Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study

Abstract

Background: Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients?

Aims: To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice.

Method: A secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool - Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability.

Results: Most people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P = 0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better 'test' of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P = 0.02).

Conclusions: Among those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting

 

DOI: 10.1192/bjp.bp.112.123976