Jochen Vollmann

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 Cohens 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.

The Cognitive Based Approach of Capacity Assessment in Psychiatry: A Philosophical Critique of the MacCAT-T

This article gives a brief introduction to the MacArthur Competence Assessment Tool-Treatment (MacCAT-T) and critically examines its theoretical presuppositions. On the basis of empirical, methodological and ethical critique it is emphasised that the cognitive bias that underlies the MacCAT-T assessment needs to be modified. On the one hand it has to be admitted that the operationalisation of competence in terms of value-free categories, e.g. rational decision abilities, guarantees objectivity to a great extent; but on the other hand it bears severe problems. Firstly, the cognitive focus is in itself a normative convention in the process of anthropological value-attribution. Secondly, it misses the complexity of the decision process in real life. It is therefore suggested that values, emotions and other biographic and context specific aspects should be considered when interpreting the cognitive standards according to the MacArthur model. To fill the gap between cognitive and non-cognitive approaches the phenomenological theory of personal constructs is briefly introduced. In conclusion some main demands for further research to develop a multi-step model of competence assessment are outlined.

Information and participation in decision-making about treatment: a qualitative study of the perceptions and preferences of patients with rheumatoid arthritis

Objectives: To elicit the perceptions and preferences of patients with rheumatoid arthritis regarding information and participation in treatment decision-making. To analyse the patients’ narratives on the background of the ethical discourse on various approaches to treatment decision-making. Design: In-depth interviews with themes identified using principles of grounded theory. Participants: 22 patients with long-standing rheumatoid arthritis. Main outcome measures: Qualitative data on patients’ perceptions and preferences regarding information and participation in decision-making about treatment. Results: Decision-making about treatment has been described by the patients as a process consisting of different stages with shifting loci of control and responsibility. Patients initially received one treatment recommendation and were not aware of alternative treatment options. Those participants in this study who wanted information about negative effects of a treatment cited “interest in one’s own health” and the potential “use of information” as reasons for their preference. The physicians’ expert knowledge and clinical experience regarding the effects of medication were cited as arguments by patients for a treatment recommendation. Conclusions: The patients’ accounts of decision-making about treatment differ from models of physician–patient relationship that have been put forward in ethical discourse. These differences may be relevant with respect to the starting point of an ethical analysis of treatment decision-making. Patients’ accounts with respect to a lack of information on treatment alternatives point to ethically relevant challenges regarding treatment decision-making in clinical practice.

End-of-life practices in palliative care: a cross sectional survey of physician members of the German Society for Palliative Medicine

Objectives: To elicit types and frequencies of end-of-life practices by physician members of the German Society for Palliative Medicine. To analyse associations between characteristics of physicians and patients and end-of-life practices with intended hastening of death. Design: Cross-sectional postal survey. Main outcome measures: Types and frequencies of end-of-life practices with foreseeable or intended hastening of patients’ death. Association between end-of-life practices with hastening of death and predefined characteristics of physicians and patients. Results: Nine hundred and one physicians participated in the study (response rate: 55.8%). There was alleviation of symptoms in 78.1% and limitation of medical treatment with possible life shortening in 69.1% of cases. In 10 cases medication had been administered by the physician (N = 9) or the patient (N = 1) with the intention to hasten death. Patients’ best interest and avoidance of possible harm to the patient were reported as reasons for non-involvement of competent patients in decision making. Physicians with added qualification in palliative medicine significantly less frequently reported end-of-life practices with intended hastening of death (p = 0.003). Conclusion: Physician members of the German Society for Palliative Medicine perform a broad spectrum of end-of-life practices including intended hastening of death. The findings on patients’ non-involvement in decision making warrant further empirical—ethical analysis.

Teaching and evaluating breaking bad news: A pre-post evaluation study of a teaching intervention for medical students and a comparative analysis of different measurement instruments and raters

OBJECTIVE To investigate changes of different domains of breaking bad news (bbn) competences after a teaching module for medical students, and to collage the results generated by different approaches of evaluation. METHODS Rating of medical student-SP interactions by means of a global rating scale and a detailed checklist used by SPs and independent raters. RESULTS Students improved their breaking bad news competency. However, the changes vary between the different domains of bbn competency. In addition, results generated by different evaluation instruments differ. CONCLUSION This study serves as a stimulus for further research on the training of specific elements of bbn and different approaches of evaluating bbn competency. PRACTICE IMPLICATIONS In light of the different facets of bbn competency, it is important to set priorities regarding the teaching aims and to provide a consistent approach.

Advance directives in patients with Alzheimer's disease. Ethical and clinical considerations.

Advance patient directives are various forms of anticipatory medical directives made by competent individuals for the eventuality of future incompetence. They are therefore appropriate instruments for competent patients in the early stage of Alzheimers disease to document their self-determined will in the advanced stages of dementia. Theoretical objections have been expressed against the concept of advance patient directives (problems of authenticity and identity) which, however, cannot negate the fundamental moral authority of advance patient directives. Therefore, patients, family members, and physicians should make use of the appropriate form of advance directive as part of common treatment and care planning. Advance directives, when utilized intelligently, represent appropriate instruments for shared decision-making by patient, family members and physician. They should be utilized to a greater extent, particularly for the treatment planning of demented patients.

Information provision and decision-making in assisted reproduction treatment: results from a survey in Germany

BACKGROUND The objective of this study was to investigate the views of patients and experts in Germany on information provision and decision-making in assisted reproduction treatment (ART). METHODS Standard questionnaire techniques were used for interviewing Reproductive Physicians (n= 230), Psychosocial Counsellors (n = 66) and Patients (n = 1590). Descriptive data analyses and non-parametric tests for significance were performed. RESULTS Higher scores were assigned for information on the chances for treatment success and on direct, physical risks of fertility treatment than for information on the risks and burden of multiple pregnancies and on the emotional risks and burden associated with infertility treatment. Three-quarters (74%) of the Patients (P) reported that they had experienced an overwhelming desire for a child at some point during their treatment, and half (47%) stated that they had experienced the feeling of losing control over the situation. According to 25% of the Reproductive Physicians (RP) and 47% of the Psychosocial Counsellors (PC), patients are often or very often limited in their capacity to decide when to stop the treatment. CONCLUSIONS A significant number of patients in reproductive care in Germany are not well informed on all the aspects that are relevant for treatment decision-making, are overwhelmed by their desire for a child, lose control over the situation, and are limited in their capacity to end unsuccessful treatment. Information provision should be ensured and monitored during treatment by standardized safeguards. A strategy for stopping ART and embarking on alternative ways of coping with infertility should be installed from the outset of every treatment.

Ethische Fragen in der Psychiatrie

Die Erschutterungen eines tiefgreifenden Wandels gesellschaftlicher Strukturen durch neue Informationstechnologien, globalen Wirtschaftswettbewerb und Grenzen der sozialen Sicherung, auch das Ende des kalten Krieges und — zumal in Deutschland — die Konfrontation unterschiedlich sozialisierter Menschen mit einer Wiederholung der Aufarbeitung von Vergangenheit bilden den Hintergrund fur die gegenwartige Sensibilisierung gegenuber den ethischen Implikationen der dramatischen Veranderungen der Medizin und damit auch der Psychiatrie. So kann die wiederaufgelebte Diskussion um die Euthanasie nicht losgelost gesehen werden von der starken Zunahme von Menschen mit schwersten Residualschaden nach intensivmedizinischer Behandlung lebensbedrohlicher Zustande und auch nicht von der Zunahme sehr alter hilfsbedurftig kranker Menschen infolge der gestiegenen Lebenserwartung, aber ebenso von einem zunehmenden Patientenwunsch nach Selbstbestimmung.

Research participants' perceptions and views on consent for biobank research: a review of empirical data and ethical analysis.

BackgroundAppropriate information and consent has been one of the most intensely discussed topics within the context of biobank research. In parallel to the normative debate, many socio-empirical studies have been conducted to gather experiences, preferences and views of patients, healthy research participants and further stakeholders. However, there is scarcity of literature which connects the normative debate about justifications for different consent models with findings gained in empirical research. In this paper we discuss findings of a limited review of socio-empirical research on patients’ and healthy research participants’ experiences and views regarding consent to biobank research in light of ethical principles for appropriate information and consent.MethodsReview question: Which empirical data are available on research participants’ perceptions and views regarding information and elicitation of consent for biobank research? Search of articles published till March 1st 2014 in Pubmed. Review of abstracts and potentially relevant full text articles by two authors independently. As categories for content analysis we defined (i) understanding or recall of information, (ii) preferences regarding information or consent, and (iii) research participants’ concerns.ResultsThe search in Pubmed yielded 337 abstracts of which 10 articles were included in this study. Approaches to information and consent varied considerably across the selected studies. The majority of research participants opted for some version of limited consent when being informed about such possibility. Among the factors influencing the type of preferred consent were information about sponsoring of biobank research by pharmaceutical industry and participants’ trade-off between privacy and perceived utility. Studies investigating research participants’ understanding and recall regarding the consent procedure indicated considerable lack of both aspects. Research participants’ perceptions of benefits and harms differ across those studies.ConclusionThe knowledge, perceptions and views of research participants who have undergone a consent procedure within the context of biobank research raise several questions on the issue of how to inform and elicit consent in an ethically acceptable way. In our empirical-ethical analysis we develop suggestions on how the practice of eliciting consent in the biobank context should be improved.

Patientenverfügungen von Menschen mit psychischen Störungen

ZusammenfassungSeit dem 01.09.2009 sind Patientenverfügungen in Deutschland gesetzlich geregelt. Der Artikel stellt die ethischen Problembereiche des verfügten Patientenwillens bei Menschen mit psychischen Störungen dar. Neben der Passgenauigkeit ist die Selbstbestimmungsfähigkeit/Einwilligungsfähigkeit des Patienten bei der Abfassung der Verfügung Voraussetzung für deren Gültigkeit. Neben dem „Decisional Competence Assessment Tool for Psychiatric Advance Directives“ werden empirische Studien aus den USA über Patientenverfügungen von Menschen mit psychischen Störungen und deren Beurteilung durch die behandelnden Psychiater vorgestellt. Für die psychiatrische Praxis werden ethische Schlussfolgerungen gezogen.SummarySince 1 September 2009, advance directives are regulated by law in Germany. This article discusses ethical challenges of advance directives in patients with mental disorders. Besides concrete information on the preferred medical treatment in concrete clinical situations, the mental capacity of the patient at the time of issuing the directive is essential.The „Decisional Competence Assessment Tool for Psychiatric Advance Directives“ and empirical studies from the USA on advance directives in patients with mental disorders and the assessment by the treating psychiatrists of these patient directives are discussed. Ethical conclusions are drawn for handling advance directives in psychiatric practice.