Anticipatory planning for research participants with psychotic disorders like schizophrenia.

Current and coincident biomedical advances make this an opportune time to encourage research with individuals who have fluctuating periods of incapacity caused by psychotic disorders like schizophrenia. Effecting research with this heterogeneous population who may have impaired decision-making capacity that diminishes their autonomy, while honoring their liberty and safeguarding their well-being, may be difficult to achieve. Federal regulations and guidelines in regard to research with this population are insufficient and cause additional obstacles. Use of research advance directives that allow for the appointment of a surrogate decision maker, the designation of a research monitor, and delineation of specific safeguards for the research participants also may provide protection for investigators and foster and improve community trust in medical research. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

"A place like that": Advance directives and nursing home admissions.

Decisions about admitting a mentally incapacitated person to a nursing home raise a variety of difficult legal, ethical, and public policy issues. A strategy for anticipating and addressing this contingency prospectively, by encouraging execution of formal advance planning directives while the individual is still capable, may mitigate some of the dilemmas associated with these issues. The author discusses the contours and feasibility of such a strategy, analyzing the possible uses of advance directives both for prospectively authorizing nursing home admission on one's own behalf and for refusing such admission, or placing explicit conditions on such admission, in advance of the time that the actual decision must be made. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Evaluation of mentally retarded persons for sterilization: Contributions and limits of psychological consultation.

As a result of recent changes in legal standards governing sterilization of mentally retarded persons, psychologists may be asked to perform evaluations regarding petitions for sterilization. Specifically, according to the standard established by the In re Hayes decision, opinions of psychologists may be sought regarding the mentally retarded individual's competence to consent to sterilization, the association of a given syndrome with sterility, the likelihood of the individual's becoming sexually active, his/her parental competence and competence in use of contraceptives, trainability in menstrual hygiene, and the probability of scientific advances that might render the need for sterilization moot. Research relevant to these questions is reviewed, and it is suggested that psychologists may be of most help in consulting on alternatives to sterilization. Careful attention should be given to the moral and legal dimensions of the problem, and psychologists should be careful not to overstep the limits of their expertise. (42 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An alternative rationale for informed consent by human subjects.

Discusses the conscientious researcher's objection to the special emphasis placed on informed consent and proposes an alternative rationale for consent. If the special emphasis on informed consent derives from a distrust of researchers, then the underlying relationship between professionals and the community at large has broken down. However, since research, by definition, involves something that the expert does not yet understand, there is no reason to trust the judgment of the expert over that of the layperson. Therefore, Ss must be able to make a decision of whether or not to participate that is based on as much information as the researcher can provide. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Advance directives and withdrawal of dialysis in the United States, Germany, and Japan

OBJECTIVE: To determine the role of advance directives in decisions to withdraw chronic dialysis in the United States, Germany, and Japan. DESIGN: Survey by questionnaire. PARTICIPANTS: Seventy-two American, 87 German, and 73 Japanese nephrologists. MAIN OUTCOME MEASURES: Each nephrologist's total number of (1) dialysis patients, (2) cases of withdrawal of dialysis, (3) patients with advance directives, and (4) uses of such directives. Nephrologists also stated whether they would continue or stop dialysis in 8 hypothetical cases. RESULTS: American, German, and Japanese nephrologists reported withdrawing dialysis for 5.1%, 1.6%, and 0.7% of their patients in the last year, respectively. Thirty percent of American patients had advance directives, and such directives were used in decision making for 3.2% of all patients. Only 0.3% of German and Japanese patients had advance directives, and such directives were used in decision making for 0.09% of patients. When asked about a hypothetical mentally incompetent patient whose family requests withdrawal of dialysis, American nephrologists were much more likely to stop dialysis in the absence of an advance directive than German or Japanese nephrologists. However, almost all nephrologists from the 3 countries would stop dialysis when a family request to withdraw was supported by a patient advance directive. CONCLUSIONS: There is a high prevalence of advance directives among American dialysis patients, and such directives frequently play a role in decision making. German and Japanese nephrologists appear willing to follow advance directives, but the low prevalence of such directives limits the frequency of their use.     

Completing advance directives for health care decisions: Getting to yes.

The concept of advance directives for health care decision making has been judicially condoned, legislatively promoted, and systematically implemented by health care institutions, yet the execution rate of advance directives remains low. Physicians should discuss with their patients advance care planning generally and end-of-life issues specifically, preferably when patients are in good health and not when they face an acute medical crisis. The physician–hospital relationship poses particular challenges for the optimal implementation of advance directives that must be addressed. Hospital administrators must improve education of patients and physicians on the value of such documents as well as internal mechanisms to ensure better implementation of directives. Health insurance plans may be better able to ensure optimal gathering and implementation of directives. Patients must become more familiar and more comfortable with advance care planning and the reality of death and dying issues. Full acceptance of the value of directives ultimately rests on achieving full participation of all involved—providers, patients, families, and payors—in this most profound process. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Molecular biology in the modern work-up of the infertile male: the time to recognize the need for andrologists

The purpose of this study was to explore dangerousness and fire setting recidivism of mentally disordered firesetters in comparison with mentally healthy arsonists. In Germany, all trials are registered centrally by the Federal Central Register. The records of this Register for the three year period from 1983 until 1985 were used in this follow-up study of arsonists to identify three samples of subjects: (1) All persons convicted of arson who have been found not guilty by reasons of insanity (n = 186), (2) all person convicted of arson who have been found guilty of diminished responsibility (n = 97), and (3) a random selection from all persons convicted of arson who have had no psychiatric examination in their trial (n = 187). The follow-up ended in 1994, providing a period of, on average, ten years. Mentally disordered arsonists differed from non-mentally disordered arsonists in the following ways: They were more likely, first, to have a history of arson before 1983, and secondly, to be convicted of arson again (11% relapse compared to 4%). Mentally disordered arsonists had fewer registrations of common offenses, such as theft as well as traffic violations and alcohol-related offenses. Based on the present sample, mentally disordered firesetters have a higher rate of recurrence of firesetting than non-mentally disordered firesetters and commit fewer common offenses other than firesetting.     

Incapable adults and informal admission: another scenario

The Court of Appeal has once again caused a flurry of consternation with its decision that patients incapable of giving consent to admission to psychiatric hospital must, if the statutory provisions are present, be admitted compulsorily under the Mental Health Act 1983. This article submits that this decision can only cause increased bureaucracy and distress for thousands of mentally incompetent adults. The long-term solution is for the Law Commission's proposals for decision making for mentally incompetent adults to be enacted.     

Minors' competence to consent to abortion.

Psychological evidence regarding minors' competence to consent to abortion is reviewed. Topics covered include the source and nature of advice regarding the abortion decision, conformity to peer and parent advice, how the "developmental tasks" of adolescence influence pregnancy decision making, and reasoning skills. The small sample size and limited generalizability of existing research make it difficult to draw conclusions about minors' competence. Although several areas of potential difference between the decision-making skills of minors and legal adults are identified, the psychological research presently provides no basis to restrict minors' decision making on the ground of competence alone. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brain metastasis model in athymic nude mice using a novel MUC1-secreting human breast-cancer cell line, MA11

OBJECTIVES: This study explored parental attitudes about their interactions with their children's providers when decision making involved critical life situations. We evaluated parents' attitudes regarding the following questions: What was the parents' understanding of their children's health care issues, and what was the parental perception of the professionals' understanding of their children and of themselves? Who should be the principal decision makers for the children? What was the parents' knowledge about advance directives? Did parents want to participate in a process of advance planning to assist with critical life decision making for their children? METHODS: We surveyed all parents attending a conference sponsored by the Massachusetts Department of Public Health for parents of children with special needs. The questionnaire was provided to all parents attending the conference. An announcement was made at the conference requesting parental participation. The 76 respondents constitute a convenience sample of parents of children with special needs sufficient for this preliminary stage of investigation. RESULTS: Of 177 parents attending the conference, 76 (43%) completed the questionnaire. Eighty-eight percent of the participants strongly agreed that they understood their children's conditions. Twenty-one percent stated that they had sufficient understanding of their children's future medical needs, and 21% thought that they had a sufficient understanding of their children's developmental potential. Ninety-nine percent of parents strongly agreed that physicians should share information with parents no matter how serious or potentially upsetting. Ninety-four percent of those parents who thought that their children's physicians understood their own needs also thought that the physicians understood their children's needs. In contrast, only half (55%) of those parents who thought the physicians did not understand their needs thought the physicians understood their children's needs. Ninety-two percent of parents who thought that the physicians understood their needs agreed that the physicians would make the best decisions in crises versus 60% of those who did not think the physicians understood their needs. Seventy-four percent stated that they would consider written guidelines for their children that dealt with critical life situations. All parents who thought their children's conditions were not understood wanted written guidelines. Of those parents who had thought their children would not survive (15 parents), 94% wanted written guidelines. All seven parents who had been told their children would not survive wanted written guidelines. CONCLUSIONS: Parents in this study were generally satisfied with care being provided to their children. Nevertheless, the results clearly suggest goals that could lead to improved capacity for parents and providers to make critical life decisions for and with children. First, physicians must understand the needs of parents to be able to make decisions that would be in the children's best interests. Second, parents should participate fully in critical life decisions for their children and should use written guidelines to assist with the process of these critical life decisions. Our findings strongly support the development of a longitudinal process, initiated early after the onset or discovery of illness and maintained longitudinally throughout the course of a child's illness, to help parents and providers work together in this vital area of health care to children.     

Informing for consent: Concepts and methods.

Consent doctrine seeks to protect individual autonomy and self-determination of potential subjects or patients. It was created and mandated in reaction to perceived abuses in patient/subject and healthcare professional relationships. In part because of the speed in which these occurred, the doctrine was created as an imperative in the absence of solid theoretical and empirical bases on how people acquire and use information. The Informing for Consent framework is presented so that the mandates of consent can be more fully examined. The implications of this framework and the need for empirical study are discussed with reference to the following areas: when children become competent to self-consent and for which areas in decision making; when competence to self-consent changes during poor physical or mental health; when people become unable to consent; and when protections such as surrogate decision makers should be instituted or removed. The implications to individual professionals and to regulatory bodies are also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

General practice of advance directives in the USA

Definition of the problem: Advance directives are written documents which tell what a person wants or does not want if he/she in the future cannot make his/her wishes known about medical treatment. There are three major forms of advance directives in the US: living will, durable power of attorney, and medical directive. Even though advance directives have been used for over 25 years, probably no more than 20% of Americans have prepared a written directive. What are the reasons for this relatively small percentage? It has been argued that they run the opposing risks of either being too general or too specific and that they often use a vague and confusing terminology. Furthermore, the two most frequently cited barriers were the patient's expectation that the physician should take the initiative and the sense that such issues were only relevant for those who were older or in worse health. Progress in developing useful advance directives cannot stop with existing documents. A critical evaluation of advance directives and the development of new ideas will be necessary. Therein, the most important area for future efforts is empirical research.     

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.     

Psychology and mental retardation.

Presents the view that mental retardation is primarily a psychoeducational and social problem. In addition to traditional services, psychology can serve the mentally retarded in other indirect areas, e.g., new direct-care personnel training, institution management, manpower utilization in the retarded population, and help in changing the public image of the mentally retarded. It is concluded that psychology should increase its participation in education, training, and research in mental retardation, and that programs should be developed to demonstrate that psychological techniques and learning theories can be applied appropriately to the problems of the retarded person. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Getting meaningful informed consent from older adults: a structured literature review of empirical research

OBJECTIVES: To perform a structured literature review of the published empirical research on informed consent with older adults in order to make recommendations to improve the informed consent process and to highlight areas needing further examination. DESIGN: Relevant literature was identified by searching electronic databases (AGELINE, BIOETHICSLINE, CancerLit, Ethics Index, Health, LegalTrac, MEDLINE, PAIS International, PsycInfo, and Sociofile). Studies were included if they were reports of primary research data about informed consent and, if patients or other subjects were used, older subjects were included in the sample. Data related to the aspect of informed consent under study (recruitment, decision-making capacity, voluntariness, disclosure of information, understanding of information, consent forms, authorization, and policies and procedures) were abstracted and entered into a specially designed database. MEASUREMENTS: Characterization of the population, age of subjects, setting, whether informed consent was being studied in the context of research or treatment, study design, the nature of outcome or dependent variables, independent variables (e.g., experimental conditions in a randomized controlled trial or patient/subject characteristics in a nonrandomized comparison), and results according to the aspect of informed consent under study. RESULTS: A total of 99 articles met all the inclusion criteria and posed 289 unique research questions covering a wide range of aspects of informed consent: recruitment (60); decision making capacity (21); voluntariness (6); disclosure (30); understanding (139); consent forms (7); authorization (11); policies (13); and other (2). In the secondary analyses of numerous studies, diminished understanding of informed consent information was associated with older age and fewer years of education. Older age was also sometimes associated with decreased participation in research. Studies of disclosure of informed consent information suggest strategies to improve understanding and include a variety of novel formats (e.g., simplified, storybook, video) and procedures (e.g., use of health educators, quizzing subjects, multiple disclosure sessions). CONCLUSIONS: A systematic review of the published literature on informed consent reveals evidence for impaired understanding of informed consent information in older subjects and those with less formal education. Effective strategies to improve the understanding of informed consent information should be considered when designing materials, forms, policies, and procedures for obtaining informed consent. Other than empirical research that has investigated disclosure and understanding of informed consent information, little systematic research has examined other aspects of the informed consent process. This deficit should be rectified to ensure that the rights and interests of patients and of human subjects who participate in research are adequately protected.     

Decision processes in personnel selection.

Reviews some of the research on decision making in personnel selection, with special attention to the greater weighting of unfavorable information in selection decisions and to the nature of causal attributions in the personnel interview. A 2-stage selection model is proposed in which decision makers first make attributions about the applicant and then categorize the applicant either as matching or not matching the dimensions of the category "good worker" as determined by deviance from the prototype "ideal worker." The attribution process ends when sufficient dimensions have been evaluated to provide a match or mismatch, and the length of the process should vary as a function of such factors as the number of dimensions, their clarity and specificity, and the accountability of the decision maker. It is suggested that job applicants perform a parallel decision-making process to match their needs and the perceived ability of the organization to meet them. (French abstract) (33 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The status of the mentally ill in Jewish law

The Jewish law goes into great detail discussing the status of the mentally ill. There are many aspects to this question over and above the legal aspects of such a person's rights, obligations, doing business, etc. What is the Halachic approach to a mentally ill person in general? Is this person subject to the code of Jewish law the same as the normal Jew? Should we make an effort to help this type of person fulfil the commandments and prevent him or her from transgressing them or perhaps since such a person is incapable of controlling his or her behaviour, there is no purpose in these efforts? Marriage and divorce are other serious issues to which the Jewish law gives special attention in this context. Marriage must be entered into by a rational and judicious person or the act will not be valid. A very serious problem arises when a husband is mentally ill and due to that halachically cannot divorce his wife and she remains an Agunah. The situation is more complicated as the definition of mentally ill encompasses a broader spectrum of cases. Which psychiatric disorders come under the definition of a mentally ill person who is unable to control his or her behaviour? Which symptoms attest the inability of a person to enter into marriage or to grant a divorce? The Talmud discusses these matters in several places and the Halacha bases its rulings on their conclusions.     

Ethical Guidelines for Psychologist Participation in Death Penalty Proceedings: A Survey.

Many states are reinstituting the death penalty and are asking psychologists to participate in the sentencing process. In some states we are asked to predict whether the person is likely to be a continuing danger to society. In other states we are asked if there are any reasons why the person should not be put to death. The question remains as to whether we as a profession want to be used as "agents of the State" in criminal, especially death penalty, proceedings. The APA (1978) task force recommended that as protection from abuses, ethical guidelines be instituted for psychologists working in legal settings. The basic thrust of these guidelines is the ensure that mental health expert testimony is truly expert and rest of a scientific, empirical base. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Minors' consent to treatment: A developmental perspective.

Discusses the cognitive and behavioral characteristics of minors in relation to the question of competence to consent to treatment. The legal standard (knowing, intelligent, and voluntary) used to judge the effectiveness of consent is translated into psychological concepts, especially cognitive abilities. A review of developmental psychological research is presented, which examines these concepts as they relate to minors' abilities to satisfy the legal standard. It is suggested that cognitive developmental stages associated with ages below 11–23 yrs might exclude such minors from meaningful consent. In addition to cognitive considerations, certain results suggest that the tendency toward deference in early adolescence is so normative that capacity for voluntary consent is questionable through age 14, but existing evidence provides no psychological grounds for maintaining the general legal assumption that minors at age 15 and above cannot provide competent consent. (63 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)