Mental incapacity among patients in medical wards more widespread than doctors realise

October 14, 2004

This release is also available in German.

Doctors working in medical wards with acutely ill and predominantly elderly patients need to be more aware that mental incapacity among their patients-and therefore the inability to give informed consent about treatment-is a potentially widespread problem.

Although patients' mental incapacity is becoming increasingly important in clinical practice, little information is available on its frequency in inpatients. Matthew Hotopf (Institute of Psychiatry, London, UK) and colleagues estimated the prevalence of mental incapacity in acutely admitted medical inpatients; they also determined the frequency that medical teams recognised patients who did not have mental capacity, and sought to identify factors associated with mental incapacity.

Around 300 acute medical inpatients were recruited to the study. The investigators used different assessments to identify whether patients had mental capacity (the ability to make valid judgements about treatment) and to identify individuals with cognitive impairment. 159 patients were interviewed for the study, of whom the researchers judged 31% to lack mental capacity; however, recognition of incapacity by clinical staff was low: only a quarter of patients identified by the investigators as not having mental capacity were identified by clinicians. Increasing age and cognitive impairment were the main factors associated with a lack of mental capacity.

Professor Hotopf comments: "A substantial proportion of inpatients in any general medical ward do not have capacity to make informed treatment decisions, a situation that is rarely recognised by doctors. If a legal approach to solve this problem is too heavy-handed-eg, requiring patients to be more explicitly identified and protected-then people who would be affected by such legislation could be adversely affected. However, to accept the passive acquiescence of such patients as evidence of true consent would be dangerous when important and irreversible decisions need to be made. Before making such decisions, the clinician should have considered the possibility that the patient is unable to give valid consent".

In an accompanying commentary (p 1383), Jason Karlawish (Institute on Ageing, Philadelphia, USA) concludes: "The critical issue is how we use these data to regulate the freedom to decide, especially in elderly people with mild stages of cognitive impairments. Data are not available but are urgently needed to answer the following questions: What information do raters use, how do they use it, and what are the consequences of these differences? Do experts, clinicians, and families still disagree on capacity judgments, even with the same information and judgment question? What are the ethical, legal, and clinical consequences of these disagreements? How do clinicians' and families' failures to recognise impairments in the capacity to make decisions affect quality of, adherence to, and outcomes of care?"
-end-
Contact: Professor Matthew Hotopf , Department of Psychological Medicine, Institute of Psychiatry, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK; T) 44-207-848-0435 or 44-798-943-3209; m.hotopf@iop.kcl.ac.uk

Dr Jason H T Karlawish, Institute on Aging, Philadelphia, Pennsylvania 19104, USA; T) 215-898-8997; jasonkar@mail.med.upenn.edu

ISSUE: 16-22 October 2004

Lancet

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