Psychiatry for Neurologists - part 10 docx

The physician’s disclosure duty requires an explanation of the nature of the treatment or procedure that is being proposed by the physician, thepossible alternatives to that treatment or

1 Jones WH Hippocrates Decorum XVI In: Jones WH, ed Hippocrates with an English Translation, Vol 2.London: Heinemann; 1923.

2 Vandekieft GK Breaking bad news Am Fam Physician 2001;64:1975–1978.

3 Creagan ET How to break bad news-and not devastate the patient Mayo Clin Proc 1994;69:1015–1017.

4 Tipper L, Bonas S, Fisher J, Barnett M Female doctors break bad news best E-Bulletin: University of Leicester: England; 2003.

5 Buckman R Breaking bad news: why is it so difficult? Br Med J 1984;288:1597–1599.

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7 Rabow MW, McPhee SJ Beyond breaking news How to help patients who suffer West J Med 1999;48:260–263.

8 Greenstine JL, Leviton SC Elements of Crisis Intervention: Crises and How to Respond to Them, Second Edition Pacific Grove, CA: Brooks/Cole; 2002.

9 Kanel K A Guide to Crisis Intervention, Second Edition Pacific Grove, CA: Brooks/Cole; 2002.

10 Rosenbluh ES Emotional First Aid Louisville, KY: American academy of crisis interveners; 1981.

11 Department of Health and Human Services Office of Civil Rights (OCR) Health Information Portability and Accountability Act www.hhs.gov/ocr/hippa/ Accessed April 24, 2005.

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13 Temkin NR, Dikmen SS, Anderson GD, et al Valproate therapy for prevention of post-traumatic seizures J Neurosurg 1999;91:595–600.

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29 Informed Consent and Competency

Legal and Ethical Issues

David Naimark, Laura Dunn, Ansar Haroun, and Grant Morris

INTRODUCTION

Clinical issues related to informed consent and competency are present in all areas of medicine andare, quite possibly, the most relevant in the disciplines of psychiatry and neurology The very nature

of the specialty (involving disease of mind or brain) often calls into question the ability of the patient

to understand the medical procedures or treatment that are being proposed

In this chapter, we begin with an exploration of the legal aspects of informed consent and tency in order to give the reader an underpinning of the basic concepts, and then proceed to a “how-to” guide for accomplishing the medical task of assessment

compe-LEGAL ASPECTS OF INFORMED CONSENT AND COMPETENCY

The Doctrine of Informed Consent

The Tort of Battery

In 1914, Justice Benjamin Cardozo, writing for the New York Court of Appeals in Schloendorff vs

Society of New York Hospital ( 1 ) declared, “Every human being of adult years and sound mind has a

right to determine what shall be done with his own body; and a surgeon who performs an operation

without his patient’s consent commits [the tort of battery], for which he is liable in damages” ( 1 ) This

early 20th-century quotation is often cited as the starting point for the law’s recognition of the patient’sright to medical self-determination

It is easy to understand why battery was the tort first chosen to champion the patient’s right to trol physician decision making Early 20th-century cases typically involved fact situations in whichthe patient either specifically prohibited any operation, or authorized an operation different than theone performed by the surgeon Under such circumstances, it was easy for the courts to find that thetort of battery had been committed That tort protects the inviolability of one’s person, described bywriters as the first and greatest right of a free citizen, one that underlies all other rights An operationperformed without permission on an anesthetized patient violates that patient’s bodily integrity Thetort is committed by the unauthorized contact, no matter how medically appropriate the surgery and

con-no matter how skillfully it is performed Neither an intent to harm the patient, con-nor negligence in forming the operation itself, are required for the tort of battery, only knowledge that the contact ismade without the patient’s consent Actual physical harm to the patient is not a prerequisite for tortliability; battery is a dignitary tort, protecting individuals from offensive as well as harmful contact

per-From: Current Clinical Neurology: Psychiatry for Neurologists

Edited by: D.V Jeste and J.H Friedman © Humana Press Inc., Totowa, NJ

When the operation, or other touching of the patient’s body, was performed without any consent,the tort of battery was, and continues to be, well suited to protect the patient’s autonomy interest Overthe years, however, patients demanded more for their autonomy right Self-determination meant morethan simply accepting or rejecting the doctor’s decision; it meant the right for patients to make thedecision themselves And to make those decisions, patients needed the information about the proposedtreatment or surgery that only their doctors could provide to them But courts were far more reluctant

to characterize as batteries treatments or operations that were performed with the patient’s consentbut without an adequate disclosure by the surgeon of the risks, benefits, and alternatives to the agreedupon procedure The tort of battery was relegated to cases in which the physician either operated with-out obtaining any consent from the patient or the patient specifically declined the operation In devel-

oping a duty of disclosure a half century after Schloendorff, courts distinguished between “real” or

“basic” consent, necessary to avoid liability for battery, and failure to obtain the patient’s “informed”consent, which most courts characterized as the tort of negligence

The Tort of Negligence

A plaintiff claiming negligence must prove that the defendant breached a duty that was owed tothe plaintiff and that the breach caused an injury to the plaintiff The term “informed consent” wasfirst mentioned in 1957 in a California Court of Appeal decision That court embraced the principle

of patient medical self-determination, declaring, “a physician violates his duty to his patient and jects himself to liability if he withholds any facts which are necessary to form the basis of an intelli-

sub-gent consent by the patient to the proposed treatment” ( 2 ) The physician’s disclosure duty requires

an explanation of the nature of the treatment or procedure that is being proposed by the physician, thepossible alternatives to that treatment or procedure, and the material risks and anticipated benefits ofthe treatment or procedure

The physician’s disclosure duty, however, is not absolute In Natanson vs Kline, the Kansas Supreme

Court acknowledged that a physician probably has a therapeutic privilege to withhold a diagnosis ofcancer or other dread disease from an unstable, temperamental, or severely depressed patient whendisclosure would seriously jeopardize the patient’s recovery The court noted, however, that suppres-sion of facts would not be warranted in the ordinary case Merely because the physician believes thatthe patient may decline a procedure or operation if the risks are explained to him or her does not excusethe physician’s failure to divulge those risks

Although physicians are not permitted to deceive patients in order to substitute their own judgment

for that of their patients, the Natanson court ruled that the physician’s duty to disclose “is limited to

those disclosures which a reasonable medical practitioner would make under the same or similar

cir-cumstances” ( 3 ) In essence, the court engrafted onto the disclosure requirement the medical custom

standard of care that is used to determine professional malpractice As long as the defendant conformed

to the level of disclosure of other physicians in good standing, and the defendant is presumed to haveconformed in the absence of expert medical testimony to the contrary, no breach of the disclosure dutywould be found

The medical custom standard is used today by a majority of states to measure whether the cian’s disclosure duty has been breached In part, the dominance of this standard was assured by thelegislative response to the perceived medical malpractice crisis of the mid-1970s As one “reform” toreduce physician liability and malpractice insurance costs, several states enacted legislation adoptingthe medical custom standard to measure breach of the physician’s disclosure duty

physi-Not all jurisdictions, however, allow physicians to establish their own standard for measuring

dis-closure In Canterbury vs Spence, the US Court of Appeals for the District of Columbia Circuit

rejected the medical custom approach, asserting, “[i]t is the prerogative of the patient, not the

physi-cian, to determine for himself the direction in which his interests seem to lie” ( 4 ) “In our view,” wrote

the court, “the patient’s right of self-decision shapes the boundaries of the duty to reveal.” The quacy of the physician’s disclosures to the patient “must be measured by the patient’s need, and that

ade-need is the information material to the decision: all risks potentially affecting the decision must beunmasked.”

Concerned that physicians might not know what risks would be material to their patients, the

Canterbury court defined “material risks” as those risks that a reasonable person in the patient’s

posi-tion would be likely to consider significant Although the court acknowledged that “orthodox gence doctrine” measures “the reasonableness of the physician’s divulgence in terms of what he

negli-knows or should know to be the patient’s informational needs,” the court transformed the individual

patient’s informational needs into those of the hypothetical, reasonable patient

The patient, the court acknowledged, has no duty to ask for information from the physician Thephysician is obligated, despite the patient’s silence, to volunteer information that the patient needs tomake his or her decision “Caveat emptor is not the norm for the consumer of medical services,” says

the court But the Canterbury court did not require the physician to inquire of the silent patient

whether there was anything he or she would like to know (i.e., what is important to that patient’s sion making) And yet, by not obligating physicians to ask their patients what their concerns are, and

deci-then to respond to those concerns, the Canterbury court, in reality, ruled that the physician’s

disclo-sure duty is owed, not to his or her patient, but only to the reasonable patient By homogenizing allpatients into reasonable patients, the court perverted the very principle it proclaimed

The Canterbury court erected other barriers to the patient’s right to self-determination If the

physi-cian fails to reveal the risks and alternatives that a reasonable patient would consider material to his

or her judgment, negligence law requires the patient to prove that this breach of duty caused harm.The harm requirement is satisfied, said the court, only if an unrevealed risk that the physician wasobligated to disclose, materializes, and the causation requirement is satisfied only if a reasonable person

in the patient’s position would have declined the treatment if the risk had been revealed

Harm, according to the court, is limited to the patient’s interest in his or her physical well-being(i.e., was the patient physically injured by the physician’s breach of the disclosure duty?) The courtassures us that “[t]he patient obviously has no complaint if he would have submitted to the therapynotwithstanding awareness that the risk was one of its perils.” The patient, however, does have a com-plaint The patient has been deprived of the right to decide That loss of individual autonomy, in and

of itself, is an injury Nevertheless, this dignitary loss, the right to make one’s own choice as to whatshall be done to one’s own body, is not compensable For the patient to succeed in a negligence claim

against the physician, Canterbury requires that the plaintiff suffer a physical injury from the

physi-cian’s breach of the disclosure duty

The Canterbury court’s analysis of the causation requirement is even more dubious If the

physi-cian does not breach the disclosure duty, the patient’s decision to accept or reject the proposed ment or surgery will not be disturbed “The patient,” the court tells us, “is free to decide for any reasonthat appeals to him.” But if the physician breaches the disclosure duty, depriving the patient of his orher right to decide, for any reason that appeals to him or her, then causation of harm will not be mea-sured by what he or she would have decided, but rather, by what a reasonable person in the patient’sposition would have decided The causation requirement is no longer an inquiry about what the patientwould have decided if he or she had not been deprived of information material to his or her judgment.The patient who has been wronged by the physician’s nondisclosure is permitted to win only if he orshe would have made a decision that the jury considers to be reasonable

treat-Despite its doctrinal deficiencies, Canterbury’s reasonable patient test—for measuring both breach

of the disclosure duty and causation—has become the “liberal” alternative to the conservative

rea-sonable doctor test For nearly half the states, Canterbury did not become a new point of departure; itbecame a final destination

Expanding the Definition of “Material Risks” That Must Be Disclosed

Suppose a physician informs the patient of the risks of and alternatives to procedures and nostic tests that the physician proposes, and the patient declines the proposed treatment To fulfill his

diag-or her disclosure duty, must the physician also disclose to the patient the risks of patient’s decision torefuse treatment? Some courts have responded in the affirmative The California Supreme Court, forexample, has ruled that this broadened disclosure obligation is needed to assure not only that the patient

gives an informed consent to treatment, but also to assure that the patient’s refusal of treatment is also

informed “The duty to disclose was imposed,” said the California Supreme Court, “so that patients

might meaningfully exercise their right to make decisions about their own bodies” ( 5 ).

But suppose, for example, that after evaluating a patient, the physician’s proposed course of action

is no action The physician decides not to order additional laboratory tests to better diagnose a patient’smedical condition, or simply decides to monitor the patient’s condition but not to administer any treat-ment, or decides to terminate treatment because, in the physician’s judgment, a successful outcomehas been achieved Must the physician disclose the risks of and alternatives to the nontreatment optionthat the physician has selected? Because the tort of battery requires unpermitted physical contact withthe patient, that tort is not committed by physician’s decision to select the “no-treatment” option.But does a negligence-based informed consent doctrine require the physician to disclose the risksand alternatives of these nontreatment options, at least if a reasonable physician would disclose them

or if a reasonable patient would find them material to his or her decision making? After all, theabsence of treatment can result in physical injury to the patient just as assuredly as can active mis-treatment In an era of managed care, cost containment, and the rationing of medical services, thisquestion is a serious concern for patients It is also a serious concern for physicians who must complywith their disclosure duty under the doctrine of informed consent and who know that their patientsare likely to demand affirmative, and costly, treatment options if they are informed of them

Some courts have imposed a duty to disclose For example, in Matthies vs Mastromonaco ( 6 ) the

New Jersey Supreme Court was unwilling to limit a negligence-based informed consent doctrine to anonconsensual touching proposed, but not adequately explained, by the physician The court specif-

ically upheld the patient’s right to make an informed decision about medically reasonable alternatives, not merely to give an informed consent to the alternative that the physician recommends The court

would not allow the physician to, in essence, decide for the patient by discussing only the physician’streatment (or nontreatment) of choice As the court stated, “physicians may neither impose theirvalues on their patients nor substitute their level of risk aversion for that of their patients By nottelling the patient of all medically reasonable alternatives, the physician breaches the patient’s right

to make an informed choice.” Although the physician’s choice might be medically appropriate andconform to the physician’s standard of care, nevertheless, it might not be the choice that the patientwould make The absence of malpractice does not assure the presence of the patient’s informed choice.Other courts, however, disagree, limiting a patient’s right to make decisions about his or her ownbody to situations in which the treating physician is proposing some affirmative course of action Thesedecisions appear erroneous Under a negligence theory, the disclosure duty is imposed not to protectthe patient from a nonconsensual touching, but rather, to protect the patient’s right to medical self-determination To make decisions about what shall be done and what shall not be done to their bodies,patients need information on the risks of and alternatives to the nontreatment option They need thatinformation, not only when they refuse a treatment proposed by the physician, but also when the physi-cian proposes no treatment

Although a physician’s “decision” to prescribe bed rest instead of surgery or to order some nostic tests but not others may conform to acceptable medical practice and thus not constitute mal-practice, the physician’s professional duties to the patient are not circumscribed by his or her clinicaljudgment calls The physician also owes the patient an independent duty of disclosure If, as the

diag-Canterbury court announced, and numerous other courts echoed, “the patient’s right of self-decision

shapes the boundaries of the duty to reveal,” the physician should be obligated to disclose informationabout alternative treatment options—including surgery and diagnostic testing—that the physician isnot recommending That information is not only material to the patient’s decision, it is often critical tothat decision The decision on what treatment, or nontreatment, is acceptable belongs to the patient

whose life will be affected by that decision, not to the physician who can only recommend options based

on his or her professional expertise Because the patient is entitled to make the decision, the physicianshould be obligated to disclose the information that the patient needs to make that decision

In recent years, some courts have defined “material risks” broadly, requiring physicians to disclosenot merely the risks and alternatives inherent in medical procedures that the physician might not rec-ommend but that the patient might want to consider, but, in addition, other risks that emanate directlyfrom the physician For example, some courts have required surgeons to inform patients of the physi-cian’s chronic alcohol abuse or HIV-positive status These physical infirmities may increase the risk

of harm to the patient and must be disclosed as material to the patient’s judgment to accept or rejecttreatment from that surgeon Other physician-specific factors raise a similar concern In one case, apatient consented to basilar bifurcation aneurysm surgery (a clipping of an aneurysm at the rear of theplaintiff’s brain) and was rendered an incomplete quadriplegic The Supreme Court of Wisconsin ruledthat information about the neurosurgeon’s limited experience in performing such surgery and the dif-ficulty of the operation should have been disclosed because it was material and would have been con-

sidered by the reasonable patient ( 7 ).

In Moore vs Regents of University of California ( 8 ), the California Supreme Court held that to obtain

a patient’s informed consent, the physician must also disclose any financial or other interest that thephysician has that conflicts with, or even potentially conflicts with the physician’s fiduciary duty tothat patient In deciding whether to consent to proposed treatment, a patient would want to know ofany research or economic interest extraneous to the patient’s health that may have affected the physi-cian’s judgment to recommend that treatment, even if that conflicting interest was not consciously

considered In Moore, for example, the plaintiff alleged that the surgeon’s research interest in the

patient’s rare blood and the surgeon’s economic interest in patenting a cell line from the plaintiff’scells may well have influenced the surgeon to recommend a splenectomy, the surgical removal of theplaintiff’s spleen

A federal appeals court, applying Minnesota law, went one step further The court imposed a duty

on physicians to disclose conflicting loyalties even when they do not recommend any affirmative course

of treatment In Shea vs Esenstein (Shea II) ( 9 ), a 40-year-old patient was experiencing symptoms of

heart disease His family doctors did not refer him to a cardiologist When the patient’s symptoms didnot improve, the patient offered to pay for the referral, but “his physicians persuaded him to trust theirjudgment that neither his age nor his symptoms justified a visit to a cardiologist.” The patient suffered

a heart attack and died In a wrongful death suit, the plaintiff alleged that the physicians failed to close financial incentives in the health maintenance organization (HMO) contract designed to mini-mize referrals to specialists and that if the patient had known of those incentives, he would not havetrusted the physicians’ medical advice but instead would have obtained the opinion of a specialist athis own expense Even though the jury found that the physicians had not committed malpractice inthe care and treatment of the patient, the court upheld the plaintiff’s separate claim for the tort of neg-ligent misrepresentation Under Minnesota law, physicians have a state-imposed ethical duty to dis-close conflicts of interests to their patients Self-serving financial incentives, such as those found in

dis-an HMO contract, conflict with the physicidis-an’s duty of loyalty to the patient’s medical welfare, dis-andmust be revealed

Although these case precedents for an expanded disclosure duty are important forays for futuredevelopment of the law, they have not been universally, or even generally, accepted in Americanjurisprudence For each case discussed here, there are others, often numerous others, that have reached

a contrary result Some courts have ruled that a physician’s medical condition, including his or heraddiction to alcoholism or drugs, or the physician’s HIV-positive status, need not be disclosed Somecourts have held that a physician’s inexperience in performing the particular surgery proposed to thepatient need not be disclosed

Courts that restrict the physician’s disclosure duty to the risks inherent in the physician’s proposedprocedure deny patients the information they need, and, in fact, must have, in order to decide whether

to trust their doctor A patient’s trust cannot be purchased with concealment or subterfuge It can only

be developed through honest communication “[D]isclosure and consent,” wrote Dr Jay Katz, “do notabolish trust Disclosure and consent only banish unilateral, blind trust; they make mutual trust pos-

sible for the first time” ( 10 ) When courts do not require that communication, their narrowly crafted

informed consent doctrine does not shield patients from their doctors’ deceptions; it leaves them nakedand exposed

Competency

Competency as a Requirement for Giving or Withholding Informed Consent

A patient’s informed consent to treatment is not required if an emergency arises that requires diate medical attention and the patient is not competent to give or withhold consent to that treatment.For example, if at the scene of an auto accident, a person lays unconscious and bleeding to death, thelaw presumes that the person would consent to treatment necessary to save his or her life The law makesthis presumption because a reasonable person faced with the need for immediate life-saving treatmentwould authorize that treatment if the person were competent to make the decision at the time The lawprotects the physician who acts in an emergency to save a life, even if subsequently facts become knownthat indicate that the unconscious person would not have consented to medical treatment

imme-Incompetence, however, is not limited to unconscious adults Children, because of their youth andinexperience, are considered mentally unable to make treatment decisions, and in the absence of alife-threatening emergency, informed consent of a parent or legally responsible guardian is requiredfor the physician to act The parent or guardian makes a substituted judgment for the child, eitheraccepting or rejecting treatment on the child’s behalf Adults, too, especially if they suffer from a severemental disorder, may be incompetent to make a treatment decision If the condition is likely to be of

a lengthy duration, the court may appoint a guardian for the person with authority to make decisionsfor him or her In essence, the guardian of the adult acts in the capacity of a parent for a child, untilsuch time as the ward is restored to competency

Civil Commitment of Mentally Disordered Persons and the Right to Refuse Treatment

When a person with a severe mental disorder is so incapacitated that he or she is either dangerous tohimor herself or to others, or is unable to provide for the basic necessities of life, such as food, clothing,and shelter, that person may be civilly committed and placed in a mental hospital Can the treating physi-cian require the civilly committed person to take psychotropic medication to eliminate symptoms andimprove the patient’s condition or does the patient, relying on the doctrine of informed consent, have aright to refuse its administration? The issue has generated great controversy between psychiatrists andlawyers Psychiatrists assert that the very purpose of placing the involuntarily committed person in amental hospital is to treat the person’s mental disorder so that the person’s freedom can be restored.Lawyers contend that even involuntarily committed mental patients retain rights, including the right

to refuse treatment, that should not be infringed on without proof of the necessity to do so

Dr Alan Stone, noted Harvard psychiatrist and former president of the American PsychiatricAssociation, has acknowledged that the legal justifications for the right to refuse treatment are so

“clear and compelling” that psychiatrists should accept the right’s existence ( 11 ) Dr Stone conceded

that a mentally disordered person’s refusal of psychotropic medication is merely one example ofrefusal of medical treatment by any ill person In a treatment refusal situation, the doctrine ofinformed consent restricts the state’s authority to intrude on the individual’s autonomy Only whenthe individual, whether from mental disorder or other cause, is unable to make competent decisions,may another’s judgment be substituted Although incompetence negates autonomous decision making,incompetence is not established solely by proof of mental disorder or proof that treatment is clini-cally indicated

Similarly, incompetence is not established by proof that the mentally disordered individual meetsthe civil commitment criteria and is subject to involuntary detention In most states, the laws do not

presume or require incompetence as a criterion for civil commitment The mentally disordered person’sdangerousness to self or others, or inability to provide for basic necessities, justifies a deprivation ofliberty but does not justify a deprivation of the patient’s right to refuse treatment or other rights Aperson may be incompetent to provide for basic necessities, but be competent to understand the risksand benefits of medication that is proposed to treat his or her condition In other words, incompetencefor one purpose does not equal incompetence for another Only when a person’s incompetence to makethe treatment decision is established can another’s judgment be substituted.

Most states have recognized the right of competent, though involuntarily committed, patients to

refuse treatment The United States Supreme Court has acknowledged that even mentally ill

prison-ers have a “significant liberty interest in avoiding the unwanted administration of antipsychotic drugs” ( 12 ) The states, however, have divided almost equally on the question of procedural protections nec-

essary to enforce that right Some states use a medical decision-maker model, allowing a staff chiatrist or hospital committee to make an informal decision of the patient’s competence Others,including the nation’s five most populous states (California, Texas, New York, Florida, and Illinois),require a formal hearing on the patient’s competence before a judge or other independent, law-traineddecision maker In these states, neither mental disorder alone, nor a decision to civilly commit theperson, equates to a finding of incompetence to make treatment decisions Before treatment may beimposed over the objection of a patient, even an involuntarily civilly committed mental patient,the judge must find that the patient lacks the mental capacity to make treatment decisions (i.e., to weighthe risks, benefits, and alternatives to the proposed medication)

psy-Competent civilly committed patients, however, do not have an absolute right to refuse chotic medication The state does have a legitimate interest in protecting other patients and staff fromdangerous mental patients Hospital staff may respond to threatening situations by segregating thepotentially dangerous patient or using physical restraints In an emergency situation, when the patientpresents an immediate danger to him or herself or to others, the patient may be involuntarily sedated.Nevertheless, this exercise of the state’s police power must end when the emergency that warrantedthis exercise of authority ends If a person’s “significant liberty interest in avoiding the unwantedadministration of antipsychotic drugs” is to have any meaning at all, an assertion that the patient wascivilly committed as being too dangerous to live in society, or that he or she presents a generalizeddanger to other patients or staff in the institution, does not justify nonemergency, coerced treatment

antipsy-of a competent civil patient

Assessing the Competence of Civilly Committed Mental Patients

to Refuse Psychotropic Medication

In Reise vs St Mary’s Hospital and Medical Center ( 13 ), the California Court of Appeal added

California to the list of states that recognize the right of a competent, but involuntarily committedmental patient to refuse psychotropic medication in nonemergency situations and require a formal courthearing to determine if the patient is incompetent The facts of the case demonstrate why the courtrejected the medical decision maker model as an inadequate protection of the competent patient’s right

to refuse Eleanor Riese was admitted to St Mary’s Hospital as a voluntary patient Previously, shehad been treated for chronic schizophrenia with Mellaril®, a psychotropic medication As a result ofthat earlier treatment, her bladder had been severely damaged Nevertheless, the treating physicianprescribed Mellaril, and she consented to its use Although she complained of dizziness and drymouth and stated that she was receiving too much medication, her concerns were ignored and thedosage was not reduced When she protested and refused medication, she was forcibly injected andcommitted as an involuntary patient Ms Riese brought a class action on behalf of patients involun-tarily committed under California’s 72-hour treatment and evaluation detention and its 14-day inten-sive treatment certification

In upholding the right of involuntary civil patients to exercise informed consent, the Reise court,

borrowing liberally from a text for psychiatrists prepared by Drs Thomas Gutheil and Paul Appelbaum

( 14 ) that identified three factors that judges should consider in assessing the competence of a patient’s

medication refusal First, the judge should consider “whether the patient is aware of his or her tion.” The court offered one example of such awareness: if the judge believes that the patient is psy-chotic, does the patient acknowledge the psychosis? The court’s singular example seems unfortunate

situa-A doctor, who has diagnosed a patient’s mental disorder and made a clinical judgment on what cation is appropriate to treat that disorder, may view the law’s requirement of obtaining a patient’sinformed consent as an unwelcome and unnecessary impediment to the doctor’s authority to make thetreatment decision If the patient does not readily acknowledge that he or she has a mental disorderand acquiesce in the doctor’s recommendation, the doctor may quickly decide, perhaps too quickly,that the patient is incompetent to make the treatment decision After all, the doctor may assert, a patientwho does not acknowledge having a mental disorder is unable to appreciate the benefits of the medi-cation prescribed to treat that disorder

medi-Although denial of mental disorder may be a factor in assessing a person’s awareness of the tion, it is certainly not the exclusive measure Even if a person denies having a mental disorder, he orshe is aware of the situation if the person knows that he or she is involuntarily confined in a mental hos-pital, that the doctor has diagnosed the person as having a mental disorder, that the doctor has prescribedpsychotropic medication to treat the disorder, that the doctor believes the medication will benefit theperson by relieving symptoms, and that the person is refusing the medication because of concern aboutmedication side effects that have been previously experienced Additionally, a person who denieshaving a mental disorder may be willing and able to acknowledge having a problem in “nonmedical”terms The person, for example, may be denying a mental disorder in order to maintain control over his

situa-or her life and to avoid being thrust into the dependent role of a mental patient The person may bedenying mental illness in an attempt to avoid a catch-22 situation (i.e., by admitting mental disorderthe patient strengthens the psychiatrist’s assertion that the prescribed medication is the appropriateremedy) Denial of mental illness may be a rational, although hostile, reaction to the family members

or the police who initiated the involuntarily commitment process, to the judge who ordered the patientcommitted, or to the psychiatrist who now seeks to impose treatment over the patient’s objection.Second, the judge should consider “whether the patient is able to understand the benefits and the

risks of, as well as the alternatives to, the proposed intervention.” Here, too, the Riese court gave an

example Even if the patient is acutely psychotic, the patient should understand that dystonic reactionsare a risk, that resolution of the psychotic episode is a benefit, and that psychotherapy, milieu therapy,and possibly electroconvulsive therapy are alternatives This example, suggested by Drs Gutheil andAppelbaum, appears helpful Nevertheless, one can question whether treating physicians typicallyconsider alternative therapies as viable substitutes for psychotropic medication In their eagerness toimpose their treatment preference, physicians may be unwilling to consider patient objections to thatchoice and to suggest other alternatives that might be acceptable to their patients

Third, the judge should assess the patient’s ability “to understand and to knowingly and intelligentlyevaluate the information required to be given patients whose informed consent is sought (§ 5326.2)and otherwise participate in the treatment decision by means of rational thought processes.” The courtcited with approval a suggestion offered by Drs Gutheil and Appelbaum that the patient should beassumed to be utilizing rational thought processes in the absence of proof clearly linking delusional

or hallucinatory perceptions to the individual’s ultimate decision An assessment of a patient’s ity to understand information begins with the information that the patient has been given Although

abil-the Riese court did not itself discuss what information must be provided, it incorporated, by specific

reference, California Welfare and Institutions Code section 5326.2 That statute itemizes informationthat must be given to the patient in a clear and explicit manner in order to obtain a voluntary andinformed consent to treatment Among the required disclosures are the following:

1 The nature and seriousness of the patient’s mental disorder that serves as a reason for treatment.

2 The nature of the proposed treatment, including probable frequency and duration.

3 The degree and duration of improvement or remission anticipated with or without such treatment.

4 The nature, degree, duration, and the probability of side effects and significant risks of the proposed ment and how and to what extent they may be controlled, if at all.

treat-5 The reasonable alternative treatments, and why the physician is recommending this particular treatment.

6 The patient has the right to accept or refuse the proposed treatment, and if the patient consents, he or she has the right to revoke the consent for any reason and at any time prior to or between treatments.

A study of competency hearings ( 15 ) reveals that often, psychiatrists do not disclose to patients

the information that the law requires them to disclose Often, psychiatrists only inform patients aboutmedication benefits Even when they disclose risks, psychiatrists do not divulge “all information rel-evant to a meaningful decisional process”—the test of disclosure required to obtain a patient’s informedconsent Sometimes psychiatrists speak about risks in general terms, informing the patient that anymedication can have detrimental as well as beneficial effects Of course, they will assert, the medi-cation is being prescribed for its beneficial effects At times, psychiatrists discuss some side effectsbut not others Typically, a psychiatrist will inform the patient of non-neurological side effects, such

as sedation or anticholinergic side effects, such as dry mouth, blurred vision, urinary retention, andconstipation, but will omit any discussion of neurological side effects such as dystonia, Parkinsonism,akathisia, akinesia, and tardive dyskinesia Obviously, if the risk of non-neurological side effects ismaterial to a patient’s decision, the risk of neurological side effects is likely to be even more so Thestudy concluded, “the failure of psychiatrists to inform patients adequately of medication risks andalternatives was not limited to a few isolated incidents It was pervasive.”

The author of the competency study suggested that in a proceeding to consider whether the patient

is competent to refuse psychotropic medication, the judge can and should appropriately respond topsychiatrist nondisclosure by finding the patient competent By failing to inform the patient, and fail-ing to provide the judge with evidence that the patient is unable to understand and to evaluate thatinformation, the psychiatrist has not sustained the burden of proving by clear and convincing evidencethat the patient is incompetent If the patient is found competent, then under traditional legal princi-ples, the psychiatrist commits the tort of battery if he or she administers psychotropic medication overthe patient’s objection, and the psychiatrist can be held liable for punitive as well as compensatorydamages Liability for the tort of negligence is limited to situations in which a competent patient con-sents to the administration of psychotropic medication but suffers an injury from a risk of the drugthat was not explained to him or her

MEDICAL ASPECTS OF INFORMED CONSENT AND COMPETENCY

Informed Consent

In clinical as well as research settings, informed consent is one of the cornerstones of ethical

prac-tice ( 16,17 ) The consent process epitomizes professional ideals and protects individual rights Too

often, however, in part due to the many competing demands of medical care and research, the informed

consent discussion “morphs” into a procedure done to the patient or research participant (i.e.,

“con-senting” the patient) This phrasing implies that the patient is a passive recipient of information whothen acquiesces to the proposed test, treatment, or research protocol Viewed through a different lens,however, the informed consent process presents an ideal opportunity for the patient and the physician

or investigator to participate in a meaningful discussion of alternatives and their potential risks andbenefits In this process, the patient or participant becomes more of a partner with the physician inmanagement of his or her own care In addition to providing information, the overall process then serves

as an optimal context for clarifying patient preferences and values, which leads to authentic making Ultimately, it is the patient who is the final decision maker

decision-In the research context, informed consent also embodies the careful attention of investigators andethics review boards to address concerns about research with human subjects The need to protect andrespect human subjects by obtaining informed consent is not merely an historical artifact related to

past abuses There are many recent instances in which ethical questions about human research haveturned on the question of whether informed consent was properly obtained In addition, concerns haveemerged relative to the capacity of some subjects to give their consent In fact, some institutional reviewboards require that researchers who plan “to recruit from populations with disorders known to be asso-ciated with impairment of decision-making capacity” have a specific plan to ensure that decisional

capacity is addressed at the earliest stages of the study ( 18 ).

The doctrine of informed consent holds that three components are necessary for valid consent

( 19,20 ) The consent must be based on full and relevant information, must be given voluntarily, and

must derive from a capable/competent decision maker (We use the term capacity here in distinction from the legal term competency, because physicians are asked to assess decision-making capacity in

the clinical setting, whereas a judge must make a determination of legal competency.) We discuss each

of these components separately

Information Provision

For patient autonomy to be promoted and respected, at a minimum, physicians should disclose what

a “reasonable person” would want to know about the recommended treatment or procedure, its risks andbenefits, as well as treatment alternatives and their attendant risks and benefits The alternative of notreatment should be discussed as well (whether or not this is the physician’s recommendation), so that

a patient’s decision to accept or reject treatment is based on an understanding of its likely consequences.Shared decision making involves going a step further, beyond the “reasonable person” standard.Asking patients open-ended questions about what other information they may need in order to makethe decision is a simple way to address this The presentation of the information must be done in such

a way as to optimize the patient’s understanding When done in a hurry or without concern for whetherthe patient has actually understood the information, the disclosure process is unlikely to meet ethicalstandards (and undermines patient autonomy) Testing for comprehension can be done fairly quicklyand efficiently using open-ended questions followed by closed-ended questions When doubt existsabout the adequacy of decision-making capacity, numerous instruments exist to assist with the capac-ity assessment; these are described in more detail below

Voluntariness

The second requirement for informed consent mandates that the decision maker give consent untarily and free from coercion This does not mean that physicians cannot provide treatment recom-mendations, patients legitimately rely on physicians to help sort through decisions Encouragement

vol-to follow a particular course of treatment is also ethically acceptable so long as there is no coercion

( 16 ) (For a summary of potential influences on voluntarism, the reader is referred to Roberts’

concep-tual framework [ 21 ].)

Decision-Making Capacity

Decision-making capacity is widely considered by experts to consist of four abilities: (a) standing (or comprehension) of the disclosed information, (b) appreciation (the ability to apply theinformation to one’s situation), (c) reasoning (weighing options, including risks and benefits), and

under-(d) expression of a stable choice ( 16,22 ).

Each of these abilities has been used, in different instances, as the legal standard for determination

of capacity, with different jurisdictions applying different standards Requiring that all four abilities

be intact is the most stringent standard There is no consensus regarding the degree of impairment thatshould be considered to represent a lack of capacity The choice of standard directly affects the pro-portion of patients who will be found to be impaired Although expression of a stable choice is viewed

as the least stringent of these standards, research into decisional abilities of patients with both atric and medical disorders has not consistently demonstrated a “hierarchy of rigorousness” among

psychi-these abilities in patients ( 22 ) In other words, demonstration of intact reasoning and appreciation does

not necessarily mean that the patient has understood the information, and vice versa It is importantfor the physician to be cognizant of differing state laws regarding the level of ability that is requiredfor the patient to retain mental capacity, even if there is some level of impairment

As a way of illustrating the differences among these ability areas, consider a patient with phrenia who lacks insight into having the illness The patient believes that agents of the governmenthave implanted a “scanning chip” in his brain for the purpose of tracking his thoughts, behavior, andmovements The patient has been diagnosed with colon cancer and is refusing what his doctors con-sider a medically necessary surgical procedure

schizo-The patient’s capacity is assessed in order to determine if he can provide meaningful informed sent The patient is provided with information about the recommended treatment, the reasons why thedoctor is recommending it, its possible risks and discomforts, and the likely benefits He is also toldthat, without the surgery, his chance of surviving the cancer is slim The patient is able to paraphrasethe information disclosed to him about the procedure’s purpose, risks, and benefits (thus evidencingadequate understanding) However, when asked specifically whether he believes this informationapplies to his own case, he talks about the government trying to force him to have the procedure because

con-“they want to put me under the knife” (in order to implant more devices in him) He believes thatthe cancer diagnosis is being invented to fool him into having surgery (thus he does not appreciate thesituation adequately) When asked to discuss how he arrived at his decision to refuse the surgery, hestates that because the government is trying to force him to do it, he doesn’t want to have the surgery(thus his reasoning is also affected by the delusional system)

In this example, the patient’s understanding and expression of a choice seem adequate, yet his ciation and reasoning appear to be driven by delusional thinking Thus, the patient has impairments

appre-in some, but not all, of the aspects of decisional capacity Most experts would agree that the patient’scapacity is diminished If at all possible, the reason for his diminished capacity (delusional thinking)should be addressed (by optimizing the patient’s antipsychotic regimen), with the goal of allowingthe patient to make the decision himself, based on rational reasons and genuine appreciation.Ultimately, a court may have to decide whether treatment may or may not be forced on him

Competency

The purpose in this section is to provide guidance on performing capacity assessments when there

is a need to determine whether the patient is legally competent Although any physician can assessdecision-making capacity, a formal consult by an expert is sometimes desirable

When Capacity Should Be Assessed

Patient capacity for medical decision making may be affected by many different factors, includingmedical and neuropsychiatric disorders The most common reason for consultations regarding deci-sional capacity is a patients’ refusal of recommended treatment Such refusal does not in and of itselfindicate impaired capacity It is reasonable, however, to be concerned about patient capacity when treat-ment refusal would jeopardize the patient’s health or well-being or seems to be irrational Empirical

data indicate that most refusals are, in fact, related to impaired decision-making capacity ( 16 ) The

most important point regarding capacity assessment is to determine the reasons for the patient’srefusal and whether these reasons may represent impaired capacity (This is addressed further below.)Many clinicians are particularly concerned about decision-making capacity in patients with psychi-atric disorders Research in this area reveals a subtle picture Although patients with schizophrenia

have higher rates of impaired decision-making capacity, they cannot be assumed to lack capacity ( 23 ).

A number of studies have demonstrated that psychiatrically ill patients show a great deal of

hetero-geneity of performance, with most not performing in the impaired range ( 24 ) The research cited above

was conducted with psychiatric inpatients, a group tending to be more severely ill than psychiatricoutpatients In a study of decision-making capacity for research in outpatients with major depression,

for example, study participants performed quite well on measures of understanding, appreciation, and

reasoning ( 25 ).

Not surprisingly, a number of studies have shown that dementia is associated with a high rate of

impaired decision-making capacity ( 26–28 ) Yet, even a diagnosis of dementia does not inevitably mean

that patients do not retain some abilities to decide for themselves It is worth emphasizing that ment in decision-making capacity does not necessarily equate to legal incompetence to make the deci-sion It has been demonstrated, for instance, that patients with mild dementia may continue to possess

impair-some decision-making abilities ( 27,28 ) It is also not known to what degree mild cognitive

impair-ment may compromise decisional abilities for medical or research-related decision making, as there

is scant research in this area

Steps in Assessing Capacity

The first step in assessment of capacity is to ensure that the patient has been provided with the evant information necessary to make the decision Provision of information, as described above,should entail using whatever formats will optimize the patient’s understanding Next, it is important

rel-to ask the patient if he or she has any questions about what has just been disclosed During the actualcapacity assessment, the goal should be to determine whether the patient has actually comprehendedthe information, not just whether he or she can repeat back the information Therefore, open-endedquestions should be used initially (i.e., “Can you tell me in your own words about the treatment [test,procedure, study] that I’ve just described to you?”) Questions should cover the nature and purpose

of the procedure, test, treatment, or research protocol, the potential risks, the possible and/or likelybenefits, as well as alternatives to the recommended treatment (including no treatment) and the risksand benefits of these alternatives Risks may be construed not simply as possible negative outcomes,but also as discomforts and consequences Risks of foregoing a treatment option should also be dis-closed and discussed

If a patient does not appear to understand any of these aspects of the treatment, the informationshould be provided again (re-disclosure) and the patient should be given at least a second opportunity

to demonstrate understanding In some cases (e.g., in a patient experiencing delirium), attentiondeficits may be worse at certain times than at others; thus, multiple attempts to test comprehensionmay be necessary if a patient does not initially grasp the information In other cases (e.g., advanceddementia), memory for the disclosed information is extremely unlikely to improve upon retesting, sopoor understanding can usually be assumed to represent a stable deficit

Appreciation, the next element of decision-making capacity, can be assessed by asking the patient

to apply the disclosed information to his or her own situation This is best achieved by disclosing, again,what the doctors think is wrong and subsequently asking the patient if he or she believes this to be thecase Patients who possess appreciation can acknowledge: (a) that they are ill (acknowledgement ofdisorder), and (b) that treatment may be effective A disbelief in either of these should be explored todetermine why the patient does not believe it The crucial distinction to make in ascertaining appre-ciation is whether a belief that one is not ill or that treatment is unlikely to be effective is based onrealistic versus delusional thinking (or other illness-based impaired thinking, such as hopelessness as

may be seen in severe depression) ( 16 ) Refusal to acknowledge a disorder does not, however,

nec-essarily equate to lack of appreciation—the patient still may comprehend the risks, benefits, and natives as they relate to him or her

alter-Assessment of reasoning can be done in conjunction with assessment of whether the patient canexpress a stable choice A treatment decision that fluctuates, with the patient changing his or her mindover time, cannot be considered to be a consistent choice The patient should be asked what choice isbeing considered, and the reasons underlying this choice should be explored Intact reasoning shouldconsist of the patient being able to compare alternatives (comparative reasoning) and generate poten-tial consequences of the various options (consequential reasoning), such as how different choices would

affect his or her everyday life or activities ( 16 ).

Several instruments have been designed to assess decision-making capacity for treatment andresearch Of these, the most thoroughly studied have been the MacArthur Competence AssessmentTools (the MacCAT-T for treatment and MacCAT-CR for clinical research) These instruments werederived from a large study of patients with schizophrenia, depression, and medical illness (ischemic

heart disease), as well as healthy community controls ( 24 ) The instruments have demonstrated

excel-lent reliability and validity in multiple populations The MacCAT-T and MacCAT-CR have become

as close to a “gold standard” as exists in capacity assessment, although this by no means implies thatthere are not other valid scales and ways to assess capacity In part, the need for standardized instru-

ments stems from the unreliability of using “expert” judgments of capacity ( 29 ) Medical students and

residents are not routinely trained in capacity assessment, and even physicians experienced in ity assessment use widely varying methods to assess capacity, often coming to different conclusions

capac-in their judgments of capacity ( 30 ) The MacArthur instruments provide a semi-structured interview

for evaluating the four widely accepted aspects of decision-making capacity: understanding,

appre-ciation, reasoning, and expression of a choice ( 31,32 ) Each of the four components is rated on a

sub-scale; no total score is derived

Cognitive screening instruments (e.g., the Mini-Mental State Examination) and other chological tests do not demonstrate enough sensitivity or specificity to serve as substitutes for direct

neuropsy-assessment of capacity for the decision at hand ( 26,33 – 38 ) Decision-making capacity is

domain-specific: individuals may be unable to manage certain functions in their daily lives, but may still retainsufficient abilities to decide about their own treatment In our autonomy-protective society, this meansthat decision-making capacity cannot be assumed to be lacking simply because impairments exist inother functional domains

CONCLUSIONS

In 20th-century American society, courts could not ignore or deny patients’ demands for determination in medical decisions that affect their own bodies and their own lives However, courtsfashioned an informed consent doctrine that limits the information that physicians must discloseabout the procedures they propose Even as that doctrine has been most liberally formulated, patients

self-do not receive the information they need to make medical decisions, but rather, only receive the mation that reasonable patients would need When physicians wrongfully deprive their patients of thisinformation, the law places no monetary value on the loss of patients’ legal right to make their owndecisions To succeed in an informed consent claim against their physicians, patients must prove thatthe breach of the disclosure duty caused them physical injury Typically, however, causation is notmeasured by a true test of causation The law does not ask whether the patients would have consented

infor-if the doctor had not breached the disclosure duty, but rather, whether reasonable patients would haveconsented Despite these limitations on the doctrine of informed consent, some courts have recentlyexpanded the definition of “material risks” that the physician is required to disclose to the patient.These courts have held that physicians must reveal their physical infirmities, inexperience in per-forming the procedure or surgery, and any financial or any other interest that potentially conflicts withtheir fiduciary duty as physicians to their patients

The law does not require a physician to obtain informed consent from a patient who is tent to give or withhold consent If a person is unconscious and emergency treatment is needed to pre-serve his or her life, the law presumes the consent of the patient The parent of a child, or the legal

incompe-guardian of an incompetent ward, may consent for the patient Mental disorder, however, does not per

se equate with incompetence to make treatment decisions Even if the mentally disordered person is

involuntarily civilly committed, in most states, the commitment order does not per se equate with

incom-petence to make treatment decisions Court decisions and legislation in many states specifically upholdthe right of involuntarily committed mental patients to refuse psychotropic medication in nonemergency

situations In essence, unless a court specifically finds that these patients are incompetent to make thetreatment decision (i.e., unless they are unable to understand the risks, benefits, and alternatives tothe proposed therapy) thenthey are entitled to give or withhold their consent Because the decisionbelongs to the patient, not the doctor, the failure of the treating physician to provide the informationnecessary for the patient to make an informed decision cannot be countenanced.

REFERENCES

1 Schloendorff vs Society of New York Hospital, 105 N.E 92 New York; 1914.

2 Salgo vs Leland Stanford Jr University Board of Trustees, 317 P.2d 170 California; 1957.

3 Natanson vs Klein, 350 P.2d 1093 Kanas; 1960.

4 Canterbury vs Spence, 464 F.2d 772 Washington DC; 1972.

5 Truman vs Thomas, 611 P.2d 902 California; 1980.

6 Matthies vs Mastromonaco, 733 A.2d 456 (New Jersey; 1999.

7 Johnson vs Kokemoor, 545 N.W.2d 495 Wisconsin; 1996.

8 Moore vs Regents of University of California, 793 P.2d 479 (California; 1990.

9 Shea vs Esenstein (Shea II), 208 F.3d 712 Eighth Circuit; 2000.

10 Katz J The Silent World of Doctor and Patient New York: Free Press; 1984:xvi.

11 Stone AA The right to refuse treatment: why psychiatrists should and can make it work Arch Gen Psychiatry 1981;38: 358–362.

12 Washington vs Harper, 494 U.S 210 Washington; 1990.

13 Riese vs St Mary’s Hospital and Medical Center, 271 Cal Rptr 199 California;1987.

14 Gutheil TG, Appelbaum PS Clinical Handbook of Psychiatry and the Law New York: McGraw-Hill; 1982:219–220.

15 Morris GH Judging judgment: assessing the competence of mental patients to refuse treatment San Diego L Rev 1995;32: 343–435.

16 Grisso T, Appelbaum PS Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals New York:Oxford University Press;1998.

17 Emanuel EJ, Wendler D, Grady C What makes clinical research ethical? JAMA 2000;283:2701–2711.

18 (2004) http://irb.ucsd.edu/decisional.shtml.

19 Faden RR, Beauchamp TL, King NMP A History and Theory of Informed Consent New York: Oxford University Press; 1986.

20 Meisel A, Roth L, Lidz C Toward a model of the legal doctrine of informed consent Am J Psychiatry 1977;134:285–289.

21 Roberts LW Informed consent and the capacity for voluntarism Am J Psychiatry 2002;159:705–712.

22 Grisso T, Appelbaum PS Comparison of standards for assessing patients’ capacities to make treatment decisions Am

treat-27 Kim SY, Caine ED, Currier GW, Leibovici A, Ryan JM Assessing the competence of persons with Alzheimer’s disease

in providing informed consent for participation in research Am J Psychiatry 2001;158:712–717.

28 Karlawish JHT, Casarett D, James B Alzheimer’s disease patients’ and caregivers’ capacity, competency, and reasons to enroll in an early-phase Alzheimer’s disease clinical trial J Am Geriatr Soc 2002;50:2019–2024.

29 Marson DC, Ingram KK Commentary: competency to consent to treatment: a growing field of research J Ethics Law Aging 1996;2:59–63.

30 Marson DC, McInturff B, Hawkins L, Bartolucci A, Harrell LE Consistency of physician judgments of capacity to sent in mild Alzheimer’s disease J Am Geriatr Soc 1997;45:453–457.

con-31 Appelbaum PS, Grisso T MacCAT-CR: MacArthur Competence Assessment Tool for Clinical Research Sarasota, FL: Professional Resource Press; 2001.

32 Grisso T, Appelbaum PS, Hill-Fotouhi C The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions Psychiatr Serv 1997;48:1415-1419.

33 Kim SY, Caine ED Utility and limits of the Mini Mental State Examination in evaluating consent capacity in Alzheimer’s Disease Psychiatr Serv 2002;53:1322–1324.

34 Marson DC Loss of competency in Alzheimer’s disease: conceptual and psychometric approaches Int J Law Psychiatry 2001;24:267–283.

35 Janofsky JS, McCarthy RJ, Folstein MF The Hopkins Competency Assessment Test: a brief method for evaluating patients’ capacity to give informed consent Hosp Community Psychiatry 1992;43:132–136.

36 Glass KC Refining definitions and devising instruments: Two decades of assessing mental competence Int J Law Psychiatry 1997;20:5–33.

37 Fitten LJ, Lusky R, Hamann C Assessing treatment decision-making capacity in elderly nursing home residents J Am Geriatr Soc 1990;38:1097–1104.

38 Marson D, Cody HA, Ingram KK, Harrell LE Neuropsychological predictors of competency in Alzheimer’s disease using

a rational reasons legal standard Arch Neurol 1995;52:955–959.

Acute grief reaction, 377–378

Acute stress disorder, 52

Adderall

attention deficit hyperactivity disorder

with Tourette’s syndrome, 219

Adderall XR

for attention deficit hyperactivity

disor-der with Tourette’s syndrome, 219

benzodiazepines, 89–90dementia, 126, 128–129, 382–383neurobiology, 129–130

Agoraphobia, 47Akathisia, 24antipsychotic medications, 319Akinetic mutism

mimicking catatonia, 85Alcohol abuse and dependenceconsequences, 97

depression, 97diagnosis, 98–99negative effects, 97–98prevalence, 95–96recognition, 97screening, 98–99sleep, 98

Alcoholics Anonymous, 100Alcoholics Victorious, 100Alienist and Neurologistdevelopment of, 6Alogia, 60

α-2-adrenergic receptorfor pervasive developmental disorders/autistic disorders, 263

ALS See Amyotrophic lateral sclerosis

Alzheimer, Alois, 11, 12, 13fAmantadine

fatigue, 304tHuntington’s disease neurologicalsymptoms, 230

American Association of Asylum tendents, 6

American Medical Association Archives of

historical interface with psychiatry, 3–8

American Society of Addiction Medicine,

attention deficit hyperactivity disorder

with Tourette’s syndrome, 219

OCD with Tourette’s syndrome, 215, 216

pervasive developmental disorders/

side effects, 325psychiatric symptoms, 324–325Anticonvulsants, 314–315

Antidepressant medications, 40t, 315–316anxiety disorders with Parkinson’s dis-ease, 166–167

depression with multiple sclerosis, 181epilepsy

selection, 194–195interaction with antidepressants, 194neuropsychiatric disturbances withParkinson’s Disease, 166sexual dysfunction with, 322side effects, 321–322

stroke, 146Antiepileptic drugscausing depression, 193Antihistamines

side effects, 326Antipsychotic medications, 316–317acute dystonia, 318

akathisia, 319atypical, 133borderline personality disorders, 114catatonia, 87

dementia, 133geriatric schizophrenia, 289neuroleptic malignant syndrome, 320Parkinsonism, 318–319

schizophrenia, 64–65, 65ttardive dyskinesia, 319–320Antisocial personality disorders, 109, 112–113

Anxietybiology, 44–45catatonia as expression of, 90dementia, 126

development, 45endocrine changes, 45epidemiology, 43multiple sclerosis, 178and neurologist, 55–56phenomenology, 43–44signs and symptoms, 128

vs stroke, 141Anxiety disorder, 43–56, 368–369cognitive interventions, 369