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OBJECTIVES: To examine older people's preferences for self-involvement in end-of-life care decision-making in scenarios of mental capacity (competency) and incapacity, and to identify associated factors. METHODS: A cross-sectional survey was conducted including 400 individuals aged 60+ years living in the city of Belo Horizonte, Brazil. RESULTS: Among 400 respondents, 95.3% preferred self-involvement when capable (due to the high percentage, associated factors were not calculated) and 64.5% preferred self-involvement when incapable through, for example, a living will. Considering that participants could choose multiple answers, the most frequent combinations in the capacity scenario were “yourself” and “other relatives” (76.8%) and “yourself” and “the doctor” (67.8%). In the incapacity scenario, the most frequent combinations were “yourself” and “other relatives” (usually their children and, less often, their grandchildren) (59.3%) and “yourself” and “the doctor” (48.5%). Three factors were associated with a preference for self-involvement in an incapacity scenario. Those who were married or had a partner (widowed; adjusted odds ratio [AOR] = 0.37; 95% confidence interval [CI] 0.19–0.68) and those who were male (female; AOR = 0.62; 95%CI 0.38–1.00) were less likely to prefer self-involvement. Those who were younger, as in age bands 60-69 years (80+; AOR = 2.35; 95%CI 1.20–4.58) and 70–79 years (80+; AOR = 2.45; 95%CI 1.21–4.94), were more likely to prefer self-involvement. CONCLUSIONS: Most participants preferred self-involvement in both scenarios of capacity and incapacity. Preference for self-involvement was higher in the scenario of capacity, while preference for the involvement of other relatives (usually their children) was greater in the scenario of incapacity.

Background: Mental capacity is a fundamental aspect that enables patients to fully participate in various healthcare procedures. To assist healthcare professionals (HCPs) in assessing patients' capacity, especially in the mental health field, several standardized tools have been developed. These tools include the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), and the Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD). The core dimensions explored by these tools include Understanding, Appreciation, Reasoning, and Expression of a choice. Objective: This meta-analysis aimed to investigate potential differences in decision-making capacity within the healthcare context among groups of patients with bipolar disorders (BD) and schizophrenia spectrum disorders (SSD). Methods: A systematic search was conducted on Medline/Pubmed, and Scopus. Additionally, Google Scholar was manually inspected, and a manual search of emerging reviews and reference lists of the retrieved papers was performed. Eligible studies were specifically cross-sectional, utilizing standardized assessment tools, and involving patients diagnosed with BD and SSD. Data from the studies were independently extracted and pooled using random-effect models. Hedges' g was used as a measure for outcomes. Results: Six studies were identified, with three studies using the MacCAT-CR, two studies the MacCAT-T, and one the CAT-PAD. The participants included 189 individuals with BD and 324 individuals with SSD. The meta-analysis revealed that patients with BD performed slightly better compared to patients with SSD, with the difference being statistically significant in the domain of Appreciation (ES = 0.23, 95% CI: 0.01 to 0.04, p = 0.037). There was no statistically significant difference between the two groups for Understanding (ES = 0.09, 95% CI:−0.10 to 0.27, p = 0.352), Reasoning (ES = 0.18, 95% CI: −0.12 to 0.47, p = 0.074), and Expression of a choice (ES = 0.23, 95% CI: −0.01 to 0.48, p = 0.60). In the sensitivity analysis, furthermore, when considering only studies involving patients in symptomatic remission, the difference for Appreciation also resulted in non-significant (ES = 0.21, 95% CI: −0.04 to 0.46, p = 0.102). Conclusions: These findings indicate that there are no significant differences between patients with BD and SSD during remission phases, while differences are minimal during acute phases. The usefulness of standardized assessment of capacity at any stage of the illness should be considered, both for diagnostic-therapeutic phases and for research and advance directives. Further studies are necessary to understand the reasons for the overlap in capacity between the two diagnostic categories compared in this study. [ABSTRACT FROM AUTHOR]

Background/objectivesBriefer measures of symptoms and functional limitations may reduce assessment burden and facilitate monitoring populations of persons with dementia (PWD).DesignProspective follow-up study.SettingUniversity-based dementia care management program.Participants1,091 PWD.MeasurementsWe assessed cognition (Mini Mental State Examination (MMSE)-11 tasks), neuropsychiatric symptom severity (Neuropsychiatric Inventory Questionnaire Severity Scale (NPIQ-S)-12 items), and functional ability (Activities of Daily Living (ADL)-6 items; Functional Activities Questionnaire (FAQ)-10 items). Item response theory was used to select subsets of items by identifying low item discrimination (

Background: Mental capacity is a fundamental aspect that enables patients to fully participate in various healthcare procedures. To assist healthcare professionals (HCPs) in assessing patients’ capacity, especially in the mental health field, several standardized tools have been developed. These tools include the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), and the Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD). The core dimensions explored by these tools include Understanding, Appreciation, Reasoning, and Expression of a choice. Objective: This meta-analysis aimed to investigate potential differences in decision-making capacity within the healthcare context among groups of patients with bipolar disorders (BD) and schizophrenia spectrum disorders (SSD). Methods: A systematic search was conducted on Medline/Pubmed, and Scopus. Additionally, Google Scholar was manually inspected, and a manual search of emerging reviews and reference lists of the retrieved papers was performed. Eligible studies were specifically cross-sectional, utilizing standardized assessment tools, and involving patients diagnosed with BD and SSD. Data from the studies were independently extracted and pooled using random-effect models. Hedges’ g was used as a measure for outcomes. Results: Six studies were identified, with three studies using the MacCAT-CR, two studies the MacCAT-T, and one the CAT-PAD. The participants included 189 individuals with BD and 324 individuals with SSD. The meta-analysis revealed that patients with BD performed slightly better compared to patients with SSD, with the difference being statistically significant in the domain of Appreciation (ES = 0.23, 95% CI: 0.01 to 0.04, p = 0.037). There was no statistically significant difference between the two groups for Understanding (ES = 0.09, 95% CI:−0.10 to 0.27, p = 0.352), Reasoning (ES = 0.18, 95% CI: −0.12 to 0.47, p = 0.074), and Expression of a choice (ES = 0.23, 95% CI: −0.01 to 0.48, p = 0.60). In the sensitivity analysis, furthermore, when considering only studies involving patients in symptomatic remission, the difference for Appreciation also resulted in non-significant (ES = 0.21, 95% CI: −0.04 to 0.46, p = 0.102). Conclusions: These findings indicate that there are no significant differences between patients with BD and SSD during remission phases, while differences are minimal during acute phases. The usefulness of standardized assessment of capacity at any stage of the illness should be considered, both for diagnostic-therapeutic phases and for research and advance directives. Further studies are necessary to understand the reasons for the overlap in capacity between the two diagnostic categories compared in this study.

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Los Angeles Countys Office of Diversion and Reentry (ODR) has removed over 3800 people from the largest jail system in the country. Across various diversion programs, ODRs fundamental goal is to provide permanent, lifetime care for each diverted person. This article describes ODRs various diversion programs, and elucidates the types of elaborate clinical and court-related interventions that are necessary to remove persons with serious mental disorders from jail custody. As Los Angeles continues to build the necessary community-based continuum of mental health care, ODRs model proves that thoughtfully removing persons with serious mental disorders from jail is possible and necessary for the health of both patients and community.

Background: The resident doctor plays an important role in people›s health care. Objective: To compare the cognition of medical residents with/without anxiety in a specialist training hospital. Material and methods: Comparative, prospective, crosssectional study. Medical residents of any grade and specialty were included, who signed informed consent. Those with a diagnosis of cognitive impairment were excluded, and who did not complete the tests were eliminated. AMASA test was applied to assess anxiety and NEUROPSI: Attention and memory test for cognitive characteristics. Mann-Whitney›s U and Spearman›s rho were used, p = 0.05 was considered significant. Results: 155 residents were evaluated, 55.5% men, mean age 32.4 years. Internal Medicine was the predominant specialty (25.2%). AMAS-A identified 94.19% residents with anxiety. NEUROPSI reported Attention and memory domain (38.7%) in normal classification, Memory (34.2%) in high normal, and Attention and executive functions (32.3%) in severe alteration as predominant assessments. Only Memory showed a significant difference between residents with and without anxiety (p = 0.015). Attention and executive functions-Physiological anxiety (r = -0.21, p=0.009) and Attention and memory-Social concern (r = -0.268, p = 0.001) correlations were significant. Conclusions: The percentage of anxiety and cognitive alterations in residents physicians is high. Anxiety decisively affects memory capacity in these medical doctors. [ABSTRACT FROM AUTHOR]

Sexual assault perpetrated by older adults is still an underreported crime and is not fully understood. To describe a series of cases of sexual assault by Brazilian older adults and discuss the associated factors based on the literature. This is a cross‐sectional descriptive analysis of five cases of older adults accused of sexual assault in the Forensic Psychiatry sector of the Medical Legal Institute (Coroner's Office) in the City of Belo Horizonte'. This review focuses on five cases involving male defendants with a mean age of 59.75 years; two with previous psychiatric treatment, and one with a previous criminal record. Their victims were prepubescent children, four of them female. Psychiatric conditions related to forensic diagnosis included dementia, schizophrenia, alcohol‐related substance use disorder, paraphilia, and one without a psychiatric diagnosis. The final forensic report on all five cases found that two of the older adults diagnosed with a mental disorder in two were considered to have a mental illness that completely impaired the cognitive and volitional domains; two other adults were diagnosed with mental health disturbance that partially impaired these domains; and the last adult was diagnosed and found without mental health impairment. While the incidence of sexual crimes committed by older adults is low, the absolute number of cases has expected to rise due to population aging. Assessing the factors related to this type of crime is therefore an initial step to understanding and formulating preventive strategies. [ABSTRACT FROM AUTHOR]

Although declines in cognitive capacity are assumed to be a characteristic of aging, increasing evidence shows that it is age-related disease, rather than age itself, that causes cognitive impairment. Even so, older age is a primary risk factor for cognitive decline, and with individuals living longer as a result of medical advances, cognitive impairment and dementia are increasing in prevalence. On March 26 to 27, 2018, the American Geriatrics Society convened a conference in Bethesda, MD, to explore cognitive impairment across the subspecialties. Bringing together representatives from several subspecialties, this was the third of three conferences, supported by a U13 grant from the National Institute on Aging, to aid recipients of Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) in integrating geriatrics into their subspecialties. Scientific sessions focused on the impact of cognitive impairment, sensory contributors, comorbidities, links between delirium and dementia, and issues of informed consent in cognitively impaired populations. Discussions highlighted the complexity not only of cognitive health itself, but also of the bidirectional relationship between cognitive health and the health of other organ systems. Thus, conference participants noted the importance of multidisciplinary team science in future aging research. This article summarizes the full conference report, "The Impact of Cognitive Impairment Across Specialties," and notes areas where GEMSSTAR scholars can contribute to progress as they embark on their careers in aging research. J Am Geriatr Soc 67:2011-2017, 2019.

Background: This study was conducted with the aim of identifying indicators of social and emotional health competence of managers of education departments, as a case study of Bandar Abbas city. Methods: This study was applied research conducted by descriptive-correlational method. In the first section, using content analysis method (interview with experts), 20 experts attend in the field of educational sciences and educational management. In the second, to design a structural-interpretive model, 15 experts were used to answer the questionnaire. Data collection was performed by a researcher-made questionnaire. The reliability of the questionnaire was confirmed by Cronbach's alpha coefficient, composite reliability coefficient and factor loads. The validity of the questionnaire was confirmed by content and construct validity. Analysis of descriptive indices and correlation matrix between them were performed with SPSS and model fit was examined with Smart PLS software. Results: Factors affecting social and emotional competencies have high influence. Professional competencies, especially basic and teaching-related competencies have a significant effect on teachers' educational performance. Themes include 8 main variables about quality of work life, protectionism, realism, trust building, social commitment, job competence, individual and social competence. Weak, medium and strong value of the structural part of the model is determined by criterion of R2 were 0.19, 0.33 and 0.33. Conclusion: Emotional and social functioning and concurrent conditions among education and referral managers for the implementation of evidence-based interventions may be useful for the overall performance. The results of study are useful for improving the emotional and social skills of education managers.

BackgroundThe California End of Life Option Act (EOLOA), which legalized physician-assisted death (PAD), became effective in 2016. The EOLOA does not require a mental health consultation in all cases nor does it state the standards for the mental health assessment. University of California, San Francisco Medical Center (UCSFMC) policy makers decided to require a mental health assessment of all patients seeking PAD under the EOLOA.ObjectivesThe Department of Psychiatry was tasked with developing a standard protocol for the mental health assessment of patients seeking PAD.MethodsMembers of the consultation-liaison (C-L) service developed a document to guide members in completing the mental health evaluations for patients requesting PAD.ResultsA committee at UCSFMC developed a clinical protocol informed by the law with an additional local expectation of an evaluation by a psychiatrist or clinical psychologist. The C-L psychiatry group at UCSF developed a standard protocol for the psychiatric assessment for use by clinicians performing these assessments. Attention to the cognitive, mood, and decisional capacity status pertinent to choosing PAD is required under the clinical guidance document. Case vignettes of 6 patients evaluated for PAD are presented.ConclusionsThe local adoption of the California EOLOA by UCSFMC requires a mental health assessment of all patients requesting EOL services at UCSF. The clinical guideline for these assessments was locally developed, informed by the literature on EOL in other jurisdictions where it has already been available.

BackgroundMedically hospitalized patients who lack decisional capacity may request, demand, or attempt to leave the hospital despite grave risk to themselves. The treating physician in this scenario must determine how to safeguard such patients, including whether to attempt to keep them in the hospital. However, in many jurisdictions, there are no laws that address this matter directly. In this absence, psychiatrists are often called upon to issue an involuntary psychiatric hold (civil commitment) to keep the patient from leaving. Yet, civil commitment statutes were not intended for, and generally do not address, the needs of the medically ill patient without psychiatric illness. Civil commitment is permitted for patients who pose a danger to themselves or others, or who are gravely disabled, specifically as the result of a mental illness, and allows the transport of such individuals to facilities for psychiatric evaluation. It does not permit detention for medical illnesses nor the involuntary administration of medical treatments. Therefore, the establishment of hospital policies and procedures may be the most appropriate means of detaining medically hospitalized patients who lack capacity to understand the risks of leaving the hospital, in addition to mitigating the potential tort risk faced by the physician for acting in a manner that protects the patient.ObjectiveThe purpose of this article is to identify the array of clinical and medical-legal concerns in these scenarios, and to describe the development of a "medical incapacity hold" policy as a means of addressing this unresolved issue.

OBJECTIVE:Making decisions is central to the exercise of control over one's well-being. Many individuals with serious mental illness (SMI) experience limitations in their decision-making capacity. These individuals have often been placed under legal guardianship and substitute decision makers have been appointed to make decisions on their behalf. More recently, supported decision making (SDM) has emerged as a possible alternative in some cases. SDM involves recruitment of trusted supports to enhance an individual's capacity in the decision-making process, enabling him or her to retain autonomy in life decisions. This overview examines issues associated with decision-making capacity in SMI, frameworks of substitute decision making and SDM, and emerging empirical research on SDM. METHOD:This is an overview of the medical and legal literature on decision making capacity and supported decision making for persons with SMI. RESULTS:Many but not all individuals with SMI exhibit decrements in decision-making capacity and skill, in part due to cognitive impairment. There are no published data on rates of substitute decision making/guardianship or SDM for SMI. Only three empirical studies have explored SDM in this population. These studies suggest that SDM is viewed as an acceptable and potentially superior alternative to substitute decision making for patients and their caretakers. CONCLUSIONS:SDM is a promising alternative to substitute decision making for persons with SMI. Further empirical research is needed to clarify candidates for SDM, decisions in need of support, selection of supporters, guidelines for the SDM process, integration of SDM with emerging technological platforms, and outcomes of SDM. Recommendations for implementation of and research on SDM for SMI are provided.

OBJECTIVES:Optimizing the research consent process simultaneously fosters respect for autonomy and protection of those with diminished capacity for autonomy. This study evaluated the effectiveness of an enhanced research consent procedure, employing multimedia disclosure and corrective feedback, in improving decisional capacity among 114 people with mild-to-moderate Alzheimer's disease (AD) and 134 non-psychiatric comparison (NC) subjects. METHODS:Participants were randomized to consent type (routine versus enhanced) and protocol type (lower versus higher risk). Outcomes included a 5-item questionnaire assessing immediate comprehension, MacArthur Competence Assessment Tool for Clinical Research assessing four components of decision-making capacity, and categorical decisional capacity (based on a cut-score established in reference to expert judgments for a subset of participants). RESULTS:There was no significant effect of the enhanced consent procedure, relative to routine consent, on immediate comprehension or decisional capacity. CONCLUSIONS:Multimedia tools do not appear to be the solution to better consent for AD research. CLINICAL IMPLICATIONS:Given the ethical primacy of informed consent and issues of justice for impaired populations who might be harmed by an absence of research-based treatment advances, continued search for ways to more meaningfully engage people with AD in the consent or assent process is warranted.

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Background: Informed consent is considered to be the standard method for respecting the autonomy of individual participants in research and practices and is thought to be based on several conditions: (1) providing information on the purpose of the research or a specific treatment, what it will entail, (2) the participants being mentally competent to understand the information and weigh it in the balance, and (3) the participants to be free from coercion. While there are studies of informed consent in other countries, especially Low and Middle Income Countries (LMICs), this study explored the experiences of clinicians regarding the process of obtaining informed consent to participate in a Randomised Controlled Trial (RCT) in particular and treatment in general in healthcare settings, both general and mental health, specifically focusing on the tension between individualistic concept of autonomy and collectivist values in cultures such as Pakistan., Methods: Qualitative interviews with 20 clinicians from healthcare settings in Pakistan who also served as recruiters in a suicide prevention RCT in Pakistan. The interviews were guided by semi-structured topic guide. All interviews were audio-recorded and transcribed verbatim., Results: The interviews revealed that shared decision making was more morally important than individual autonomy, the role of the family played a dominant part in the consent-taking procedure, the decision of the elder and/or family patriarch took prominence, and that clinician-researchers encountered significant challenges in consent process in Pakistan, while recruiting patients into the trial as well as during routine treatment processes in healthcare settings. Four distinct themes emerged which were (1) Family deciding for patients, (2) Benefits of involving family in consent process, (3) Gender disparity in consent process, (4) Challenges experienced by clinician-researchers during consent process in Pakistan., Conclusions: The concept of consent is generally considered important in many cultures, however, there are two strands of understanding. There seems to be consensus that participant agreement is necessary to protect the participant but with regards to autonomy there are significant cultural differences whether it is the right for autonomy of the individual (individualistic concept) or family, community, or expert authority in other cultures. In Pakistan clinician-researchers sometimes preferred one approach and sometimes the other as they appreciated the interests of the patient to be., Competing Interests: Declarations Consent for publication Not Applicable. Competing interests IBC, NC, and NH have disclosed engagements encompassing presentations and consultancy roles with Eli Lilly, Bristol Myers Squibb, Lundbeck, AstraZeneca, and Janssen Pharmaceuticals. These interactions led to reimbursements for them or their respective employing institutions. NH and IBC have held positions as trustees at the PILL in the past. NH has also held roles as a trustee for organizations including Manchester Global Foundation, Lancashire Mind, and Abaseen Foundation, UK. Additionally, NH is an NIHR senior investigator and serves as the Director of Research and Innovation at Mersey Care NHS Foundation Trust. Importantly, none of the aforementioned companies maintain any financial stake in this research. RM is Director of Manchester Global Foundation and has also held trustee position at UK Association for Medical Aid to Pakistan (UKMAP) and PILL in the past. Ethics approval and informed consent to participate for the main study was obtained from the National Bioethics Committee of Pakistan (Ref: No.4–87/NBC419/19/1213) and the Research Ethics Committee University of Manchester (Ref: 2019-5024-10755). Ethics approval for RM’s thesis was granted by Science and Technology Department, University College London (Ref. STSEth159). All participants gave informed written consent to participate., (© 2024. The Author(s).)

Dementia may reduce individuals' capacity for autonomy and decision-making competence. Advance directives are subject to theoretical bioethical debate as tools to safeguard or extend autonomy in dementia. However, the extent and manner in which advance directives are actually used for these purposes in practice remain less examined. We aimed to examine how advance directives are used as tools for individual autonomy in dementia care. We systematically searched six databases and performed a thematic analysis and synthesis of included reviews based on an original model of six autonomy-relevant dimensions of advance directives. A total of 18 reviews met the inclusion criteria. We identified 12 themes across six dimensions. We found a lack of knowledge integration on the actual use of advance directives for autonomy in dementia care. Evidence suggests significant variation in the autonomy-relevant dimensions of advance directives, with a tendency towards an inconsistent or low level of implementation as a tool for autonomy. Further reviews and primary studies on all aspects of the use of advance directives for autonomy in dementia care would contribute significantly to dementia research and practice., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Sigurd Lauridsen reports financial support was provided by Velux Foundation. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Competing Interests: Competing interests: None declared.

Advance directives for withholding life-saving treatment are controversial for dementia patients whose previously expressed wishes conflict with their currently expressed desires. To illustrate this ethical dilemma, McMahan conceives a hypothetical case in which an intellectually proud creative woman signs an advance directive stipulating her refusal to receive life-saving treatment if she contracts a fatal condition with dementia. However, when she develops dementia and forgets this advance directive, she contracts pneumonia and now expresses a desire to live. In response to such dilemmas, scholars like Norman Cantor have defended the moral authority of advance directives by giving credence to one's prior competent wishes over one's current incompetent preferences. I argue that their arguments, which are rooted in the principle of respect for autonomy, operate under ableist assumptions about incompetent persons and exclude other important features of respect. I propose an ethics of care model as an alternative moral approach that reconceptualises respect as a matter of caring about people's contemporaneous interests, even if they are not competently conceived. It fosters the virtues of care by encouraging healthcare providers to recognise dementia patients as legitimate narrative agents capable of authoring their own evolving life story. I argue that the ethics of care model not only provides an ethical defence of the creative woman's current incompetent desire to live despite her advance directive, but also vindicates our moral intuitions about what it means to demonstrate respect to dementia patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Transgender and gender expansive (TGE) youth often seek a variety of gender-affirming healthcare services, including pubertal suppression and hormone therapy requiring that TGE youth and their parents participate in informed consent and decision making. While youth must demonstrate the ability to understand and appreciate treatment options, risks, benefits, and alternatives as well as make and express a treatment choice, standardized approaches to assess the capacity of TGE youth to consent or assent in clinical practice are not routinely used. This scoping review identified the currently available data regarding adolescent capacity to consent to gender-affirming medical treatments., Methods: Articles relevant to assessing adolescent capacity for clinical decision-making were identified using OVID Medline, Web of Science, and PubMed. Articles were reviewed and thematically analyzed., Results: Eight relevant articles were identified using three tools for measuring adolescent clinical decision-making capacity: Measure of Understanding, Measure of Competence, and MacArthur Competence Assessment Tool (MacCAT). These studies explored hypothetical treatment decisions, mental health treatment decisions, HIV treatment decisions, genetic testing decisions, and gender-affirming medical decisions. Only one study specifically examines the capacity of TGE youth to consent to medical treatments. Age was correlated with capacity in most, but not all studies. Other studies found cognitive measures (IQ, literacy, numeracy) may impact important aspects of capacity (understanding and reasoning)., Conclusions: For clinicians caring for TGE youth, tools such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) may prove useful, in conjunction with consideration of youth developmental abilities and utilization of shared decision-making practices. A standardized, collaborative approach to assessing TGE youth capacity would benefit TGE youth and their parents, and allow clinicians to more easily resolve ethical concerns., (© 2024. The Author(s).)

Background: Advance healthcare decision-making presumes that a prior treatment preference expressed with sufficient mental capacity ("T1 preference") should trump a contrary preference expressed after significant cognitive decline ("T2 preference"). This assumption is much debated in normative bioethics, but little is known about lay judgments in this domain. This study investigated participants' judgments about which preference should be followed, and whether these judgments differed depending on a first-person (deciding for one's future self) versus third-person (deciding for a friend or stranger) perspective., Methods: A vignette-based survey was conducted ( N  = 1445 US Americans; gender-balanced sample), in a 3 (relationship: self, best friend, stranger) × 2 (T1 preference: treat, do not treat) × 2 (T2 contrary preference: ambiguous, unambiguous) design., Results: Participants were more likely to defer to the incapacitated T2 preference of a third-party, while being more likely to insist on following their own T1 capacitated preference. Further, participants were more likely to conclude that others with substantial cognitive decline were still their "true selves," which correlated with increased deference to their T2 preferences., Conclusions: These findings add to the growing evidence that lay intuitions concerning the ethical entitlement to have decisions respected are not only a function of cognition, as would be expected under many traditional bioethical accounts, but also depend on the relationship of the decision to the decision-maker's true self.

Involuntary psychiatric holds, such as the 5150 hold in California, allow for an individual to be taken into custody for evaluation and treatment for up to 72 h when they present a risk of danger to themselves. 5150s and other coerced holds present a bioethical tension as patient autonomy is overridden to provide psychiatric care. I discuss two arguments that aim to provide ethical justifications for overriding patient autonomy during 5150 holds: the "clinical benefit" and "lack of capacity" arguments. By demonstrating that these arguments do not always hold, I argue that overriding patient autonomy during 5150 holds is not always ethical and can be harmful. Lastly, I make recommendations for the 5150 and similar involuntary psychiatric holds to minimize harmful breaches of patient dignity: creating consistent field guidelines for assessing prehospital capacity, educating prehospital providers about the potential harms of 5150s, and utilizing existing support structures within the social context of the patient when they have capacity to refuse further prehospital care., (© 2024 John Wiley & Sons Ltd.)

Background: Consent is a prerequisite for medical diagnostic and therapeutic action. There is no standardised procedure for assessing the ability to give consent. The most widely used tool for structured assessment is the MacArthur Competence Assessment Tool for Treatment (MacCAT-T)., Objectives:  People with dementia have impaired capacity to consent because of their disease. In order to answer the question to what extent structured assessment procedures can be usefully applied to people with dementia, we analyse the function, strengths and weaknesses of structured assessment procedures with a focus on the MacCAT-T and discuss suggestions for modification and further development of the tool., Methods: Using the PubMed literature database, a systematic literature search and analysis was conducted on papers published since 2010, following PRISMA guidelines.Results Although the MacCAT-T is a valid and reliable tool, it cannot comprehensively address memory problems in people with dementia. It primarily measures cognitive functions. However, Decisions based on emotions, intuitions and values, are not captured by the MacCAT-T. Communicative limitations in people with dementia are not taken into account., Conclusions:  It is recommended to provide information in simple language, written down and visualised for people with dementia. The development and elaboration of a graduated procedure for the examination of capacity to consent is indicated. The gradations of the scope and depth of the assessment to be determined should be based on the severity of the cognitive impairment, the benefit/risk ratio of the proposed medical intervention and the individual profile of affective functions and value-based imprints., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The assessment of medical decision-making capacity as part of the process of clinical informed consent has been considered a bioethical housekeeping matter for decades. Yet in practice, the reality bears little resemblance to what is described in the medical literature and professed in medical education. Most literature on informed consent refers to medical decision-making capacity as a precondition to the consent process. That is, a clinician must first determine if a patient has capacity, and only then may the clinician engage with the patient for the rest of informed consent. The problem with this two-step approach is that it makes no sense in actual practice. We see the assessment of medical decision-making capacity within the process of informed consent as a spiral staircase, not just two steps, requiring clinicians to keep circling up and around, making progress, until they get to where they need to be: 1. Clinicians start with a general presumption of capacity for most adults, sometimes having a provisional appraisal of capacity based on prior patient contact. 2. Then, they begin performing informed consent for the current situation and intervention options. 3. Next, they must reassess capacity during this process. 4. After that, they continue with informed consent. 5. If capacity is not yet clear, they repeat 1-4., Competing Interests: Declaration of Competing Interest On behalf of David Satin, Philip Day and myself, I wish to declare that we have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

In this paper, I examine the connections between bipolar disorder and consent. I defend the view that many (although far from all) individuals with bipolar disorder are competent to consent to a wide variety of things when they are in a manic state., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

In a recent article, Director makes the case that many individuals with bipolar disorder have the capacity to consent to many decisions while acutely manic, even when those decisions are out of character and cause harm. Referring to recent qualitative evidence, I argue that Director overlooks a key mechanism of manic incapacity, an inflexible experience of the future that impairs one's ability to value. Without attention to the illness-specific experience of decision-making, capacity assessments risk false negatives in people with mania., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The current human rights framework can shield people from many of the risks associated with neurotechnological applications. However, it has been argued that we need either to articulate new rights or reconceptualise existing ones in order to prevent some of these risks. In this paper, we would like to address the recent discussion about whether current reconceptualisations of the right to mental integrity identify an ethical dimension that is not covered by existing moral and/or legal rights. The main challenge of these proposals is that they make mental integrity indistinguishable from autonomy. They define mental integrity in terms of the control we can have over our mental states, which seems to be part of the authenticity condition for autonomous action. Based on a fairly comprehensive notion of mental health (ie, a notion that is not limited to the mere absence of illness), we propose an alternative view according to which mental integrity can be characterised both as a positive right to (medical and non-medical) interventions that restore and sustain mental and neural function, and promote its development and a negative right protecting people from interventions that threaten or undermine these functions or their development. We will argue that this notion is dissociated from cognitive control and therefore can be adequately distinguished from autonomy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Many technology ethicists hold that the time has come to articulate neurorights : our normative claims vis-à-vis our brains and minds. One such claim is the right to mental integrity ('MI'). I begin by considering some paradigmatic threats to MI (§1) and how the dominant autonomy-based conception ('ABC') of MI attempts to make sense of them (§2). I next consider the objection that the ABC is overbroad in its understanding of what threatens MI and suggest a friendly revision to the ABC that addresses the objection (§3). I then consider a second objection: that the ABC cannot make sense of the MI of the non-autonomous This objection appears fatal even to the revised ABC (§4). On that basis, I develop an alternative conception on which MI is grounded in a plurality of simpler capacities, namely, those for affect , cognition , and volition Each of these more basic capacities grounds a set of fundamental interests, and they are for that reason worthy of protection even when they do not rise to the level of complexity necessary for autonomy (§5). This yields a fully general theory of MI that accounts for its manifestations in both the autonomous and the non-autonomous., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The experience of serious illness or injury frequently results in increased vulnerability. In cases in which decision-making capacity is compromised, this vulnerability is compounded by threats to a patient's autonomy. This case report presents an opportunity to explore the elaborately entwined relationship between autonomy and vulnerability in patients with severe impairment who are reliant on surrogate decision-makers. Expanded views of autonomy and vulnerability are applied to the case of a young woman with a severe and life-altering spinal cord injury and iatrogenic loss of decisional capacity to illustrate how one can experience enhanced autonomy despite special vulnerability and can be made less vulnerable through surrogate-mediated autonomy. Also revealed is how attitudes and actions of surrogates can potentiate pathogenic vulnerability and disturb the balance between patient autonomy and vulnerability. Through methodical review and robust deliberation, clinical ethics committees can play a stabilizing role in helping distressed care teams reconcile the two., (©2024 American Association of Critical-Care Nurses.)

Hospitalized patients with cancer face pivotal decisions that will affect their cancer care trajectory and quality of life, but frequently lack decision making capacity (DMC). Standardization is conspicuously missing for inpatient oncology teams and for consultation-liaison psychiatrists performing DMC assessments for patients with cancer. This study sought to characterize a single institutional experience of psychiatric consultations to assess DMC. We conducted a retrospective chart review of 97 consecutive psychiatric consultations for DMC from 2017 to 2019. Demographic, hospital-based, and psychiatry consult differences were assessed based on the reasons for DMC evaluation (uncertainty, patient refusal, and emergency) and whether patients had decisional capacity. Out of 97 consultations, 56 (59%) hospitalized patients with cancer were unable to demonstrate capacity. Consultations came from medical services almost exclusively. Only 5% of primary teams documented their own DMC evaluation. Only 22% of DMC evaluation by consultation-liaison psychiatrists documented four determinates of DMC. Few commented on reversibility or tenuousness of DMC, and the identification of agents/surrogates; however, psychiatry consultants were more likely to follow up on patients without DMC. One-third of patients died in the hospital and two-thirds of patients were deceased 3 months after the consult. Given the substantial heterogeneity in the documentation of DMC evaluations in this retrospective chart review, we call for more rigor and standardization in documentation of DMC evaluations., (Copyright © 2024 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

For patients who may lack capacity, the Mental Capacity Act 2005 requires capacity to be assessed for each decision at the time that treatment is offered, but this is not practical for every element of basic care and intervention delivered to patients undergoing rehabilitation following acquired brain injury, especially if their needs are changing. In this quality improvement project, we introduced a system for screening Mental Capacity and documentation to identify patients with a) largely intact cognition for whom capacity may be reasonably be presumed, and b) those in prolonged disorders of consciousness who clearly lacked capacity for all decisions. This enabled the multidisciplinary team to concentrate on evaluation of capacity in the third group who had more nuanced ability and required detailed assessment or support for decision-making. Two rounds of audit demonstrated that implementation improved the consistency of assessment and documentation. Multicentre roll-out of this approach is now required., Competing Interests: Declaration of competing interest There are no personal or financial conflicts of interest. All authors are employed by Northwick Park Hospital, King's College London, or University College London Hospitals NHS Foundation Trust, which may cite this article as part of their quality improvement and development programmes. We do not consider that any of these relationships or activities have influenced the submitted work., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

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Background: The concept of decision-making capacity (DMC) or competence remains controversial, despite widespread use. Risk-sensitive DMC assessment (RS-DMC)-the idea that the higher the risk involved in a decision, the greater the decisional abilities required for DMC-has been particularly controversial. We conducted a systematic, descriptive review of the arguments for and against RS-DMC to clarify the debate. Methods: We searched PubMed/MEDLINE (National Library of Medicine), PsycInfo (American Psychological Association) and Philpapers, updating our search to February 15th, 2022. We targeted peer-reviewed publications in English that argue for or against RS-DMC. Two reviewers independently screened the publications and extracted data from each eligible manuscript. Results: Of 41 eligible publications, 22 supported a risk-sensitive threshold in DMC assessment. Most arguments for RS-DMC rely on its intuitive appeal and practicalmerits. The arguments against RS-DMC primarily express concerns about paternalism and the seeming asymmetry between consent and refusal; critics of RS-DMC support epistemic, rather than substantive (i.e., variable threshold), risk-sensitivity; counterarguments responding to criticisms of RS-DMC address charges of paternalismand exhibit a notable variety of responses to the issue of asymmetry. Authors used a variety of frameworks regarding the definition of DMC, its elements, and its relation to decisional authority, and these frameworks were significantly associated with positions on RS-DMC. A limitation of our review is that the coding relies on judgment and interpretation. Conclusion: The review suggests that some of the debate about RS-DMC stems from differences in underlying frameworks. Most defenses of RS-DMC rely on its intuitive appeal, while most criticisms reflect concerns about paternalism or the asymmetry between consent and refusal. Defenses of RS-DMC respond to the asymmetry problem in a variety of ways. Further research is needed on the implications of underlying frameworks, the asymmetry problem, and the distinction between epistemic and substantive models of RS-DMC. [ABSTRACT FROM AUTHOR]

How people choose to help each other can be just as important as how much people help. Help can come through relatively paternalistic or agentic aid. Paternalistic aid, such as banning certain foods to encourage weight loss or donating food to alleviate poverty, restricts recipients' choices compared with agentic aid, such as providing calorie counts or donating cash. Nine experiments demonstrate that how people choose to help depends partly on their beliefs about the recipient's mental capacities. People perceive paternalistic aid to be more effective for those who seem less mentally capable (Experiments 1 and 2), and people therefore give more paternalistically when others are described as relatively incompetent (Experiment 3). Because people tend to believe that they are more mentally capable than are others, people also believe that paternalistic aid will be more effective for others than for oneself, effectively treating other adults more like children (Experiments 4a-5b). Experiencing a personal mental shortcoming-overeating on Thanksgiving-therefore increased the perceived effectiveness of paternalism for oneself, such that participants thought paternalistic antiobesity policies would be more effective when surveyed the day after Thanksgiving than the day before (Experiment 6). A final experiment demonstrates that the link between perceived effectiveness of aid and mental capacity is bidirectional: Those receiving paternalistic aid were perceived as less mentally capable than those receiving relatively agentic aid (Experiment 7). Beliefs about how best to help someone in need are affected by subtle inferences about the mind of the person in need. (PsycINFO Database Record

ObjectiveInvestigators conducting Alzheimer's disease (AD) research need to consider participants' capacity to consent. Cognitive functioning is a significant predictor of decisional capacity, but there is a dearth of information on the influence of neuropsychiatric symptoms in AD on decisional capacity. We examined the rates of decisional capacity associated with two types of research protocols, and the association of capacity with neuropsychiatric symptoms and other participant characteristics.MethodsWe comprehensively evaluated decisional capacity among 64 patients with mild-to-moderate AD and 70 healthy comparison (HC) subjects randomized to consider either a medium risk or higher risk hypothetical research protocol. Additional measures included sociodemographics, cognitive deficits, and neuropsychiatric symptoms.ResultsTwenty AD patients (31.3%) and 67 HCs (95.7%) were deemed capable; 44 AD patients (68.8%) and 3 HCs (4.3%) incapable of consent. Age, education, and severity of cognitive deficits were associated with incapable status; there were no significant associations with severity of neuropsychiatric symptoms or protocol risk level.ConclusionsFindings highlight the importance of understanding of capacity and its assessment among people with AD, rather than treating AD diagnosis as synonymous with impaired capacity. As novel treatments move from bench to bedside, methods of assessing and addressing capacity impairment must similarly advance.Clinical implicationsIn assessing research consent capacity, use structured assessments with population specific cut scores interpreted in the context of the person's background including education, culture, and language. Individuals should be encouraged to execute research proxy documents when able.

BackgroundThe concept of decision-making capacity (DMC) or competence remains controversial, despite widespread use. Risk-sensitive DMC assessment (RS-DMC)—the idea that the higher the risk involved in a decision, the greater the decisional abilities required for DMC—has been particularly controversial. We conducted a systematic, descriptive review of the arguments for and against RS-DMC to clarify the debate.MethodsWe searched PubMed/MEDLINE (National Library of Medicine), PsycInfo (American Psychological Association) and Philpapers, updating our search to February 15th, 2022. We targeted peer-reviewed publications in English that argue for or against RS-DMC. Two reviewers independently screened the publications and extracted data from each eligible manuscript.ResultsOf 41 eligible publications, 22 supported a risk-sensitive threshold in DMC assessment. Most arguments for RS-DMC rely on its intuitive appeal and practical merits. The arguments against RS-DMC primarily express concerns about paternalism and the seeming asymmetry between consent and refusal; critics of RS-DMC support epistemic, rather than substantive (i.e., variable threshold), risk-sensitivity; counterarguments responding to criticisms of RS-DMC address charges of paternalism and exhibit a notable variety of responses to the issue of asymmetry. Authors used a variety of frameworks regarding the definition of DMC, its elements, and its relation to decisional authority, and these frameworks were significantly associated with positions on RS-DMC. A limitation of our review is that the coding relies on judgment and interpretation.ConclusionThe review suggests that some of the debate about RS-DMC stems from differences in underlying frameworks. Most defenses of RS-DMC rely on its intuitive appeal, while most criticisms reflect concerns about paternalism or the asymmetry between consent and refusal. Defenses of RS-DMC respond to the asymmetry problem in a variety of ways. Further research is needed on the implications of underlying frameworks, the asymmetry problem, and the distinction between epistemic and substantive models of RS-DMC.

Background: We evaluated the versatility of the Korean version of the University of California San Diego Performance-based Skills Assessment, Validation of Intermediate Measures version (K-UPSA-2-VIM) as a new diagnostic modality to overcome the difficulties associated with an accurate objective assessment of functional capacity for evaluating mental competency. Methods: One hundred sixteen community-dwelling elderly individuals were enrolled. Questionnaires, including the Mini-Mental State Examination (MMSE), the clinical dementia rating (CDR), the neurocognitive battery of the Korean version of the consortium to Establish a Registry for Alzheimer’s Disease Assessment Packet (CERAD-K-NP), the Korean version of Instrumental Activities of Daily Living Index (K-IADL), and the K-UPSA-2-VIM, were administered. A receiver operating characteristic (ROC) curve analysis was performed to explore the discriminative potential. Results: Seventy-eight cognitively normal (CN) participants and 38 individuals with cognitive impairment no dementia (CIND) were analyzed. The K-UPSA-2-VIM showed fair internal consistency (Cronbach alpha = 0.886). There were significant differences among groups in all subdomains (finance, communication, comprehension/planning, transportation, and household skills) of the K-UPSA-2-VIM, which were significantly correlated with CERAD-K-NP subscales. The K-UPSA-2-VIM showed high sensitivity (73.7%) and specificity (82.1%), with an area under the curve (AUC) of 0.828 (95% confidence interval: 0.747–0.909, p < 0.001) to discriminate CIND. Conclusion: The K-UPSA-2-VIM is a reliable performance-based instrument for evaluating real-world high-functional capacity of older Korean adults in the community. [ABSTRACT FROM AUTHOR]

BACKGROUND: Mindfulness-based cognitive therapy (MBCT) is one of the techniques for shaping behavior and procedure for changing non-adaptive beliefs by using cognitive-behavioral theory to treat addiction disorders. This study was conducted to determine the effectiveness of cognitive therapy based on mindfulness on mental well-being of opioid users. METHODS: This pretest-posttest experimental study was conducted among drug users in Sanandaj city, Northwest of Iran, during 2016. To conduct the research, 20 participants were selected using available sampling method, and randomly divided into two equal groups of experimental and control. The experimental group received knowledge about cognitive therapy for 8 sessions of 90 minutes. We gathered the data of two study groups using Mental Well-being Questionnaire before and after intervention. Data analyses conducted using independent sample t test. RESULTS: Mindfulness therapy had a significant effect on subjective well-being of opium users. So that, the mean scores of the variable of the overall index of mental well-being in the experimental group (177.90 ± 20.14) was significantly larger than the control group (141.30 ± 19.16) in the posttest with the control of the effect of the pretest (P < 0.001). CONCLUSION: Findings of the present study suggest that cognitive therapy based on mind-awareness strategies helps people to replace reasonable beliefs with irrational beliefs in order to achieve new insights that seek to communicate with others and improve subjective well-being.

AbstractUnbefriended patients are those with decisional impairments who lack family or friends to serve as healthcare surrogates. When such patients cannot make decisions, the court typically appoints a professional guardian to make choices aligned with the patient's values and preferences. However, this case report illustrates ethical challenges that can arise when professional guardians disregard the patient's authentic wishes. In this case study, the 38-year-old unbefriended African American male patient expressed fears about traumatic resuscitation efforts and ultimately desired de-escalation of care, which the guardian was hesitant to honor despite confirmed decision-making capacity. The guardian quickly reversed a new do-not-resuscitate order when the patient later changed his mind. Decisions about aggressive interventions like a colostomy were significantly delayed while awaiting final judgments involving the guardian's supervisors and the judicial system. The case highlights pitfalls with guardians defaulting to treatment escalation without sufficiently engaging with ethical standards or eliciting the patient's narrative identity, leading to inconsistent surrogate decisions. We propose that more robust reforms are needed, including enhanced training of guardians in ethical decision-making, and we present other means to facilitate best practices in proxy decision-making.

AbstractBackground: Clinical ethics consults are sometimes requested for patients who lack capacity and do not assent to discharge recommendations, particularly those with neurocognitive or psychiatric disorders desiring home discharge. Balancing the risks and benefits of overriding patient preferences involves considering dignity, values, clinical information, and available resources. Outcomes of such consultations lack characterization in the literature., Methods: We examined clinical ethics consultations from December 2015 to June 2023 at a large, urban academic medical center serving a diverse community with high poverty rates. Time to readmission and proportion readmitted within 30 days were analyzed by discharge disposition., Results: Among 1,163 ethics consults, 167 were for discharge planning. The median age was 65.4. Of these, 56.7 percent were male; 29.9 percent, Black, non-Hispanic; 26.9 percent, Hispanic; and 19.1 percent, White, non-Hispanic. More than 37 percent had a psychiatric diagnosis, with a similar percentage affected by dementia. Discharge to skilled nursing facilities (SNFs), home without nursing care, home with nursing care, subacute rehabilitation facilities, and elopement constituted 33, 26, 26, 2, and 2 percent, respectively. The discharged-to-home group showed the highest average days to readmission (243), while the average for the discharged-to-SNF group was 153. These differences were not statistically significant when controlling for age, gender, and comorbid conditions., Conclusions: Half of the patients consulted for discharge planning were discharged home and were not at higher risk for early readmission. This higher-than-expected percentage may reflect increased attention to patient values when bioethics is involved.

To evaluate the usability and acceptability of the Mental Capacity Assessment Support Toolkit (MCAST) in healthcare settings and whether its use was associated with increased legal compliance and assessor confidence. A mixed methods convergence triangulation model was used. Multidisciplinary professionals used the MCAST during mental capacity assessments for UK hospital patients with diagnoses of stroke or acute or chronic cognitive impairment. Changes in legal compliance were investigated by comparing scores on case note audits before and after implementation of the MCAST. Changes in assessor confidence and professionals' perceptions of the MCAST's usability and acceptability were explored using surveys. Patients' and family members' views on acceptability were determined using semi-structured interviews. Data were integrated using triangulation. Twenty-one professionals, 17 patients and two family members participated. Use of the MCAST was associated with significant increases in legal compliance and assessor confidence. Most professionals found the MCAST easy to use and beneficial to their practice and patients. Patients and family members found the MCAST materials acceptable. The MCAST is the first toolkit to support the needs of individuals with communication disabilities during mental capacity assessments. It enables assessors to deliver high quality, legally compliant and confident practice. Mental capacity assessment practice needs to be improved to maximise patient autonomy, safety and well-being. The MCAST is a paper-based toolkit designed to facilitate and improve mental capacity practice in England and Wales. This study suggests the MCAST would be easy and acceptable to use in healthcare settings and could lead to improvements in assessment quality and assessor confidence. [ABSTRACT FROM AUTHOR]

Introduction: Informed consent is an indispensable condition of the clinical practice for the provision of health care. The main objective of this study is to translate the MacArthur competence assessment tool for treatment (MacCAT-T) into Turkish and evaluate the validity and reliability of the Turkish version in schizophrenia patients and healthy control subjects. Methods: In this cross-sectional study, 30 hospitalized schizophrenia patients and 25 healthy subjects were assessed with MacCAT-T, Mental Competence Evaluation Form for Assessment of Competency (MCEF), Positive and Negative Syndrome Scale, Beck Depression Inventory, Mini Mental State Examination, Wechsler Adult Intelligence Scale (WAIS) - Similarities subtest and the Schedule for Assessing the Three Components of Insight. Psychometric properties of MacCAT-T were examined by intraclass correlation coefficients and Cronbach's alpha values. Results: Intra-class correlations ranged between 0.83 and 0.99 for four subscales of the tool. Cronbach alpha value of MacCAT-T was found 0.89. Severity of psychopathology and indices of insight were found to be negatively correlated with the subscales of the tool. WAIS-Similarities subtest scores were found to be positively correlated with understanding and reasoning subscales of MacCAT-T. Conclusion: The Turkish version of MacCAT-T is a valid and reliable instrument for Turkish patients. The severity of psychopathology, insight and executive functions were shown to be significantly related to the decision making capacity in patients with schizophrenia. [ABSTRACT FROM AUTHOR]

Background and Objectives: Healthcare organizations in terms of providing and maintaining community health have many challenges throughout the world and their proper functioning depends on how well they are managed. Also, the study of the state of Iran healthcare system shows that Iran does not have the proper clinical leadership and needs to made some modifications. The aim of this study was to identify and explain the competence of clinical leadership among the managers of Guilan University of Medical Sciences. Material and Methods: This research is a qualitative research that was done by using content analysis approach. The statistical population was the managers of Guilan University of Medical Sciences in 2019, which selected with the approach of purposeful sampling of 18 senior managers as participants. To obtain reliability and validity of the data, two methods used by reviewing participants and reviewing non-participating experts. Results: After analyzing and combining the data in the form of 264 basic concepts, 5 main categories (specifications, importance, barriers, executive tactics and achievements) and 28 sub-categories classified. Conclusion: Given the importance of leadership competence and the complexity of professional work, the role of the Ministry of Health in determining the management perspective, its implementation and monitoring throughout the country for determining the comprehensive road-map for health is very key and important. At the individual level, educating individuals and equipping Iran health managers with management tools, also to purely specialized generation training, is very key and vital.