- Email: [email protected]
Mental capacity of inpatients
Correspondence
decision to seek less rather than more information and influence on therapeutic decisions. In his accompanying Comment (p 1383),4 Jason Karlawish suggests that this study validates the standard cut-off of 24 or lower for the minimental state examination (MMSE), and that such low scores indicate mild cognitive impairment. MMSE scores are affected by many factors, including age and, particularly, education, and cut-offs should be adjusted accordingly.5 Furthermore, whether the ascertainment of capacity in the study could have been biased by prior access to the MMSE score is unclear. Karlawish’s comment about using the results of the study “to regulate the freedom to decide, especially in elderly people with mild stages of cognitive impairment” is chilling. The fact that many people have difficulty contributing to medical decisionmaking represents a challenge to doctors to improve their communication skills and to develop better educational aids. If patients are at risk of losing their right to participate in decision-making on the basis of tests such as the MMSE, they would be well advised to practise skills such as drawing intersecting pentagons before they go near a doctor. I declare that I have no conflict of interest.
Shaun T O’Keeffe [email protected] Department of Geriatric Medicine, Unit 4, Merlin Park Regional Hospital, Galway, Ireland 1
2
3
4 5
Raymont V, Bingley W, Buchanan A, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: crosssectional study. Lancet 2004; 364: 1421–27. Lloyd AJ. Communicating and understanding risk: the extent of patients’ understanding of the risk of treatments. Qual Health Care 2001; 10: i14–18. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996; 125: 763–69. Karlawish JHT. Competency in the age of assessment. Lancet 2004; 364: 1383–84. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state examination by age and educational level. JAMA 1993; 269: 2386–91.
www.thelancet.com Vol 365 February 12, 2005
Authors’ reply The points raised by Shaun O’Keefe relate mainly to the criterion validity of the mental capacity judgments we made. Unfortunately, an objective threshold for mental capacity is difficult to set,1 and there is no gold standard against which to compare our assessment. We put questions to participants in a systematic way, using a semi-structured interview,2 and we were able to show good inter-rater reliability when assessing transcripts of the interviews. In the absence of a gold standard to ascertain mental capacity, use of a group of experienced doctors to make the judgment seems a reasonable approach—the fact that we were able to agree most of the time, suggests that the threshold set was reasonable. O’Keefe rightly points out that research is different from clinical practice, and we agree that proper clinical assessments would be more flexible. For example, one might interview a patient several times, and give information to the patient in several different ways. Unfortunately, in our experience, clinical assessments are often less than thorough. We neither advocate nor would we condone the use of the MMSE as a substitute for a broader clinical assessment. Although we agree that many patients might exercise the right not to know about their condition or its treatment, we doubt that such patients can truly exercise informed choice when a treatment or investigation is proposed. We agree that strong emotions are inevitably present around some decisions, and that they could affect the way in which these decisions are made. Such emotions often do impair mental capacity (for example in patients refusing treatment after an overdose). Incapacity is not solely a cognitive factor. O’Keefe implies that to judge that a patient does not have the capacity to make a decision means automatically that the patient loses the right to participate in decision making. Our study suggests that this process happens much of
the time anyway. Many of the patients we interviewed did not know why they were in hospital, what their diagnoses were, or what treatments they were on. Such patients are not able to participate in a decision making process. To recognise that they have problems in decision making is the first step in improving their autonomy and making sure that their best interests are looked after. We declare that we have no conflict of interest.
*Matthew Hotopf, Vanessa Raymont, Anthony David, Alec Buchanan [email protected] Department of Psychological Medicine, Institute of Psychiatry, Weston Education Centre, London SE5 9RJ, UK (MH); Vietnam Head Injury Study, National Naval Medical Center, Bethesda, MD, USA (VR); Department of Psychological Medicine, Institute of Psychiatry, London, UK (AD); and Yale University Department of Psychiatry, New Haven, CT, USA (AB) 1
2
Buchanan A. Mental capacity, legal competence and consent to treatment. J R Soc Med 2004; 97: 415–20. Grisso T, Applebaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatric Services 1997; 48: 1415–19.
Health financing and access to services Natasha Palmer and colleagues (Oct 9, p 1365)1 are correct to conclude that more systematic research is needed to adequately assess the effect of different health financing approaches on equitable access to health services. We are a team committed to applied research in health financing, and as such could not agree more with their overall argument. We were disappointed, however, by some of the elements raised in their discussion. First, we were taken aback by the inclusion of cash transfers in a discussion focussed on health financing. The World Health Report 20002 clearly states that the three key functions of health financing are revenue collection, resource pooling, and service purchasing. Conditional cash transfers fulfil none of these functions. We therefore find their inclusion in a formal analysis of health financing 569
decision to seek less rather than more information and influence on therapeutic decisions. In his accompanying Comment (p 1383),4 Jason Karlawish suggests that this study validates the standard cut-off of 24 or lower for the minimental state examination (MMSE), and that such low scores indicate mild cognitive impairment. MMSE scores are affected by many factors, including age and, particularly, education, and cut-offs should be adjusted accordingly.5 Furthermore, whether the ascertainment of capacity in the study could have been biased by prior access to the MMSE score is unclear. Karlawish’s comment about using the results of the study “to regulate the freedom to decide, especially in elderly people with mild stages of cognitive impairment” is chilling. The fact that many people have difficulty contributing to medical decisionmaking represents a challenge to doctors to improve their communication skills and to develop better educational aids. If patients are at risk of losing their right to participate in decision-making on the basis of tests such as the MMSE, they would be well advised to practise skills such as drawing intersecting pentagons before they go near a doctor. I declare that I have no conflict of interest.
Shaun T O’Keeffe [email protected] Department of Geriatric Medicine, Unit 4, Merlin Park Regional Hospital, Galway, Ireland 1
2
3
4 5
Raymont V, Bingley W, Buchanan A, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors: crosssectional study. Lancet 2004; 364: 1421–27. Lloyd AJ. Communicating and understanding risk: the extent of patients’ understanding of the risk of treatments. Qual Health Care 2001; 10: i14–18. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996; 125: 763–69. Karlawish JHT. Competency in the age of assessment. Lancet 2004; 364: 1383–84. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state examination by age and educational level. JAMA 1993; 269: 2386–91.
www.thelancet.com Vol 365 February 12, 2005
Authors’ reply The points raised by Shaun O’Keefe relate mainly to the criterion validity of the mental capacity judgments we made. Unfortunately, an objective threshold for mental capacity is difficult to set,1 and there is no gold standard against which to compare our assessment. We put questions to participants in a systematic way, using a semi-structured interview,2 and we were able to show good inter-rater reliability when assessing transcripts of the interviews. In the absence of a gold standard to ascertain mental capacity, use of a group of experienced doctors to make the judgment seems a reasonable approach—the fact that we were able to agree most of the time, suggests that the threshold set was reasonable. O’Keefe rightly points out that research is different from clinical practice, and we agree that proper clinical assessments would be more flexible. For example, one might interview a patient several times, and give information to the patient in several different ways. Unfortunately, in our experience, clinical assessments are often less than thorough. We neither advocate nor would we condone the use of the MMSE as a substitute for a broader clinical assessment. Although we agree that many patients might exercise the right not to know about their condition or its treatment, we doubt that such patients can truly exercise informed choice when a treatment or investigation is proposed. We agree that strong emotions are inevitably present around some decisions, and that they could affect the way in which these decisions are made. Such emotions often do impair mental capacity (for example in patients refusing treatment after an overdose). Incapacity is not solely a cognitive factor. O’Keefe implies that to judge that a patient does not have the capacity to make a decision means automatically that the patient loses the right to participate in decision making. Our study suggests that this process happens much of
the time anyway. Many of the patients we interviewed did not know why they were in hospital, what their diagnoses were, or what treatments they were on. Such patients are not able to participate in a decision making process. To recognise that they have problems in decision making is the first step in improving their autonomy and making sure that their best interests are looked after. We declare that we have no conflict of interest.
*Matthew Hotopf, Vanessa Raymont, Anthony David, Alec Buchanan [email protected] Department of Psychological Medicine, Institute of Psychiatry, Weston Education Centre, London SE5 9RJ, UK (MH); Vietnam Head Injury Study, National Naval Medical Center, Bethesda, MD, USA (VR); Department of Psychological Medicine, Institute of Psychiatry, London, UK (AD); and Yale University Department of Psychiatry, New Haven, CT, USA (AB) 1
2
Buchanan A. Mental capacity, legal competence and consent to treatment. J R Soc Med 2004; 97: 415–20. Grisso T, Applebaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatric Services 1997; 48: 1415–19.
Health financing and access to services Natasha Palmer and colleagues (Oct 9, p 1365)1 are correct to conclude that more systematic research is needed to adequately assess the effect of different health financing approaches on equitable access to health services. We are a team committed to applied research in health financing, and as such could not agree more with their overall argument. We were disappointed, however, by some of the elements raised in their discussion. First, we were taken aback by the inclusion of cash transfers in a discussion focussed on health financing. The World Health Report 20002 clearly states that the three key functions of health financing are revenue collection, resource pooling, and service purchasing. Conditional cash transfers fulfil none of these functions. We therefore find their inclusion in a formal analysis of health financing 569