment question? Wht are the ethical, legal, and clinical consequences of these disagreements? How do clinicians' and families' failures to recognise impairments in the capacity to make decisions affect quality of, adherence to, and outcomes of care?"
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