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Background: Dementia is assumed to alter mental capacity, which may necessitate legal guardianship. However, only limited research exists on how dementia affects mental capacity, and most studies have focused solely on a medical perspective and concentrate on memory functions. The aim of this qualitative study was to investigate physicians' and legal experts' perceptions on a broad range of cognitive and neuropsychiatric domains potentially affecting mental capacity and the need for guardianship in people with dementia. Methods: Physicians (N = 30) and legal experts (N = 20) participated in semi‐structured individual interviews. The data were analyzed by using content analysis and further semi‐quantified according to the cognitive and neuropsychiatric domains. Results: Physicians considered neuropsychiatric symptoms and executive dysfunction to be the most important deficits in the legal context, while legal experts highlighted episodic memory impairment and dyscalculia. Perceptions regarding the importance of several cognitive and neuropsychiatric symptoms varied between and within the professional groups. Conclusions: Physicians and legal experts diverged in their perceptions of cognitive and neuropsychiatric domains affecting mental capacity and the need for guardianship. The evaluation and influence of medical evidence among legal experts heavily rely on subjective opinions. Given the substantial potential impact on patients' equal access to their rights, developing standardized guidelines is essential. [ABSTRACT FROM AUTHOR]

Should the assessment of decision‐making capacity (DMC) be risk sensitive, that is, should the threshold for DMC vary with risk? The debate over this question is now nearly five decades old. To many, the idea that DMC assessments should be risk sensitive is intuitive and commonsense. To others, the idea is paternalistic or incoherent, or both; they argue that the riskiness of a given decision should increase the epistemic scrutiny in the evaluation of DMC, not increase the threshold for DMC. We respond to the critics' main concerns by providing a comprehensive account of how risk‐sensitive DMC is coherent, avoids paternalism, and best fulfills the epistemic goal of DMC evaluations. [ABSTRACT FROM AUTHOR]

Genetic variations are overrepresented in people with intellectual disability (PwID), particularly those with physical and mental health co‐morbidities, but remain significantly under‐diagnosed. Lack of suitable research studies, a natural extension of the complexities posed of consenting and recruitment is considered culpable. There is a resultant dearth of evidence on establishing bespoke genetic studies for adult PwID. This report outlines the challenges faced in the implementation and administration of a pilot genetic study for adult PwID hoping to better inform future genetic study designs for PwID. Adult participants with a diagnosis of ID (ICD10 F70‐F73) and epilepsy (ICD10 G40) were recruited to The Peninsula study exploring genomic stratification in intellectual disability and epilepsy via the ethically approved Royal Devon and Exeter Tissue Bank (RDETB) (16/SC/016). Managed within the National Institute for Health Research (NIHR) Exeter Clinical Research Framework, the RDETB was set up to proactively collect and store 'spare' tissue from routine clinical procedures such as venepunctures for routine good practice biochemistry monitoring. Participants who satisfied the criteria for the need for routine bloods to monitor their general health were identified to be invited for participation. From October 2017 to March 2020 from a total caseload of 375 PwID and epilepsy, 291 were screened (77.6%), 116 (39.9%) identified as potentially eligible and sent study information and genetic samples obtained from 30 (8%). Analysis showed 75% of PwID had some biochemical abnormalities requiring further medical attention. The recruitment was influenced by the clinical care set up in implementing the sanctioned ethics. However, where bloods were achieved it proved to be beneficial in identifying hitherto undiagnosed medical problems. While the challenges to gain consent, are considerable, the reasonable adjustments needed to facilitate participation and the immediate clinical benefits where engagement was successful are significant. [ABSTRACT FROM AUTHOR]

The number of adults who self‐neglect and thus fall under the aegis of local authority adult safeguarding procedures in England has increased substantially since the introduction of the Care Act 2014. The requirement for collaborative working between agencies dealing with these adults in a safeguarding context is explicit in government policy and legislation. Decisions made by the multiplicity of agencies that may work with people who self‐neglect are largely guided by the Mental Capacity Act 2005 (MCA). The overall objective of this research was to develop a clearer understanding of how the range of agencies that might typically be involved in the life of a self‐neglecting person work together. This article examines how agencies put the MCA into practice in their work with people who self‐neglect, and how they understand their own and others' roles and responsibilities in so doing. This qualitative study took place in two local authorities in England from 2016 to 2017 and informed a wider action research study which was completed in 2019. Non‐probability purposive sampling was used to recruit participants from the professional groups who might typically be involved with self‐neglect cases. À total of 245 participants from across 17 different professional groups took part in semi‐structured interviews, in a group, paired or individual format, decided by their customary working configuration. Data from the interview transcripts was analysed using thematic analysis. Three key themes in relation to how participants understood the MCA and multi‐agency working emerged from the analysis of this data set. These were; a lack of understanding of the MCA by participants and other agencies; a reluctance to engage with MCA assessments; and a perception of manipulation of the MCA by other professionals. This study underlines the importance of the informed application of the MCA in working with people who self‐neglect, and an urgent need to consider how this could be enhanced if the service user is not to experience intrusive interventions resulting from professional misinterpretation. [ABSTRACT FROM AUTHOR]

This study explores the experiences of professionals who worked with care home residents with impaired mental capacity in England and Wales during the COVID‐19 pandemic. It explores (i) how competing risks were balanced and (ii) how the Mental Capacity Act (MCA) functioned in care homes under pandemic conditions, with particular focus on its associated Deprivations of Liberty Safeguards (DoLS) and Independent Mental Capacity Advocacy (IMCA) systems. Between March and May 2021, we held an online survey and five focus groups aimed at professionals who worked in or with care homes during the pandemic. The study explored issues pertaining to residents with impaired mental capacity, alongside several other topics on which we report elsewhere. For this paper, we filtered data to only include responses from 'capacity professionals'. The resulting sample comprised 120 (out of 266) survey participants and 18 (out of 22) focus group participants. We performed manifest content analysis on the filtered data and found that (1) participants reported a 'massive discrepancy' between the ways different care homes balanced the risk of COVID‐19 infection with the risks associated with severe restrictions. (2) Some suggested this was due to vague guidance, as well as care home type and size. Participants told us the pandemic (3) obstructed smooth operation of statutory safeguards designed to protect residents' human rights and (4) resulted in confusion about the remit of the MCA during a public health crisis. Our findings raise concerns about the impact of pandemic‐related measures upon care home residents with impaired mental capacity. We urge further exploration and analysis of (a) the variability and inconsistency of restrictions applied at care homes, (b) the strain placed on key safeguards associated with the MCA, (c) uncertainty about the remit of the MCA during a public health crisis and (d) the human rights implications hereof. [ABSTRACT FROM AUTHOR]

Background: The need for highly effective therapies in rheumatologic diseases has led to the widespread and growing use of a heterogeneous class of molecules called biological agents. The increasing experience with biological agents has raised concerns about safety and efficacy issues that need to be discussed in the informed consent acquisition process. Methods: The authors performed a review of the literature on biological agents focusing on their most important characteristics concerning the informed consent procedures. Results: No studies specifically addressed the issue of informed consent in patients receiving biological agents. Several studies reported data about off‐label use of biological agents usually with no obvious attention to informed consent shortcomings. Conclusion: The reported association between biological agents and serious infections or malignancies, including reactivation of latent tuberculosis, needs specific disclosure in informed consent acquisition, together with information about the possible efficacy in clinical contexts often characterized by resistance to previous treatments. Ethical and clinical issues bound to the need for experimenting with new agents with potentially serious adverse effects deserve specific attention. Studies aimed at evaluating mental capacity to consent in subjects receiving biological agents are required. [ABSTRACT FROM AUTHOR]

This article presents the findings from a qualitative, participatory research project which explored how people with intellectual disabilities and/or mental health problems have, or have not been, supported to make their own decisions. The aim of the research is to help inform how supported decision‐making, as required by Article 12 of the UN Convention on the Rights of Persons with Disabilities, can be effectively operationalised. The project provides an overview of experiences of support as well as identifying which supports are valued. It was conducted between July 2017 and July 2018 and was a partnership between disabled people, service providers and a University. It involved peer researchers interviewing 41 people with mental health problems and/or intellectual disabilities, in community settings, about their experiences and views of support. The key findings include that decision‐making is a central aspect of people's lives. Participants discussed the positive role which decision‐making can have but also how it felt when they were not supported to make their own decisions. Participants said that there were three main things that make decision‐making harder: the type of decision; the role of other people; and what the outcome might be. Time was consistently identified as a very important factor. In terms of support, people said that they would like: practical support including more accessible information; emotional support including someone to talk to; and sometimes the options to choose from. There was very little mention of existing, more formal processes of support such as advance decisions or care planning. The peer researcher aspect of the project was valued by participants. The main implications of the research are for how support for decision‐making should be provided including the need for an individualised approach as the support needed varies across decisions, time and people. [ABSTRACT FROM AUTHOR]

Objective: Decision-making capacity assessments for hospital settings are challenging as it is dominated by the ethical and legal principles of maintaining autonomy and protection. Health clinicians, especially in rural areas, are challenged with a lack of a standardised processes and pathways for decision-making capacity assessment. A literature review was conducted to determine what measurement tools clinicians are utilising in the hospital setting for decision-making capacity assessment and how decisions relating to consent to treatment, independent living and finances are made. Design: Literature review. Method: A search of MEDLINE, EMBASE and PsycINFO databases from January 2006 to April 2019 was conducted for peer-reviewed articles to determine how decision-making capacity assessments are conducted and the tools clinicians are utilising in the hospital setting. Results: Five main themes were identified from this review: (a) domains of capacity; (b) capacity assessment; (c) capacity assessment instruments; (d) who performs capacity assessment; and (e) challenges and limitations to capacity assessment in the hospital setting. Currently, there is no gold standard for capacity assessment. Conclusion: This review shows that there is currently a lack of a uniform approach or a singular test to determine capacity. It is proposed that a multidisciplinary approach to decision-making capacity assessment could be an effective model in the hospital setting, especially in rural health due to limited access to aged care specialists. It is important that clinicians receive ongoing training in decision-making capacity assessment and further research is recommended in this specialised area of practice. [ABSTRACT FROM AUTHOR]

Background: A new legal capacity act was introduced in Ireland in 2015. This study aimed to identify and critically examine key issues in the area of decision‐making capacity from the perspective of psychologists working with adults with an intellectual disability. Methods: A qualitative exploratory approach was employed, and the study was positioned in a social constructionist framework. Purposive and snowballing sampling methods were used to recruit 15 clinical psychologists working with adults with an intellectual disability. Data were collected with the use of individual semistructured interviews. Interview transcripts were analysed using a model of thematic analysis. Results: Six themes were identified: (1) a presumption of capacity but a culture of incapacity, (2) supporting decision making as a process, (3) authenticity of decision making, (4) need for support and training, (5) contributions of psychology and (6) the way forward. Conclusions: Participants described that people with intellectual disabilities were often excluded from decision‐making processes. They welcomed the functional approach to decision making, considered substituted decision making to be necessary within a support framework and described supporting decision making as a process. Systemic, resource and attitudinal challenges were identified. [ABSTRACT FROM AUTHOR]

Capacity assessments are performed when there is suspicion that a person is unable to adequately care for their physical, medical, or financial well‐being. The purpose of these assessments is to inform the legal system as to whether or not guardianship may be necessary. It is well established that certain mental illnesses, such as neurocognitive disorders (dementia) or psychotic disorders (like schizophrenia), may diminish capacity and, in some cases, lead to the need for establishment of a legal guardian. However, personality disorders are another common category of mental illness which may impair decision‐making. There is very little information in the literature about how or why these disorders could impair capacity, and thus, it can often be difficult to discern whether clients with personality disorders are substantially unable to care for themselves—versus unwilling to act in a way contrary to their ingrained habits. We present a series of three cases in which clients are determined to lack capacity primarily mediated by a personality disorder diagnosis. They are demonstrated to have mild deficits in cognitive functioning, but they show impaired decision‐making out of proportion to these deficits. In all three cases, it is apparent that the personality disorder is substantially impairing their ability to care for themselves. Discussion includes consideration for ways to incorporate evaluations of cognitive function, activities of daily living, and personality considerations into capacity assessments, and how to approach recommendations (such as guardianship vs. less restrictive option) based on both level and scope of impairment. [ABSTRACT FROM AUTHOR]

This study reviewed perceived changes to planning and management of transitions to adulthood for young people with special educational needs and disabilities in three local authorities in England, following implementation of the Children and Families Act (2014). Wenger's 'community of practice' theoretical framework was used to examine how groups of professionals and managers working in education, health and social care in three areas, set about implementing selected radical changes required by the legislation. Telephone interviews with sixteen participants were transcribed and subjected to thematic analysis. Themes identified related to professional activity, planning and organisation, implications for young people and families and outcomes. There were indications of shifts in professional conceptualisations and reported practices as a result of the Act. Participants described enhanced cross‐service communication and co‐ordinated working practices, achieved though service restructuring, co‐location and changed lines of accountability. An increased emphasis on long‐term planning and involving young people in planning and decision‐making was evident with regard to defining outcomes, and living and working as an adult. The results are considered in relation to the extent that mandated change can influence attitudes and cultures within communities of practice, contributing to the contemporary theoretical debate to incorporate issues relating to power. [ABSTRACT FROM AUTHOR]

Background: Mental capacity assessments currently rely on subjective opinion. Researchers have yet to explore the association between key cognitive functions of rational decision making and mental capacity classifications for people with intellectual disabilities. Method: Sixty‐three adults completed the Montreal Cognitive Assessment, which yielded estimates of their overall cognitive ability (MoCA‐LD) as well as their memory, attention, language and executive functioning. Differences in scores were explored for those who had, and lacked, capacity, and logistic regression was used to test the predictive validity of each measure. Results: There were significant differences between both groups for all measures. Logistic regression identified MoCA‐LD as a significant predictor of capacity assessment outcomes. ROC curve analysis provided novel, evidence‐based benchmarks to help guide clinical practice based on MoCA‐LD scores. Conclusion: This study offers a foundation for more objective approaches to mental capacity assessment. This demonstrates that assessments of cognitive ability can yield information that is helpful for mental capacity evaluations. [ABSTRACT FROM AUTHOR]

Background: This article is about interactions that occur when someone with intellectual disabilities is engaged in everyday activities with a personal assistant (PA) or a support worker. Method: We examine the detail of nine hours of naturally occurring video‐recorded interactions, to explore how "relational autonomy" is done in practice. Nine people with ID and seven staff took part in the research, which took place in England from 2016–17. Results: We selected six extracts to illustrate different types of joint decision‐making. Informed by inclusive research with a drama group of people with intellectual disabilities, we focus on the ways in which (a) future plans are discussed; (b) choices are offered during an activity; (c) people reflect on their decisions. Conclusion: The article concludes with discussion about the teaching and learning content of choice‐making, on relational autonomy, and the practice learning for PAs, support workers and for people with intellectual disabilities. [ABSTRACT FROM AUTHOR]

ABSTRACT: Background: This research explores the current and potential future role of independent mental capacity advocates (IMCAs) in critical care. The Mental Capacity Act (MCA) of 2005 introduced IMCAs as advocates for patients without anyone to represent their best interests, but research suggests that this role is not well understood or implemented. No existing research explores the role of IMCAs in critical care or their potential use when families are judged ‘appropriate to act’ on the patient's behalf. It is suggested that families may not be best placed to advocate for their sick family member when they themselves are in a state of shock. Aim: To investigate existing levels of knowledge and awareness of the MCA and understanding of the role of IMCAs in critical care as a prelude to considering whether the role of IMCAs might usefully be extended. The concept of ‘IMCA clinics’ is introduced and explored. Design and methods: A small‐scale qualitative study using thematic analysis of 15 interviews across two NHS sites and a survey of IMCA services were undertaken. Results: Some knowledge of the MCA was evident across both study sites, but training on MCA remains unsatisfactory, with confusion about the role of IMCAs and when they should become involved. Overall, participants felt that the broader involvement of IMCAs on a regular basis within critical care could be useful. Conclusions: There was evidence of good practice when instructing IMCAs, but further work needs to be conducted to ensure that critical care staff are informed about the referral process. It was clear that expanding the role of an advocate warrants further investigation. Relevance to clinical practice: Further training on the role of IMCAs within critical care is required, and good practice examples should be shared with other units to improve referral rates to the IMCA service and ensure that vulnerable patients are properly represented. [ABSTRACT FROM AUTHOR]

Abstract: In 1989, the House of Lords first derived a ‘best interests’ test for the medical treatment of adults who lack capacity from the doctrine of necessity and, now codified, the test continues to apply today. The Mental Capacity Act 2005 sets out a non‐exhaustive checklist of relevant considerations, but it gives no particular priority to the patient's wishes. There is also no formal expectation that the patient will participate directly in any court proceedings in which her best interests are to be determined. This article will consider the advantages and disadvantages of providing additional guidance to decision‐makers in order to help them navigate both taking seriously the wishes of people who lack capacity and, at the same time, not abandoning patients who need help and support. More specifically, this article advocates formalising current best practice in the Court of Protection through the introduction of a series of rebuttable presumptions, or starting points. [ABSTRACT FROM AUTHOR]

Background This small, qualitative study sought to develop a richer understanding of the way in which the deprivation of liberty safeguards (DOLS) were being used for people with intellectual disabilities. It is important to note that this study was completed prior to the changes resulting from the P v Cheshire West and Chester Council judgement. Method Six DOLS cases were identified and two people involved in each case were interviewed (care home managers, key workers, social workers, specialist nurses or psychologists), using semi-structured interviews. The data were analysed using grounded theory techniques. Results The interviewees described DOLS as providing a framework leading to positive outcomes for the people they supported, in some cases avoiding inpatient stays. However, they had a number of concerns including lack of knowledge and training, potential under use of DOLS and disappointment with case law. Conclusion Overall, these findings are encouraging in regard to the specific individuals for whom DOLS applications were made; however, they also highlight the need for a stronger agenda regarding wider dissemination of information, and training about DOLS, as well as some reform. [ABSTRACT FROM AUTHOR]

This paper reports findings from a study that aimed to explore how practitioners were bringing together the demands of the personalisation agenda, in particular the offer of direct payments (DPs), with the Mental Capacity Act, and to investigate current practices of offering and administering indirect payments for people who lack capacity to consent to them, including the use of 'suitable person' proxies under the new regulations ( DH, 2009). The study adopted a qualitative interview-based design; participants were social work practitioners (67) and recipients of 'indirect' payments (18) in six local authorities in England in 2011-2012. The paper reports on five key decision-making points in the indirect payments process: the decision to take on an indirect payment, the assessment of mental capacity, the identification of a suitable person, the establishment of the care recipient's best interests and the decisions about how to execute the indirect payment. We found that practitioners and suitable people had different experiences of the system, although in both cases, there was overarching support for the benefits of enabling people who lack capacity to consent to a DP to receive their social care funding in the form of an 'indirect' payment via a proxy suitable person. [ABSTRACT FROM AUTHOR]

Accessible summary Accurate assessment of a patient's mental capacity is important, yet out of the clinical assessments currently available, there does not appear to be sufficient accessible tools suitable for people with a learning disability., Incorrect assumptions are often made regarding the capacity of patients who have learning disabilities to make decisions about important aspects of their life., This preliminary study investigated whether or not it was possible to adapt a well-known assessment of cognitive impairment (The Montreal Cognitive Assessment) and use this as a tool to determine capacity in patients with a learning disability., Abstract Objective: To determine the psychometric properties of the Montreal Cognitive Assessment (MoCA) in patients with a learning disability and examine it's utility for conducting mental capacity assessment. Method: This study was a cross-sectional, instrument validation study in an inpatient hospital setting, located in the East of England. The sample consisted of two groups: (i) 31 consecutively admitted hospital patients and (ii) 10 multidisciplinary team members who served as a comparison group. The MoCA, a 12-item screen for mild cognitive impairment and the Dysexecutive Questionnaire (DEX), were used in this study. Item analysis was conducted by comparing item endorsement for all participants that had a learning disability utilising Difficulty and Discrimination Indices for each item on the MoCA. We examined the internal consistency of a revised scale derived from item analysis and used a one-way ANOVA to determine concurrent validity by comparing scores between two patient subgroups and the comparison group. Results: A 7-item scale, 'MoCA-LD' (alpha coefficient = 0.82) emerged from item analysis. A statistically significant negative correlation was observed between MoCA-LD and DEX (Pearson correlation = −0.66, P < 0.01). As expected, participants in the borderline category scored higher on MoCA-LD than those with mild learning disability, as did those with no learning disability ( P < 0.001). Conclusion: The MoCA-LD has the potential to be a useful tool for mental capacity assessment in patients with a learning disability. [ABSTRACT FROM AUTHOR]

This article addresses 'statutory wills' executed under the Mental Capacity Act 2005 ( MCA) for persons with impaired mental capacity. The article provides an overview of the historical development of statutory wills, before exploring their rising contemporary significance. It considers the shift from the previous 'hypothetical substituted judgment' test to the contemporary 'best interests' orientation of the MCA. The article assesses the problems that the best interests approach raises in this area, and its (in)compatibility with the right to equal recognition before the law under the UN Convention on the Rights of Persons with Disabilities, arguing that the pervasive reach of best interests in contemporary mental capacity law requires reconsideration. The paper concludes by suggesting that a more limited framing of the power to execute statutory wills is required in order to appropriately balance the rights of individuals with disabilities with practical considerations around the distribution of assets on death. [ABSTRACT FROM AUTHOR]

The Convention on the Rights of Persons with Disabilities is increasingly seen as driving a paradigm shift in mental health law, particularly in relation to the understanding that it requires a shift from substituted to supported decisions. This article identifies two competing moral commitments implied by this shift, both of which appeal to the notion of autonomy. It is argued that because of these commitments the Convention is in tension with more general calls in the medical ethics literature for preserving patient autonomy through support. The competing commitments within the Convention also present a particular challenge in putting the support it requires into practice. A discursive control account of freedom is used to develop some practical guidelines for navigating this new moral territory. [ABSTRACT FROM AUTHOR]

Objectives Implemented in 2007, the Mental Capacity Act (MCA) 2005 codified decision-making for adults unable to make decisions for themselves in England and Wales. Among other changes, two new offences of wilful neglect and ill-treatment were created under Section 44. Our study explored how the MCA was being implemented in community-based dementia care, focusing on frontline practice. Method Using qualitative longitudinal methodology, we interviewed 279 practitioners, in the London and South-East area of England, two or three times over 3 years. We applied framework analysis to identify and delineate recurrent themes. Results Views of the new offences were positive overall, but understanding ranged from partial to non-existent among some participants. Conclusions Clinicians may be increasingly called upon to provide advice on whether an alleged victim or perpetrator lacks decision-making capacity in cases of suspected elder abuse. They need to be aware of the new criminal offences to ensure that people with dementia, among others, are not abused and that abusers are brought to account. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Compulsory in-patient refeeding of patients with severe anorexia nervosa (AN) has caused considerable controversy. The effects of such treatment on longer-term outcome are not well known. The objective of this article is to review the evidence on the outcome of compulsory treatment for AN. Method Three large databases were searched for studies regarding compulsory treatment in AN. Results Detained patients have more severe symptoms and comorbidity and a longer duration of inpatient stay. In the short term compulsory refeeding in AN appears to be beneficial, but the longer term effects remain uncertain. Clinicians report no worsening of the therapeutic relationship after compulsory treatment. Discussion In severe cases of AN where the patient refuses life-saving treatment compulsory treatment needs to be considered. Future research should focus on the longer term effects of compulsory treatment and also on questions related to mental capacity in AN. © 2014 Wiley Periodicals, Inc. (Int J Eat Disord 2014; 47:845-852) [ABSTRACT FROM AUTHOR]

The recent Mental Capacity Act (2005) sets out a test for assessing a person's capacity to make treatment choices. In some cases, particularly in psychiatry, it is unclear how the criteria ought to be interpreted and applied by clinicians. In this paper, I argue that this uncertainty arises because the concept of capacity employed in the Act, and the diagnostic tools developed to assist its assessment, overlook the inherent normativity of judgements made about whether a person is using or weighing information in the decision-making process. Patients may fail on this criterion to the extent that they do not appear to be handling the information given in an appropriate way, on account of a mental impairment disrupting the way the decision process ought to proceed. Using case law and clinical examples, I describe some of the normative dimensions along which judgements of incapacity can be made, namely epistemic, evaluative and affective dimensions. Such judgements are complex and the normative standards by which a clinician may determine capacity cannot be reduced to a set of criteria. Rather, in recognizing this normativity, clinicians may better understand how clinical judgements are structured and what kinds of assumption may inform their assessment. [ABSTRACT FROM AUTHOR]

Ruissen AM, Widdershoven GAM, Meynen G, Abma TA, van Balkom AJLM. A systematic review of the literature about competence and poor insight. Objective: Formally, incompetence implies that a patient cannot meet the legal requirements for informed consent. Our aim was to review the scientific literature on the relationship between competence and insight in patients with psychiatric disorders, how competence and insight are connected in these patients and whether there are differences in competence and insight among patients with different disorders. Method: A search in PubMed/Medline was performed. Articles were assessed on relevance criteria by two independent reviewers. Study design, population, variables, and outcomes were extracted. Results: Seven articles were included on studies of psychiatric inpatients and outpatients and of psychotic and non-psychotic patients. All studies used the MacArthur Competence Assessment Tool (MacCAT). All studies but one found a strong correlation between poor insight and incompetence. Psychotic patients with poor insight are very likely to be incompetent, and psychotic patients with adequate insight are generally competent. One well-executed study showed that in non-psychotic disorders, however, another relationship emerges; competence and insight do not completely overlap in these patients. Conclusion: Most incompetent psychotic patients have poor insight, but non-psychotic patients with adequate insight were incompetent in a substantial number of cases. In sum: non-psychotic patients with adequate insight can be incompetent. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the state of knowledge of mental capacity issues among health and social services professionals working in community teams supporting people with learning disabilities. A structured interview was constructed around three scenarios, based on actual cases, concerning a financial/legal issue, a health issue and a relationships issue, as well as a set of ten 'true/false' statements. The interview aimed to elicit respondents' understanding in relation, primarily, to assessment of capacity and best-interests decision making. Forty interviews were conducted (two social workers and two health professionals from each of ten community teams). Most participants had attended training on the . Performance of social services and health staff was similar throughout. Fourteen areas of concern were identified where there appeared to be significant gaps in knowledge. Participants, particularly those who had experience of dealing with mental capacity issues, had good insight into the extent of their knowledge, and most participants said that the interview had made them aware of further training needs. [ABSTRACT FROM AUTHOR]

Background An assessment of mental capacity includes an evaluation of the ability to ‘weigh up’ information, but how to do this is uncertain. We have previously used a laboratory decision-making task, temporal discounting, which involves a trade-off between the value and the delay of expected rewards. Participants with intellectual disabilities (ID) showed very little evidence of ‘weighing up’ of information: only a third of participants showed consistent temporal discounting performance, and when present, consistent performance was usually impulsive; and the ability to perform consistently was more strongly related to executive functioning than to IQ. The aim of the present study was to replicate these observations and extend them to a more realistic financial decision-making task. Methods We administered a temporal discounting task and a financial decision-making task, as well as tests of executive functioning and IQ, to 20 participants who attended day services for people with learning disabilities (mean Full-Scale IQ = 59), and to 10 staff members. Results Performance in both decision-making tasks was related more strongly to executive functioning than to IQ. In both tasks, decisions by service users were made largely on the basis of a single item of information: there was very little evidence in either task that information from two sources was being ‘weighed’. Conclusions The results suggest that difficulty in ‘weighing up’ information may be a general problem for people with ID, pointing to a need for psycho-educational remediation strategies to address this issue. The importance of executive functioning in decision-making by people with ID is not recognized in the legal test for mental capacity, which in practice includes a possibly irrelevant IQ criterion. [ABSTRACT FROM AUTHOR]

The Mental Capacity Act 2005 introduced legal safeguards (which came into force in April 2009) aimed at protecting the liberty of people lacking capacity admitted to institutions in England and Wales. This paper discusses the adequacy of the Deprivation of Liberty Safeguards for protecting the liberty of residents in social care settings and the role of regulation in monitoring their implementation. In particular, the potential impact of planned unitary regulation on the regulator's ability to protect residents’ liberty is critiqued, centring on people with dementia living in care homes. It is suggested that the capacity of the safeguards to adequately protect the liberty of residents with dementia may be limited by under-recognition of the extent to which deprivation of liberty can actually occur in care homes, insufficient resourcing and a lack of critical independence in their proposed implementation. In addition, the planned contraction of regulation – especially a reduction in inspections – will constrain the regulator's ability to ensure that residents’ right to liberty is protected. The author concludes that the new model of regulation adopted by the UK government has prioritised economic efficiency over safeguarding the right to liberty of vulnerable residents in institutions. [ABSTRACT FROM AUTHOR]

On the night of August 19, 2000, at the foot of Castel del Monte, an 8-year-old girl was brutally murdered. The perpetrators were identified as five young men who captured their victim and sexually abused her. The policemen found the cadaver by following “Mario,” one of the five, who had been discovered lying on the ground, near the castle. Investigation led to demonstrate that the murder was not premeditated. The only desire of the group was to sexually molest the little girl. Mario showed signs of psychiatric pathology and for that he underwent psychiatric evaluation by judicial authorities. Analysis of this case, combined with a criminological and medical-legal perspective led to conclusions very much different from the expectations of Mario’s defense attorneys. Mario, a marginal figure and seemingly the least intelligent, played the role of group instigator, both in the initiation of sexually abusing the child, as well as in the elimination of an inconvenient witness. However, the group was able to activate Mario’s sadistic fantasies and his sexual perversions, and he ended up in a catalyzing role influencing the behavior of others and realizing what would otherwise remain only fantasies. The circularity of the group allows people like Mario, who are apparently subordinate, to influence the behavior of others. Mario was found to have a mental disorder but it was not sufficient to diminish his personal responsibility related to the crime. In fact, according to Italian judicial code, it is necessary that the motivation for the crime was psychopathological. It was for this reason that, according to Italian law, all of the members of the group were considered to be responsible for the crimes committed and were condemned. [ABSTRACT FROM AUTHOR]

The Mental Capacity Act 2005 came into force in England and Wales during 2007. The Act enshrines a legal right to autonomy (negative and positive) of people lacking decision-making capacity, such as people with dementia. This paper examines the extent to which the legislation promotes the social citizenship of people with dementia, focusing on its effectiveness in protecting liberty and promoting self-determination and in providing social rights to facilitate autonomy. In particular, the author considers the degree to which the Act will facilitate decision-making by people with dementia, centring on decisions relating to where to live (at home or in an institution). In addition, the historical detention (usually informal) of people with dementia in institutional care, and the role of the Act in promoting recognition of their right to liberty, is highlighted. However, the author points out that the civil rights to liberty and self-determination accorded under the Act – particularly the right to decide where to live – are restricted rights only, as the views of the person lacking capacity can be over-ridden by the decisions of others. In addition, the facilitation of these civil rights is constrained by a lack of access to social rights, particularly the availability of domiciliary and community services to avoid institutional admission. Consequently, whilst the legislation promotes the social citizenship of people with dementia, it has limited capacity to facilitate their full citizenship status. [ABSTRACT FROM AUTHOR]

Purpose: This report describes the uncommon psychopathological state best known as folie à deux, or shared psychotic disorder, in a unique case in which the grandiose, religious delusions of a woman with uterine cancer are shared with her husband. Overview: More than 50% of patients with cancer meet the criteria for diagnosis of major psychiatric disorders. Certainly, these disorders may occur as a result of the stress of the cancer diagnosis and treatment, but also because of a predisposition to psychiatric illness or a pre-existing psychiatric illness. In the medical setting, the phenomenon of folie à deux poses significant problems not only for the patient, but also for the involved family member, psychiatric consultant, and healthcare team. Clinical implications: In this case, the patient's delusional system had a grave impact on her ability to make rational healthcare decisions, for which she was deemed incompetent. The first choice for her healthcare surrogate, her husband, was so affected by his sharing of her psychotic condition that he could not fulfill this role. In assessing a suspected case of folie à deux, awareness of several issues—the point at which religious overideation becomes delusional, the spectrum of competency, informed consent, and treatment refusal—is important. [ABSTRACT FROM AUTHOR]

We argue that acceptance of competence as decision-specific, together with a resultant likely increase in limited guardianship orders, will lead to an increase in requests for restoration of legal competence by those under such orders. Six central issues facing the assessor of capacity/competence in the restoration of legal competence are discussed. Suggestions are made as to how these issues can be addressed in forming a clinical judgement. The profile of 17 cases where there was a request to restore legal competence is reviewed. [ABSTRACT FROM AUTHOR]

One hundred and eleven capacity assessments are described where three criteria to assess the ability to make decisions were investigated. These were ability to identify decision options, the ability to understand the consequences of decisions and the ability to implement decisions. The effectiveness of these criteria in differentiating capable/incapable patients supports the idea of decision-making capacity or decision-specific capacity. The criteria applied, nevertheless, are not sufficient in all cases to determine capacity. [ABSTRACT FROM AUTHOR]

The mental and physical capacity of all persons living permanently in a nursing home in Bergen were estimated and their neuroleptic drug consumption and duration of stay were registered. Fifty-one per cent were severely and 14% moderately mentally impaired. Eighty-seven per cent demanded more extensive nursing care. Physical dependence was significantly associated with mental decline, but not with age. 32.6% received regularly neuroleptic and decreasing ability to perform personal hygiene. [ABSTRACT FROM AUTHOR]

In two recent cases the courts have declined to accord to carers any formal right to a private and family life with the person for whom they care. This paper briefly considers why it is that the courts still view carers as people merely in need of services and sympathy – rather than people entitled to such basic human rights. [ABSTRACT FROM AUTHOR]