Adults with Incapacity: Assessing Capacity to Consent to Treatment - Case Study Example

ADULTS WITH INCAPA ASSESSING CAPA TO CONSENT TO TREATMENT Department Introduction Capa is defined as the ability of adults to succinctly understand relevant information that has impact on action or decisions and appreciate the reasonably foreseeable aftermath of taking or not taking that decision or actions. Incapacity is outlined in, “the adults with capacity (Scotland) Act 2000 (the Act)” which outlines the statutory framework for the medical treatment of adults with incapacity. This act is meant to provide directions to providing treatments in emergencies or acute cases to persons who are incapable of giving consent. Section five of this act was amended in 2005 and clause relating to medical treatment and research were introduced. This act is central in decision making process and clarifies the legal basis upon which doctors make medical treatments of incapacitated adults (Berghmans, 2008). Doctors are often involved in assessing a person’s capacity to make decisions about these matters and it is part 5 of the act which regulates research and medical treatment and will have impact on medical practice. Incapacity is outlined in the act that the inability to act, make decisions, communicate decisions, understanding decisions or keeping the memory of decisions resulting from physical disability or mental disorder (Cornish & Preston-Shoot, 2013). This incapability is however not because deficiency or lack of communication if that deficiency or lack can be made good by mechanical or human aid. The act outlines the following as the principles that underpin incapacity assessment and decision making process: minimum intervention, benefit, views of the specified persons, past and present wishes and exercising and developing skills. Assessment of capacity to consent to treatment is therefore a very important ethical and legal issue for doctors and staff working in acute and emergency general hospitals. Studies have suggested that approximately 30-52% of the total people admitted to hospitals will lack the capacity to consent to treatment (Murray, 2013). This paper focuses on assessing capacity to consent to treatment for adults with incapacity. This paper reflects on the attitudes and values that underpin professional practice and the factors that may affect capacity. The ethical and clinical judgments that need to be considered in relation to assessing capacity and the assessment methods available to determine capacity and implications for their practice have also been discussed in the paper. . Reflection on the Attitudes and Values That Underpin Professional Practice Assessment of capacity to consent is very important aspect in the professional practice in respect to offering medical treatment thus incapacity should never be presumed just because a person has certain disability or condition such as learning disabilities, mental health problems or dementia. As stated by Lamont et al. (2013), assessment of incapacity should begin by assuming that individual has the capacity because it is from then that health professional would be able to independently assess capacity. Certain values and attitude are central to assessing capacity for consent to treatment for adults with incapacity. As outlined in the introduction above, most of these values have been entrenched in “The Adults with Incapacity (Scotland) Act 2000) (Scottish Government, 2008). Lack of proper legal authorization therefore means that a person’s right to make decisions about their care can be violated thus the act places an obligation on the staff to not only understand the legislation but also be able to appropriately apply it. Medical treatment can be defined as a treatment or a procedure that is designed to safeguard mental or physical health of an individual (Taylor, 2014). Medical treatment is therefore broad and includes even the fundamental aspects of care such as hygiene, nutrition and specific treatments for conditions and illnesses. The principle of patient autonomy is the leading principle underpinning assessment of capacity to consent to treatment. According to, providing treatment that is not in light with the wishes of a patient capable of consenting to treatments is a violation of patient autonomy principle and can amounts to assault. Maxmin et al (2009) also asserted that people posses the fundamental rights to determine how their bodies are supposed to be handled in the process of administering medication thus healthcare professionals must respect that right. In this respect, it is necessary to give people opportunity to give valid consent to all forms of treatment and healthcare from a major surgery to a personal care (Johan et al. 2014). Capable adult can therefore refuse to undergo any medical intervention even if such decision may result to death or harm because of the right to self determination. Emergency situations however present dilemma to healthcare professionals thus they have to make decisions from one time to the other depending often the prevailing conditions of individuals at that particular time. Healthcare professionals may therefore provide medical treatments in emergency situations without necessarily having to seek consent to treatment but must prove that such treatments are necessary to prevent serious deterioration in health condition or to preserve life (Racine & Billick, 2012). In this respect, healthcare professionals are required t ensure that they keep a detailed and accurate record of the decision and the process resulting into making such a decision. These set out clear statements of principles that direct the ethical basis for the provision of legislation and the values that underpin it as outlined in the part 5 of the act (Bingham, 2012). The principles outlined above are also reinforced by the legislation on human rights and may be the subject for judicial review. There are five principles that everyone carrying out functions under the act must apply with respect to the medical treatment of a person thus applies to assessment of capacity to consent to treatment. They include; maximum benefit, lest restrictive alternative, minimum necessary to achieve benefit, consultation with adults and relevant others and adults motivated to exercise residual capacity (Chaudhuri et al. 2013). Maximum benefit as a principle states that any medical treatment that is administered to an adult should result into direct personal benefit to the adult. For instance, incapacitated adult with advanced dementia fell and suffered a broken hip that requires hip replacement operation due to failing mobility. In this respect the individual ability to cope independently and mental well being is deteriorated thus operation should be aimed at the adults to maintain social supports and retain independence (Willner et al. 2013). This applies the principle of maximum benefit to the person thus treatments must consider this in the whole process of operation. The second value of least restrictive alternative outlines how medical treatment administered should be necessary to a person’s health and is not possible in another less intrusive way. For instance avoiding the use of chemical intervention when a patient’s catheter bag shows poor draining and restricting the passage of urine but instead recommending a bladder wash is a way of delivering medical treatment in less restrictive alternative. Administration of the minimum possible medication necessary to achieve desired benefit with the least restrictions of the adults rights as possible. Consultation with the adult and other relevant people is the fourth principle and it emphasizes on the importance of trying to determine through discussions with the adults and others the views of the adult with respect to the proposed intervention regardless of his or her capacity (Samsi et al. 2012). These views may have been written earlier own as some form of directive statements such as in the planning for care for person’s with advanced dementia. The fifth principle encourages adults to exercise residual capacity as much as possible in making their decisions. This is very important since adults are encouraged to participate as much as possible in making decisions that affect their medication. As stated by Wagemans et al. (2013), maximizing residual capacity is a statutory duty on any proxy decision maker and is the responsibility of health professionals in the event there is no decision maker. Maximizing residual capacity decision making therefore involves making all arrangements possible and encouraging , enabling and supporting person to use the current skills to develop new ones when capacity is limited or fluctuating (Devi, 2013). Establishing an individual’s beliefs, values and their consistency in decision is the most important aspect, especially when they have impaired cognitive ability. According to Emmett et al. 2013), the key to achieving this is a close relationship between professionals and the person involved in the care and exploitation of their skills. Factors that may affect Capacity People’s capacity to make decisions can be affected by several factors both within the internal and external environment. Factors that affect capacity may be external or internal to the person and includes previous hospital experience, communication, environment, co-existent health problems and the form of information provided to them. Personal, psychological, physical and situational factors play a vital role in influencing capacity. These are the general health condition of an individual patient who seeks treatment. According to Basso et al. (2010), patients with dementia are most likely to show deficiencies in comprehending, precluding thorough appreciation of the medical condition, treatment options and course of illness. This is however depended on the stage of dementia because persons with mild dementia will still exhibit reasoning capacity. As stated by Udo et al. (2013), it is therefore important to make every effort to clarify any limitations to comprehension in order to effectively circumvent such limitations. Studies have shown that delirium is a major factor that influences capacity (Kim, 2010). Delirium which is the abrupt onset of memory impairments is mainly linked to unstable consciousness and inattentiveness to individual’s surrounding. According to Soo (2013), persons with delirium are mainly disorganized and disoriented in thought thus experience illuminations that disrupt reasoning. A temporary reversal of a delirium impending decision-making capacity is therefore possible to a large extent. According to Evers (2008), such situations require immediate treatment of delirium in order to restore cognitive ability thus restore the capacity to make treatment decisions. In this regard, frequent assessments of persons with previous condition of delirium are very important especially when there are changes in the required interventions or medical conditions. Other mental conditions or any disorder that impairs mental ability is an important factor influencing decision making capacity for individuals. Other medical conditions that can affects an individual’s decision making capacity include pneumonia infections, influenza, urinary tract infections, cardiovascular illnesses, chronic pain or endocrine disorders (McKoy et al. 2014). According to Moye et al. (2007), individuals going through discomfort, pain or receiving medication that causes drowsiness such as those used in diabetes may also lose their decision-making capacity. Studies have shown that effective state is another important factor that influences decision-making capacity (Ross, 2009). However, this should not be confused by just a mere presence of high level emotion since it does not affect cognitive ability. According to Barsky (2010), extreme emotions have the capability to adversely affect capacity since individuals undergo anxiety especially when the patient is facing a medical decision. In this respect, this level of anxiety is likely to interfere with retention of information, comprehension and making the right choice among the available options Devettere (2010). Studies have suggested that severe depression is also important factor affecting decision making capacity. According to (Calveley, 2012), severe forms of depressions when accompanied by hopelessness or delusions can interfere with the decision making process of an individual. Research shows that these patients are likely to underestimate the benefits of receiving a particular treatment option or may overestimate the risks involved with a particular medical treatment. Depression is often associated with hopelessness which is very dangerous since it will interfere with the patients’ ability and understanding of the available treatment options and could be a good predictor of suicide. Resources and support available for patients is also an important factor influencing decision making capacity. According to Bærøe & Norheim (2011), the nature of the relationships between people can have a great bearing on the impacts of the decision to be made thus may influence the capacity of someone to make a decision. For example, in a situation where the person relating to others is at risk or threatened by another person they can be subjected to undue pressure thus refuse or consent to treatment instead of making an autonomous decision. However, if this is suspected to be the case, the health professionals have the responsibility to follow the adult protection procedures in line with the “Adults Support and Protection (Scotland) Act of 2007. As outline in this discussion earlier, healthcare professionals have the responsibilities to preserve the dignity, values and wishes of the patient. Diversity and equality issues such as the ethnic background of individuals as well as disability are also important factors affecting capacity to decision making. According to Agar et al. (2013 p.488), these are major considerations in capacity assessment in order to remove the risk of misinterpreting indicators of cultural differences as reduced cognitive function and incapacity. People come from different cultural backgrounds and with different believes and norms thus what one person sees as right may be totally wrong for another person. According to Moye et al (2013), healthcare professionals must therefore be sensitive to the person’s specific cultural and religious needs which may make language interpreters necessary or just a referrals to specialists. Religious believes are often held dearly to the hearts of many individuals though may contradict certain scientific evidence thus patients may lack the capacity to chose the best alternative treatment (Moye et al. 2013). This are important factors that are most likely to be encountered in day to day work in healthcare facility thus must be considered and all practical steps taken to enable people to make the decision themselves. In this respect, experts have recommended central component of communication and passing of information in a way that can be understood easily by the person as well as making good use of the residual capacity as provided for in the act (Tallberg et al. 2013). Partnership and patient centred relationships between healthcare professionals and patients in caring and communicating is therefore important. The Ethical and Clinical Judgments Considered In Relation To Assessing Capacity Assessment of the capacity to consent to treatment requires consideration of certain ethical and legal issues in making ethical and clinical judgements. A psychiatrist is often called to make a determination especially when an individual’s capacity to make decision is in question thus clinicians will assume that the initial psychiatric conclusions are regarded clinically conclusive (Jesus, 2012). This is because the psychiatrist is after all trained in this field and exhibit high expertise in this area. However, ethically, this assumption may not be warranted since the judgement made by the psychiatrists that the patient lacks or has capacity is not wholly clinical (Owen et al. 2008). It is therefore important to note that the determination of capacity involves two components, the ethical and clinical components. Ethical and clinical judgements that need to be considered in respect to assessing capacity includes: respect to human dignity, respect for vulnerable persons, concern for the welfare of individual, respect for autonomy, maximizing benefit while minimizing harm and non-maleficence. During the process of assessing individuals for capacity to consent to treatment, all individuals should be treated with respect and dignity throughout the process. Adults with incapacity must therefore receive the same standards of care as all patients with capacity. Respect and dignity entails respect for their rights to privacy and high quality care within comfortable surroundings. Those close to the patients must also be treated with compassion and understand and their views and suggestions should be considered to a great extent. As stated by Owen et al. (2013), equality, human rights and capacity laws reinforce the ethical duty on healthcare professionals to ensure that all patients receive the same standards of care. It is therefore important for doctors and healthcare professionals to be well conversant with these ethical principles set out in the law. Human rights requirements outlines in-depth the various obligations and ethical principles that underpin decision making including assessment of capacity to consent to treatment. The right to chose is reinforced by the ethical principles of autonomy (Lewis-Fernández et al. 2014) which is supported in both healthcare policy and the law. The principle of autonomy is so fundamental to the extent that every decision must yield to the principle of self determination (Cole, 2010). However, healthcare professionals often find it difficult to respect the rights of their patients and may feel frustrated due to the fact that certain choices may be reckless or foolish and may also feel uncomfortable since failure to provide care may result into liability in civil law (Hindmarch et al. 2013). In this respect, there would always be question on the capacity of the patient to make decision especially when they refuse treatment. In this respect, cases are often referred for a court declaration on the validity of the proposed course of action (Warner et al. 2008). The ethical principle of autonomy therefore reinforces that nobody should be subjected to any unwanted intervention or touching or be treated against their will and thus a valid consent must be received from the patients before touching their body. When assessing capacity, healthcare professionals and doctors should consider maximizing benefit while minimizing harm. In this regard, other issues such as diversity and cultural background have to be considered because they affect the individual’s welfare. According to Galeotti et al. (2012), patients’ capacity determination should not be determined ultimately by the moral view of the person doing the evaluation. Monroe et al. (2013) also suggested that arbitrary view of this issue is likely to contravene the principle of equity. The differences in moral believe between that of the psychiatrist or any person doing the evaluation and the patient is therefore an important consideration in determination of decision making capacity. Earlier in this text we stated that the views of the patient whether they are right or not have to be respected in assessing capacity to make decisions. It is therefore important for psychiatrists to consider cultural diversity in determining patients’ decision making capacity and they should not therefore impose their own morals and values on the decision making. The above discussed ethical and clinical judgements are very important considerations in assessing adults for capacity to consent to treatment. According to Grisso & Appelbaum (2007), ethical principles; dignity, privacy and safety may be compromised in a healthcare setting catering for a wide number of clients with different cultural backgrounds. For instance, in clinical practice staffs are often more busy and focussed on personal care tasks for people with dementia thus will not be able to meet the needs of people with other functional illness while assessing capacity. Experts have therefore recommended patient centred care as being very important in assessing capacity in such situations (Breden & Vollmann, 2004). Studies have also suggested that evaluations for capacity should be done in separate environments because of the diversity in special needs that the groups will have. Separate environments would also go hand in hand in keeping medical records so as to improve on privacy and confidentiality of medical records. The Assessment Methods Available To Determine Capacity Assessment of capacity is important because there is need to support and help a person in making accurate and important decisions that affects their lives. However, this does not automatically mean that the person is not able to make decisions (Tan et al. 20069). As stated in the act, it is mandatory to support the persons in communicating their feelings and views and nobody can act or make decisions for someone who is capable of doing so for her or himself (Kim et al. 2007). According to Halpern (2012), there is no universal test for incapacity and the evaluations are normally depended on the decision to be taken or tasks to be accomplished. The fundamental principles of maximizing an individual’s capacity and use of least restrictive alternatives underline the importance of not making blanket assessments of incapacity (Lamont et al. 2013). Thus consideration of residual capacity that an adult has outlined earlier in this text is the key to assessment of capacity to consent to treatment. Experts have suggested that the presumption that someone has capacity is often the starting point for assessing person’s capacity to make a decision (Suhonen et al. 2013). The act also provides that the burden of proof will be based on the person who concludes that the person lacks capacity thus they must show that capacity is lacking. According to Howe (2009 p.16), this law (section 5 of the act) was designed with the main purpose of promoting personal autonomy as well as protects adults with incapacity to make all or some decisions. It is therefore important for the healthcare professional, doctor or psychiatrist to have the ability to communicate with the person and assess their capacity to make decision in hand. However, this strategy of assessing capacity has serious implications in clinical practice. The biggest challenge in using this strategy is how to find ways to assist the person to understand what decision or decisions that needs to be made, why they should be made and how to help and support them reach their own decision as far as possible (Young et al. 1993). In this respect when taking an assessment of capacity, it is fundamentally important to consider as much as possible the ability of a person to decide. The second strategy recommended for clinical practice is that people should not be treated as being unable to make decisions merely because they make unusual or eccentric decisions. According to (Owen et al. 2009 p.1395) many people presented with similar circumstances will make different decisions because people give weight to certain factors rather than others. It is also important to note that factors influencing our decisions are diverse and could include preferences, own values as well as personal beliefs. According to Basso et al. (2010), through the decision making process, some people are more willing to taking risks than others while others are more keen to express their own individuality. However, the biggest implication of this methodology in assessment of capacity is that there could be a cause of concern if an individual repeatedly makes unwise decisions which place him or her at risk of getting harm (Lamont et al 2013). In such situations where person makes a particular decision which is contrary to all rationality notions, and is seen to be out of character a concern has to be triggered. Such situations should however not led to automatic conclusion that capacity is lacking but further investigations should be conducted since this indicate there is doubt about capacity. Making conclusions that a person has impaired capacity to make a particular decision should be arrived at after considering a number of factors. According to Tallberg et al. (2013), evaluation of the patients if they have any mental disorder is the first and most important strategy. Mental disorders often include learning disability, mental illness, acquired brain injury, dementia or physical disability resulting into communication difficulty such as stroke or severe sensory impairment (Racine & Billick, 2012). However, mental disorders should not be used exhaustively to reach a conclusion of lack of capacity thus the second factor has to be considered. The second factor and the most important one are to evaluate whether the mental disorder has made the person unable to make decisions at hand for himself. According to the 200 act, an individual is considered unable to make decisions for him or herself resulting from a mental disorder, physical disability or inability to communicate if he or she exhibit inability to make decisions, act, communicate decisions, understand and retain the memory of decisions (Taylor, 2014). However, the challenge and limitation of determining impaired capacity according to the act is that the act has not outlined how to asses capacity though outlines the above factors as being very critical depending on the decision at hand. Case Study: A Competent Patient Refuses Treatment Mr. Jerald is 65 years male with renal problems and need dialysis as soon as possible since without dialysis his life will be in danger. However, Jerald has refused treatment because he is scared of pain since he believes that the nature of the procedure is invasive. He has also undergone counselling through which he has been taken though the nature of his illness, alternative treatments and he has been told that there are no alternatives that would be practically beneficial. However, upon evaluation by the psychiatrist, she is found to be competent and have capacity to make treatment decisions. He has also been made to understand that his decision is risky, harmful and if he maintains his decision and refuses dialysis he will die. He also tells clinician that he has a 15 year old daughter whom he lives with at home. The clinician however has very strong feelings that he would go through dialysis but despite several efforts to persuade him she refuses. This case involves ethical dilemma and the biggest question is whether the clinician can do ahead and carry out the procedure. First, it is important to acknowledge that Mr Jerald is competent thus has the autonomy to make treatment decisions. If this principle is given the highest value then her refusal is respected irrespective of whether it results to death. Another point to note in this case is that Jerald is making an informed decision since he has received counselling but still believes it is invasive. However, the clinician may feel that he or she is not doing the right thing with respect to the principle of acting beneficently towards his or her patient if he accepts Jerald’s decision. Also how are we going to consider the interest of the 15 year old child? Nevertheless, Mr. Jerald has been assessed to have capacity thus he has capacity to consent to treatment and his decisions must be respected. Failure to respect Jerald’s decision would amount to committing battery. It is also important to note that if Jerald’s condition worsens in the future, then assessment of capacity would be done again and if he is found to have incapacity then his previously expresses wishes made when competent must be respected. This is to respect the process of decision making and assessment of capacity on a case by case basis. The principle of autonomy dictates that adults over the age of 16 have the sole right to control what happens to their bodies. In this respect, they can only be guided through the process of making decision but the ultimate choice is their own. References Agar, M., Ko, D., Sheehan, C., Chapman, M., & Currow, D. (2013) Informed Consent in Palliative Care Clinical Trials: Challenging but Possible. Journal of Palliative Medicine 16 (5) 485-491 Bærøe, K. & Norheim O. (2011) Mapping Out Structural Features In Clinical Care Calling For Ethical Sensitivity: A Theoretical Approach To Promote Ethical Competence In Healthcare Personnel And Clinical Ethical Support Services (CESS). Bioethics 25 (7) 394-402 Basso, M., Candilis, P., Johnson, J., Ghormley, C., Combs, D. & Ward, T. (2010) Capacity to make medical treatment decisions in multiple sclerosis: A potentially remediable deficit. Journal Of Clinical & Experimental Neuropsychology 32 (10) 1050-1061 Berghmans, P. (2008) Informed Consent and Decision-Making Capacity in Neuromodulation: Ethical Considerations. Neuromodulation 11 (3) 156-162 Bingham, S. (2012). Refusal of treatment and decision-making capacity. Nursing Ethics 19 (1) 167-172 Breden, T. & Vollmann, J. (2004) The cognitive based approach of capacity assessment in psychiatry: a philosophical critique of the MacCAT-T. Health Care Analysis: HCA: Journal Of Health Philosophy And Policy 12 (4) 273-283 Calveley, J. (2012) Including adults with intellectual disabilities who lack capacity to consent in research, Nursing Ethics 19 (4) 558-567 Chaudhuri, T., Yeatts, D. & Cready, C. (2013) Nurse aide decision making in nursing homes: factors affecting empowerment. Journal Of Clinical Nursing 22 (17) 2572-2585 Cole, M. (2011) Clinical Assessment of Mental Capacity of The Older Adult. McGill Journal of Law and health 5 (2) 273- 277 Cornish, S., & Preston-Shoot, M. (2013) Governance in adult safeguarding in Scotland since the implementation of the Adult Support and Protection (Scotland) Act 2007. Journal Of Adult Protection 15 (5) 223 Devi, N. (2013) Supported Decision-Making and Personal Autonomy for Persons with Intellectual Disabilities: Article 12 of the UN Convention on the Rights of Persons with Disabilities. Journal Of Law, Medicine & Ethics 41 (4) 792-806 Emmett, C., Poole, M., Bond, J. & Hughes, J. (2013) Homeward bound or bound for a home? Assessing the capacity of dementia patients to make decisions about hospital discharge: Comparing practice with legal standards, International Journal of Law and Psychiatry 36 (1) 73-82 Evers, C. (2008) Assessing capacity: developing an integrated care pathway. Learning Disability Practice 11 (1) 30-33 Galeotti, F., Vanacore, N., Gainotti, S., Izzicupo, F., Menniti-Ippolito, F., Petrini, C., Chiarotti, F., Chattat, R. & Kaschetti, R. (2012) How Legislation on Decisional Capacity Can Negatively Affect the Feasibility of Clinical Trials in Patients with Dementia. Drugs & Aging 29 (8) 607-614 Grisso, T. & Appelbaum, P. (2007) Appreciating Anorexia: Decisional Capacity and the Role of Values. Philosophy, Psychiatry, & Psychology 4 (1) 293-297 Halpern, J. (2012) When Concretized Emotion-Belief Complexes Derail Decision-Making Capacity. Bioethics 26 (2) 108-116 Hindmarch, T., Hotopf, M. & Owen, G. (2013) Depression and decision-making capacity for treatment or research: a systematic review. BMC Medical Ethics. Howe, E. (2009) Ethical Aspects of Evaluating A Patients Mental Capacity, Psychiatry (1550-5952) 6 (7) 15-22 Jesus, J. (2012) Ethical Problems in Emergency Medicine: A Discussion-Based Review, Hoboken, N.J.: Wile Johan, F., Roshan, R., Nanji, K., Sajwani, U., Warsani, S. & Jaffer, S. (2014) Factors affecting the process of obtaining informed consent to surgery among patients and relatives in a developing country: results from PakistanFacteurs influant sur le processus dobtention dun consentement eclaire pour une intervention chirurgicale chez des patients et des parents dans un pays en developpement: resultats du Pakistan, Eastern Mediterranean Health Journal, 9, p. 569 Kim, S., Appelbaum, P., Swan, J., Stroup, T., McEvoy, J., Goff, D., Jeste, D., Lamberti, J., Leibovici, A. & Caine, E. (2007) Determining when impairment constitutes incapacity for informed consent in schizophrenia research. The British Journal Of Psychiatry: The Journal Of Mental Science 191 (15) 38-43 Kim, S. H. (2010) Evaluation Of Capacity To Consent To Treatment And Research. Oxford: Oxford University Press Lamont, S., Jeon, Y. & Chiarella, M. (2013) Assessing patient capacity to consent to treatment: an integrative review of instruments and tools Journal Of Clinical Nursing 22 (18) 2387-2403 Lamont, S., Jeon, Y. & Chiarella, M. (2013) Health-care professionals’ knowledge, attitudes and behaviours relating to patient capacity to consent to treatment: An integrative review, Nursing Ethics 20 (6) 684-707 Lewis-Fernández, R., Aggarwal, N., Bäärnhielm, S., Rohlof, H., Kirmayer, L., Weiss, M., Jadhav, S., Hinton, L., Alarcón, R., Bhugra, D., Groen, S., van Dijk, R., Qureshi, A., Collazos, F., Rousseau, C., Caballero, L., Ramos, M. & Lu, F. (2014) Culture and Psychiatric Evaluation: Operational zing Cultural Formulation for DSM-5. Psychiatry: Interpersonal & Biological Processes 77 (2) 130-154 Maxmin, K., Cooper, C., Potter, L. & Livingston, G. (2009) Mental capacity to consent to treatment and admission decisions in older adult psychiatric inpatients, International Journal Of Geriatric Psychiatry 24 (12) 1367-1375 McKoy, J., Burhenn, P., Browner, I., Loeser, K., Tulas, K., Oden, M. & Rupper, R. (2014) Assessing cognitive function and capacity in older adults with cancer, Journal Of The National Comprehensive Cancer Network: JNCCN 12 (1) 138-144 Monroe, T., Herr, K., Mion, L. & Cowan, R. (2013) Ethical and legal issues in pain research in cognitively impaired older adults, International Journal Of Nursing Studies, 50, Special Issue Improving The Care Of Older Persons 1283-1287. Moye, J., Karel, M., Edelstein, B., Hicken, B., Armesto, J. & Gurrera, R. (2007) Assessment of Capacity to Consent to Treatment: Challenges, the "ACCT" Approach, Future Directions, Clinical Gerontologist 31 (3) 37-66 Murray, A. (2013) The Mental Capacity Act And Dementia Research, Nursing Older People 25 (3) 14-20 Owen, G., David, A., Richardson, G., Szmukler, G., Hayward, P. & Hotopf, M. (2009) Mental capacity, diagnosis and insight in psychiatric in-patients: a cross-sectional study, Psychological Medicine 39 (8) 1389-1398 Owen, G., Szmukler, G., Richardson, G., David, A., Raymont, V., Freyenhagen, F., Martin, W. & Hotopf, M. (2013) Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study. British Journal Of Psychiatry 203 (6) 461-467 Racine, C. & Billick, S. (2012) Assessment instruments of decision-making capacity. Journal Of Psychiatry & Law 40 (2) 243-263 Ross, L. K. (2009) Changes in Decision-Making Capacity in Older Adults: Assessment and Intervention. JAMA, The Journal Of The American Medical Association 7 777 Samsi, K., Manthorpe, J., Nagendran, T. & Heath, H. (2012) Challenges and expectations of the Mental Capacity Act 2005: an interview-based study of community-based specialist nurses working in dementia care. Journal Of Clinical Nursing 21 (12) 1697-1705 Scottish Government. (2008) Adults with Incapacity (Scotland) Act 2000: Code of Practice for Local Authorities Exercising Functions under the 2000 Act, 1 April 2008. Public Information Online, EBSCOhost (accessed November 30, 2014). Soo, W. (2013) Older adults with cancer and clinical decision-making: The importance of assessing cognition, Cancer Forum 37 (3) 201-205 Stacey, D., Menard, P., Gaboury, I., Jacobsen, M., Sharif, F., Ritchie, L. & Bunn, H. (2008) Decision-making needs of patients with depression: a descriptive study. Journal Of Psychiatric & Mental Health Nursing 15 (4) 287-295 Suhonen, R., Stolt, M., & Leino-Kilpi, H. (2013) Older people in long-term care settings as research informants: Ethical challenges. Nursing Ethics 20 (5) 551-56 Tallberg, I., Stormoen, S., Almkvist, O., Eriksdotter, M. & Sundström, E. (2013) Investigating medical decision-making capacity in patients with cognitive impairment using a protocol based on linguistic features. Scandinavian Journal Of Psychology 54 (5) 386-392 Tallberg, I., Stormoen, S., Almkvist, O., Eriksdotter, M. & Sundström, E. (2013) Investigating medical decision-making capacity in patients with cognitive impairment using a protocol based on linguistic features. Scandinavian Journal Of Psychology 54 (5) 386-392 Tan, J., Stewart, A. & Hope, R. (2009) Decision-Making as a Broader Concept. Philosophy, Psychiatry, & Psychology 4, 345-357 Taylor, H. (2014) Helping people with learning disabilities exercise their right to autonomy. Learning Disability Practice 17 (7) 32-37 Taylor, H. (2014) Promoting a patients right to autonomy: implications for primary healthcare practitioners. Part 1. Primary Health Care 24 (2) 36-41 Udo, I., Mohammed, Z. & Gash, A. (2013) Psychiatric issues in palliative care: assessing mental capacity. Palliative Care: Research And Treatment 37 Wagemans, A., Van Schrojenstein Lantman-De Valk, H., Proot, I., Metsemakers, J., Tuffrey-Wijne, I. & Curfs, L. (2013) The factors affecting end-of-life decision-making by physicians of patients with intellectual disabilities in the Netherlands: a qualitative study. Journal Of Intellectual Disability Research 57 (4) 380-389 Warner, J., McCarney, R., Griffin, M., Hill, K. & Fisher, P. (2008) Participation in Dementia Research: Rates and Correlates of Capacity to Give Informed Consent. Journal of Medical Ethics 3 (11) 167-170 Willner, P., Bridle, J., Price, V., Dymond, S. & Lewis, G. (2013) What do NHS staff learn from training on the Mental Capacity Act (2005)?. Legal & Criminological Psychology 18 (1) 83-101 Young, E., Corby, J. & Johnson, R. (1993) Does depression invalidates competence? Consultants ethical, psychiatric, and legal considerations. Cambridge Quarterly of Healthcare Ethics: CQ: the International Journal of Healthcare Ethics Committees 2 (4) 505-515 Read More