Manuel Trachsel

Cognitive Fluctuations as a Challenge for the Assessment of Decision-Making Capacity in Patients With Dementia

Decision-making capacity (DMC) is an indispensable prerequisite for medical treatment choices, including consent to treatment, treatment discontinuation, and refusal of treatment. In patients with dementia, DMC is often affected. A particular challenge in assessing DMC are cognitive fluctuations that may lead to a fluctuation in DMC as well. Cognitive fluctuations are a diagnostic core feature of dementia with Lewy bodies and occur in Parkinson’s and Alzheimer’s diseases. In this article, these challenges are discussed and suggestions for assessing the DMC of patients with dementia with cognitive fluctuations are presented.

Physicians’ personal values in determining medical decision-making capacity: a survey study

Decision-making capacity (DMC) evaluations are complex clinical judgements with important ethical implications for patients’ self-determination. They are achieved not only on descriptive grounds but are inherently normative and, therefore, dependent on the values held by those involved in the DMC evaluation. To date, the issue of whether and how physicians’ personal values relate to DMC evaluation has never been empirically investigated. The present survey study aimed to investigate this question by exploring the relationship between physicians’ value profiles and the use of risk-relative standards in capacity evaluations. The findings indicate that physicians’ personal values are of some significance in this regard. Those physicians with relatively high scores on the value types of achievement, power-resource, face and conformity to interpersonal standards were more likely to apply risk-relative criteria in a range of situations, using more stringent assessment standards when interventions were riskier. By contrast, those physicians who strongly emphasise hedonism, conformity to rules and universalism concern were more likely to apply equal standards regardless of the consequences of a decision. Furthermore, it has been shown that around a quarter of all respondents do not appreciate that their values impact on their DMC evaluations, highlighting a need to better sensitise physicians in this regard. The implications of these findings are discussed, especially in terms of the moral status of the potential and almost unavoidable influence of physicians’ values.

Testing a german adaption of the entrapment scale and assessing the relation to depression.

The construct of entrapment is used in evolutionary theory to explain the etiology of depression. The perception of entrapment can emerge when defeated individuals want to escape but are incapable. Studies have shown relationships of entrapment to depression, and suicidal tendencies. The aim of this study was a psychometric evaluation and validation of the Entrapment Scale in German (ES-D). 540 normal subjects completed the ES-D along with other measures of depressive symptoms, hopelessness, and distress. Good reliability and validity of the ES-D was demonstrated. Further, whereas entrapment originally has been regarded as a two-dimensional construct, our analyses supported a single-factor model. Entrapment explained variance in depressive symptoms beyond that explained by stress and hopelessness supporting the relevance of the construct for depression research. These findings are discussed with regard to their theoretical implications as well as to the future use of the entrapment scale in clinical research and practice.

Disclosure of incidental constituents of psychotherapy as a moral obligation for psychiatrists and psychotherapists

Informed consent to medical intervention reflects the moral principle of respect for autonomy and the patients right to self-determination. In psychotherapy, this includes a requirement to inform the patient about those components of treatment purported to cause the therapeutic effect. This information must encompass positive expectancies of change and placebo-related or incidental constituent therapy effects, which are as important as specific intervention techniques for the efficacy of psychotherapy. There is a risk that informing the patient about possible incidental constituents of therapy may reduce or even completely impede these effects, with negative consequences for overall outcome. However, withholding information about incidental constituents of psychotherapy would effectively represent a paternalistic action at the expense of patient autonomy; whether such paternalism might in certain circumstances be justified forms part of the present discussion.

Informed consent for psychotherapy: still not routine

www.lancet.com/psychiatry Vol 2 September 2015 775 public understanding both of the natural history of the illness and of the options in end-of-life care. At present, the pathway for people with dementia is likely to include a fragmented set of interactions with diff erent healthcare services that is weighted towards a diagnosis, while the day-to-day management of the condition relies on families and communities. The availability of post-diagnostic support can be unduly infl uenced by the pressure to discharge patients from services. Integration of health and social services could provide a window of opportunity for intelligent commissioning that takes a whole-systems approach and identifi es a coordinator of care that is most appropriate to the individual; such integration can also signpost to a range of services and help people to plan for future needs. Advance care planning is just one of many postdiagnostic interventions that include cognitive stimulation therapy, education, carer’s support, and social groups, which contribute to the possibility of living well with dementia. However, these interventions are currently denied to many patients because mental health services are commissioned to tackle discrete tasks such as diagnosis and crisis management, whereas primary-care services have the task of reviewing care annually and also off er anticipatory care planning. Coordinated support through the course of the illness is lacking. Additionally, to broaden the public’s understanding of the natural history of dementia and of the options for future care, we depend on two things. The fi rst is our willingness as clinicians to share information on the course of the illness. We need to be far more skilled at information sharing and supporting informed decision making. For people with dementia to make valid decisions, they need to know what it means to have dementia, what the future might involve, and what decisions will have to be made. Second, we need the support of the wider media in generating a fuller public understanding of dementia and in tackling, not promulgating, myths around end-oflife care. Truly informed decision making needs patients, clinicians, and the public to be brave enough to have some very diffi cult conversations.

Compulsory Treatment in Chronic Anorexia Nervosa by All Means? Searching for a Middle Ground Between a Curative and a Palliative Approach

Geppert (2015) has argued that mental disorders like anorexia nervosa (AN) do not fulfill the classic criteria for futility. We agree with her central thesis that “the contention that an ‘end-stage...

Paternalism, Placebos, and Informed Consent in Psychotherapy

From a legal as well as ethical point of view, healthcare professionals are nowadays obliged to obtain informed consent (IC) of patients. Consequently, paternalism is eschewed in most ethical codes of practice and IC. But what should IC mean in psychotherapy? With respect to this question, the claim that psychotherapy may be a placebo may raise grave concerns for its ethical practice. Indeed, almost since the inception of psychotherapy some scholars have claimed that psychotherapy is a sham and/or it may work as a placebo. However, we argue that in clinical biomedicine there is still much conceptual confusion about the terms ‘placebo’ and ‘placebo effect’; moreover, we contend that the term ‘placebo’, when applied to psychotherapy, may invite more questions than it can easily resolve. Nonetheless, we assert that the core moral debate about clinical placebos raises important themes that are transferable to a psychotherapy context: namely: Are therapists providing adequate information to patients about how psychotherapy works? In light of ongoing empirical research into psychotherapy we argue that therapists may be failing to mention key features (so-called common factors) that are relevant to the process of therapeutic change. We assert that current psychotherapy practice appears to exhibit misplaced paternalism in failing to provide patients with this information. We conclude that any justification for paternalism on the grounds of beneficence is unfounded and that adequate disclosure policies are likely to enhance rather than undermine the therapeutic process.Gesundheitsfachpersonen sind heutzutage sowohl aus rechtlicher als auch ethischer Sicht dazu verpflichtet, für jede medizinische Intervention die informierte Einwilligung ihrer Patienten einzuholen. Dementsprechend hat paternalistisches Vorgehen gegenüber Patienten in den meisten ethischen Richtlinien keinen Platz mehr. Was genau bedeutet aber informierte Einwilligung im Kontext der Psychotherapie? In Bezug auf die ethische Rechtfertigung von Psychotherapie könnte z.B. die Behauptung, dass Psychotherapie nichts anderes als Placebo sei, für die informierte Einwilligung zum Problem werden. Tatsächlich wurde seit der Entstehung der modernen Psychotherapie immer wieder kritisiert, sie sei Augenwischerei und ihre Wirkung gründe auf einem Placeboeffekt. Wir argumentieren, dass im gesamten Feld der Biomedizin nach wie vor konzeptuelle Unschärfen hinsichtlich der Begriffe «Placebo» und «Placeboeffekt» bestehen. Wir sind zudem überzeugt, dass der Begriff «Placebo» im Bereich der Psychotherapie mehr Fragen aufwirft als die Auseinandersetzung damit zu beantworten vermag. Nichtsdestotrotz sind wir sicher, dass die moralisch geführte Kerndebatte über Placebo im klinischen Kontext wichtige Themen berührt, die in den psychotherapeutischen Kontext überführt werden können, nämlich: Informieren Therapeuten ihre Patienten in adäquater Weise über die Wirkmechanismen von Psychotherapie? Legen sie die potenziellen Risiken unerwünschter Nebeneffekte offen? In Anbetracht der kontinuierlichen empirischen Psychotherapieforschung folgern wir, dass Therapeuten ihren Patienten die allgemeinen Wirkfaktoren der Psychotherapie, die maßgeblich den Veränderungsprozessen während der Behandlung unterliegen, nicht hinreichend transparent machen. Somit scheint uns, dass es in der psychotherapeutischen Praxis oft zu verstecktem und unangebrachtem Paternalismus kommt. Wir sind davon überzeugt, dass sich Paternalismus in der Psychotherapie auch beim Vorliegen guter Absichten nicht rechtfertigen lässt und dass eine adäquate Offenlegung der angenommenen Wirkfaktoren für den therapeutischen Prozess nützlich ist.

Emotion and Value in the Evaluation of Medical Decision-Making Capacity: A Narrative Review of Arguments

Ever since the traditional criteria for medical decision-making capacity (understanding, appreciation, reasoning, evidencing a choice) were formulated, they have been criticized for not taking sufficient account of emotions or values that seem, according to the critics and in line with clinical experiences, essential to decision-making capacity. The aim of this paper is to provide a nuanced and structured overview of the arguments provided in the literature emphasizing the importance of these factors and arguing for their inclusion in competence evaluations. Moreover, a broader reflection on the findings of the literature is provided. Specific difficulties of formulating and measuring emotional and valuational factors are discussed inviting reflection on the possibility of handling relevant factors in a more flexible, case-specific, and context-specific way rather than adhering to a rigid set of operationalized criteria.

Palliative psychiatry for severe and persistent mental illness

Despite all of psychiatrys efforts to prevent mental illness and to promote recovery, some patients will develop severe and persistent mental illness (SMI). These patients represent a particularly vulnerable population, at risk of either therapeutic neglect or overly aggressive care. We propose a complementary approach in the treatment of SMI; palliative psychiatry, as a means to improve quality of care, person-centeredness, and autonomy for SMI patients.

Attributional styles and stress-related atherogenic plasma lipid reactivity in essential hypertension

OBJECTIVE Hypertension and an atherogenic lipid profile are known risk factors for coronary heart disease (CHD). Hypertensives show greater changes in atherogenic plasma lipids to acute stress than normotensives. In this study, we investigated whether attribution of failure is associated with lipid stress reactivity in hypertensive compared with normotensive men. METHODS 18 normotensive and 17 hypertensive men (mean±SEM; 45±2.2 years) underwent an acute standardized psychosocial stress task that can be viewed as a situation of experimentally induced failure. We assessed external-stable (ES), external-variable (EV), internal-stable (IS), and internal-variable (IV) attribution of failure and psychological control variables (i.e. extent of depression and neuroticism). Moreover, total cholesterol (TC), low-density-lipoprotein cholesterol (LDL-C), and norepinephrine were measured immediately before and several times after stress. RESULTS ES moderated TC- and LDL-C-stress reactivity in hypertensives as compared to normotensives (interaction mean arterial pressure [MAP]-by-ES for TC: F=3.71, p=.015; for LDL-C: F=3.61, p=.016). TC and LDL-C levels were highest in hypertensives with low ES immediately after stress (p≤.039). In contrast, hypertensives with high ES did not differ from normotensives in TC and LDL-C immediately after stress (ps>.28). Controlling for norepinephrine, depression, and neuroticism in addition to age and BMI did not significantly change results. There were no significant associations between lipid baseline levels or aggregated lipid secretion and IS, IV, or EV (ps>.23). CONCLUSION Our data suggest that ES may independently protect from elevated lipid stress reactivity in hypertensive individuals. ES thus might be a protective factor against CHD in hypertension.