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Medical Decisions in Question: Mental incapacity missed by docs

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9:40am, October 20, 2004
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It's bad enough to be a patient in a hospital. What's worse, according to a team of British researchers, is that a substantial minority of medical patients is legally incompetent to make decisions about their treatment, yet their physicians often overlook this limitation.

Over an 18-month period, about one-third of a predominantly elderly group of people treated at a London hospital for at least 2 days exhibited an inability to understand the treatment decisions that they faced, say psychiatrist Matthew Hotopf of the Institute of Psychiatry in London and his colleagues. Yet physicians taking care of these patients rated only a small number of them as mentally incapacitated.

"More should be done to protect the interests of . . . the high proportion of medical patients who are treated without being able to give valid consent," the investigators conclude.

In particular, physicians need to assess and document mental capacity in elderly patients facing critical health decisions, in Hotopf's view. Such choices include a patient's acceptance of placement in a nursing home and whether he or she wants physicians to withhold treatment under certain circumstances.

The new study appears in the Oct. 16 Lancet.

Hotopf's team considered 302 patients consecutively admitted mainly for acute heart, lung, or neurological disorders. None of them suffered from a progressive brain condition, such as Alzheimer's disease.

Of the patients, 72 exhibited cognitive problems too severe to join the study. Another 71 refused to participate or were unable to speak English.

Researchers conducted standardized interviews with the remaining 159 patients to determine their medical-decision-making capacities. Interviews focused on the extent to which a person understood his or her disorder and its treatment, knowledge of how a treatment would affect his or her life, and the ability to compare alternative medical choices before picking an option.

Decision-making incapacity characterized 50 patients, or 31 percent of those interviewed. Only 12 patients, however, were rated by treating clinicians as unable to make informed decisions.

Of the 109 patients that the researchers characterized as mentally competent, none was tagged by doctors as mentally incapacitated.

Psychiatric disorders were rare in both groups.

The most troubling result, Hotopf contends, was the tendency of incapacitated persons to trust in physicians who failed to recognize or address those patients' decision-making deficiencies.

The new findings don't apply to all medical patients. For instance, an earlier study using the same standardized interviews with 82 people being treated for chronic ischemic heart disease in three U.S. hospitals found that nearly all of them possessed decision-making competence. That study, directed by Paul S. Appelbaum and Thomas Grisso, both of the University of Massachusetts Medical School in Worcester, included mainly middle-aged patients rather than elderly ones.

Further research needs to examine whether researchers, clinicians, and families, given the same interview information, agree on patients' competency, remarks geriatric physician Jason H.T. Karlawish of the University of Pennsylvania in Philadelphia.

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