Capacidad e internamiento involuntario de pacientes con anorexia nerviosa: un estudio cualitativo sobre percepciones y actuación de psiquiatras y psicólogos clínicos / Competence and Involuntary Commitment of Patients with Anorexia Nervosa: A Qualitative study on the Perceptions and Performance of Psychiatrists and Clinical Psychologists

RESUMEN Introducción: La anorexia nerviosa plantea un importante problema bioético, ya que los pacientes, a menudo, rechazan el tratamiento a pesar del peligro que ello supone para su salud, y no está claro que su decisión sea autónoma. El objetivo de este trabajo es investigar las percepciones/actuación de psiquiatras y psicólogos clínicos ante la capacidad y el internamiento involuntario de pacientes con anorexia nerviosa. Métodos: Se entrevistó a 7 psiquiatras, 4 psicólogas clínicas y 1 psicóloga residente de tercer año. Se utilizó un enfoque de investigación cualitativa basado en la teoría fundamentada. Resultados: El análisis de datos mostró que estos profesionales articulan la atención del paciente en torno a una categoría principal, a saber, el internamiento como último recurso y la búsqueda de la voluntariedad, lo que implica un cambio en la dinámica asistencial habitual. En torno a esa categoría central, se erigen algunos conceptos importantes; estrés de rol, coerción informal, peso, familia y cronicidad. Conclusiones: La dificultad de conciliar demandas profesionales puede suponer un menoscabo en la calidad de la asistencia y en la propia satisfacción laboral, lo que pone en evidencia la necesidad de reflexionar e investigar sobre los fundamentos de las atribuciones asumidas.

ABSTRACT Introduction: Anorexia nervosa poses an important bioethical quandary, since patients often refuse treatment despite the danger that this poses to their health, and it is not clear that their decision is autonomous. The aim of this study was to investigate the perceptions/performance of psychiatrists and clinical psychologists regarding the capacity and involuntary hospitalisation of patients with anorexia nervosa. Methods: Seven psychiatrists, four clinical psychologists, and one third-year resident psychologist were interviewed. A qualitative research approach based on grounded theory was used. Results: The data analysis showed that these professionals articulate patient care around one main category - hospitalisation as a last resort and the search for voluntariness, which implies a change in the usual healthcare dynamics. Around this central category, some important concepts emerge: role stress, informal coercion, weight, family and chronicity. Conclusions: The difficulty of reconciling professional demands can undermine the quality of care and job satisfaction itself, which highlights the need for reflection and research into the foundations of the responsibilities assumed.

Actitudes de los profesionales de la salud mental ante la capacidad y el internamiento no voluntario en anorexia nerviosa: construcción, validación y resultados del cuestionario ACINOVAN / Mental Health Professionals' Attitudes Towards Mental Competency and Involuntary Commitment in Anorexia Nervosa: Construction, Validation and Results of the Acinovan Questionnaire

RESUMEN Introducción: La anorexia nerviosa es un trastorno grave que causa tasas elevadas de morbilidad y mortalidad. La aplicación de una intervención no voluntaria solo es legalmente admisible si el paciente no es competente. Sin embargo, la evaluación de su capacidad puede ser extremadamente compleja. Ello conlleva que la decisión final pueda verse influida por las actitudes individuales del facultativo. Objetivo: Crear y validar empíricamente un cuestionario en español que permita medir la actitud hacia la capacidad y el internamiento no voluntario y comparar entre grupos categóricos. Métodos: Formaron la muestra 338 profesionales de salud mental. Los ítems fueron validados por grupos de expertos. Se realizaron un análisis factorial exploratorio y comparaciones grupales. Resultados: Se obtuvo un modelo de 13 ítems formado por 3 factores: prointervención, ausencia de capacidad y cronicidad. Los profesionales tienden a creer en la ausencia de capacidad y la necesidad de la intervención no voluntaria, así como en la idoneidad diferencial en virtud de la cronicidad. El respaldo previo a intervenciones involuntarias se relacionó significativamente con los factores prointervención y ausencia de capacidad y la formación en bioética, con la cronicidad. Conclusiones: El instrumento resultante es válido y fiable. Puede ser útil a profesionales, pacientes y sociedad.

ABSTRACT Introduction: Anorexia nervosa is a serious disorder that causes high rates of morbidity and mortality. Involuntary treatments are only legally admissible if the patient is not competent. However, assessing their capacity can be really complex. This implies that the final decision might be influenced by the individual attitudes of the physician. Objective: To create and empirically validate a questionnaire in Spanish that makes it possible to measure the attitude towards capacity and involuntary commitment and compare between categorical groups. Methods: The sample consisted of 338 mental health professionals. The items were validated by groups of experts. An exploratory factor analysis and group comparisons were carried out. Results: Favourable evidence was obtained of a 13-item model consisting of three factors: pro-intervention, lack of capacity and chronicity. Professionals tend to believe in the lack of capacity and the need for involuntary interventions, as well as differential suitability due to chronicity. Having ever supported involuntary interventions was significantly related to the pro-intervention and lack of capacity factors, and training in bioethics to chronicity. Conclusions: The resulting instrument is valid and reliable. Its use can be useful to professionals, patients and society.

Older people's preferences for self-involvement in decision-making if faced with serious illness / As preferências de pessoas idosas pelo autoenvolvimento na tomada de decisão numa situação de doença grave

OBJECTIVES: To examine older people's preferences for self-involvement in end-of-life care decision-making in scenarios of mental capacity (competency) and incapacity, and to identify associated factors. METHODS: A cross-sectional survey was conducted including 400 individuals aged 60+ years living in the city of Belo Horizonte, Brazil. RESULTS: Among 400 respondents, 95.3% preferred self-involvement when capable (due to the high percentage, associated factors were not calculated) and 64.5% preferred self-involvement when incapable through, for example, a living will. Considering that participants could choose multiple answers, the most frequent combinations in the capacity scenario were "yourself" and "other relatives" (76.8%) and "yourself" and "the doctor" (67.8%). In the incapacity scenario, the most frequent combinations were "yourself" and "other relatives" (usually their " children and, less often, their grandchildren) (59.3%) and "yourself" and "the doctor" (48.5%). Three factors were associated with a preference for self-involvement in an incapacity scenario. Those who were married or had a partner (widowed; adjusted odds ratio [AOR] = 0.37; 95% confidence interval [CI] 0.19-0.68) and those who were male (female; AOR = 0.62; 95%CI 0.38-1.00) were less likely to prefer self-involvement. Those who were younger, as in age bands 60-69 years (80+; AOR = 2.35; 95%CI 1.20-4.58) and 70-79 years (80+; AOR = 2.45; 95%CI 1.21-4.94), were more likely to prefer self-involvement. CONCLUSIONS: Most participants preferred self-involvement in both scenarios of capacity and incapacity. Preference for self-involvement was higher in the scenario of capacity, while preference for the involvement of other relatives (usually their children) was greater in the scenario of incapacity.

OBJETIVOS: O objetivo deste estudo foi examinar as preferências de pessoas idosas pelo autoenvolvimento na tomada de decisões nos cuidados de saúde em fim de vida em cenários de capacidade e incapacidade mental (competência), e identificar os fatores associados. METODOLOGIA: Foi realizado um estudo transversal, com 400 indivíduos, com idade 60 anos ou mais, residentes na cidade de Belo Horizonte, Brasil. RESULTADOS: Entre os 400 entrevistados, 95,3% preferiram o autoenvolvimento, quando capazes, na tomada de decisões (devido ao alt percentual, fatores associados não foram caculados); e 64,5% preferiram o autoenvolvimento, quando incapazes de tomar decisões, por meio, por exemplo, de um testamento em vida. Considerando que os participantes puderam escolher mais de uma resposta, as combinações mais frequentes para o cenário de capacidade foram: participantes e outros familiares (76,8%); e participantes e médicos (67,8%). No cenário de incapacidade, as combinações mais frequentes foram: participantes e outros familiares (geralmente filhos e netos) (59,3%); e participantes e médicos (48,5%). Três fatores foram associados à preferência pelo i-r autoenvolvimento em um cenário de incapacidade. Aqueles que eram casados ou com companheiro (viúvo; odds ratio ajustada (AOR) = 0,37; intervalo de confiança (IC) 95% 0,19-0,68) e os homens (mulheres; AOR = 0,62; IC95% 0,38-1,00) foram menos propensos a preferir o autoenvolvimento. Os mais jovens: 60-69 anos (80+; AOR = 2,35; IC95% 1,20-4,58) and 70-79 anos (80+; AOR = 2,45; IC95% 1,214,94) foram mais prováveis de preferir o autoenvolvimento. CONCLUSÕES: A maioria dos participantes preferiu o autoenvolvimento em ambos os cenários de capacidade e incapacidade. A preferência pelo autoenvolvimento foi maior no cenário de capacidade, enquanto a preferência pelo envolvimento de outros familiares (geralmente filhos) foi maior no cenário de incapacidade.

Evaluación de competencia de pacientes antes de la cirugía / Assessment of mental competency of patients, before surgery

Resumen Objetivo: Evaluar las alteraciones de la competencia en pacientes entre 18 y 65 años programados a cirugía general en el Hospital Clínico UC-Christus. Se estudiaron las alteraciones en habilidades cognitivas asociadas a la competencia de los pacientes, en distintos momentos previos a una cirugía electiva, bajo la hipótesis de que la capacidad de tomar decisiones varía o fluctúa antes de una intervención quirúrgica. Material y métodos: Estudio observacional, de carácter transversal. Fueron evaluados 85 pacientes, 44 en la unidad preoperatoria y 41 en el pabellón quirúrgico, por medio del test Montreal cognitive asessment tool (MoCA). Resultados: No hubo diferencias significativas entre la evaluación en la unidad preoperatoria y en el pabellón quirúrgico (p = 0,19). Ni tampoco en cuanto a porcentaje de pacientes con puntaje MoCA menor a puntaje de corte de 26 puntos en ambos lugares (30 vs. 26%; p = 0,61). Discusión: Variables como edad y nivel educacional pueden estar asociadas a alteraciones en la competencia de los pacientes. El momento de evaluación de los pacientes no influye significativamente en los resultados del test MoCA. Conclusiones: No fue posible concluir que existan diferencias en la capacidad de consentir de los pacientes, evaluada según puntaje en escala MoCA, en momentos próximos a una intervención quirúrgica.

Abstract Objective: To evaluate competence related alterations, in patients between 18 and 65 years old, scheduled to surgery in the Hospital Clínico UC-Christus. Alteration of cognitive skills associated to patients competence were observed in the preoperatory service, and in the surgical theatre. The underlying hypothesis was than the skills related to decision making fluctuates in the previous moments to a surgical intervention. Material and methods: Observational study. A total of 85 patients were evaluated, 44 in the preoperatory room and 41 in the surgical theatre, using the Montreal Cognitive Asessment Tool (MoCA). Results: There were no differences between evaluations in the preoperatory room and the surgical theatre (P=.19). Neither were differences between the percentage of patients who achieved less than 26 points (the cutoff of the test) in both evaluated places (30 vs. 26%, P=.61). Discussion: Other associated variables, such as age and educational level, could be related to competence related alterations in patients. The patient evaluation moment does not influences the results of the MoCA test. Conclusions: It is not possible to conclude than there are no differences in the patients ability to consent, evaluated by the MoCA tool, in the moments prior to a surgical intervention.

MacArthur Competence Assessment Tool for Treatment in Alzheimer disease: cross-cultural adaptation / MacArthur Competence Assessment Tool for Treatment na doença de Alzheimer: adaptação transcultural

ABSTRACT Objective: We adapted the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to Brazilian Portuguese, pilot testing it on mild and moderate patients with Alzheimer's disease (AD). Methods: The cross-cultural process required six steps. Sixty-six patients with AD were assessed for competence to consent to treatment, global cognition, working memory, awareness of disease, functionality, depressive symptoms and dementia severity. Results: The items had semantic, idiomatic, conceptual and experiential equivalence. We found no difference between mild and moderate patients with AD on the MacCAT-T domains. The linear regressions showed that reasoning (p = 0.000) and functional status (p = 0.003) were related to understanding. Understanding (p = 0.000) was related to appreciation and reasoning. Awareness of disease (p = 0.001) was related to expressing a choice. Conclusions: The MacCAT-T adaptation was well-understood and the constructs of the original version were maintained. The results of the pilot study demonstrated an available Brazilian tool focused on decision-making capacity in AD.

RESUMO Objetivo: Adaptamos o MacArthur Competence Assessment Tool for Treatment (MacCAT-T) para o português brasileiro, realizando estudo piloto em amostra de pessoas com doença de Alzheimer (DA) leve e moderada. Métodos: O processo transcultural apresentou seis passos. Posteriormente, avaliamos competência para consentimento do tratamento, cognição global, memória de trabalho, consciência da doença, funcionalidade, sintomas depressivos e gravidade da doença de 66 pessoas com DA. Resultados: Os itens apresentaram equivalência semântica, idiomática, conceitual e experiencial. Não encontramos diferenças entre pessoas com DA leve e moderada nos domínios do MacCAT-T. Regressões lineares demonstraram que raciocínio (p = 0.000) e funcionalidade (p = 0.003) estavam relacionados à compreensão. Compreensão (p = 0.000) estava relacionada ao julgamento e raciocínio. Consciência da doença (p = 0.001) estava relacionada à expressão da escolha. Conclusões: A adaptação da MacCAT-T foi bem compreendida e os constructos da versão original mantidos. Resultados do estudo piloto apontaram disponibilidade de ferramenta brasileira sobre tomada de decisões na DA.

Evaluación de la capacidad del paciente para emitir un consentimiento válido: ¿es posible la estandarización? / Assessment of patients’ capacity to give a valid consent

Autonomy is an inherent condition of every ethical act. This attribution is expressed, when decisions are made, as capacity. Physician-patient alliance is defied when there is a reasonable doubt of patients’ ability to make a choice, an extraordinarily complex scenario. As a response, in the last few decades multiple tools have been developed aiming to determine in a standardized fashion whether capacity is present or not. In the present article, we present a classification of the most well-known tools and discuss their usefulness, the implications for standardization of capacity, and make recommendations for their use, based in evidence.

What are the boundaries of legal guardianship in Alzheimer's disease? An evidence-based update in the context of the Brazilian Civil Code

The Brazilian Civil Code, which came into force in 2002, established a functional criterion for guardianship proceedings and introduced the concept of “limited guardianship,” applied to cases in which incapacity to exercise civil rights is partial. With population aging and the growth in the number of older people with cognitive impairments, such as Alzheimer’s disease (AD), the need to invoke legal remedies against elder abuse increased; however, difficulties in assessing capacity still lead to a majority of decisions in favor of plenary guardianship. The present article compiled data on capacity in AD subjects. The varying degrees of decision-making impairment at different stages of AD might be compatible with limited guardianship in milder cases of the disease.

Comentarios de la psiquiatría forense al concepto de inimputabilidad en Colombia / Comments forensic psychiatry the concept of criminal responsibility in Colombia

Este artículo de reflexión presenta los aspectos relevantes de la figura jurídica de la inimputabilidad, desde el punto de vista de la psiquiatría forense con base en el análisis de la legislación penal colombiana al respecto. Se define el concepto de imputabilidad, se muestran las asociaciones jurídicas psiquiátricas forenses que se correlacionan con los hallazgos psicopatológicos más frecuentes, que determinan la defensa por insania mental, a la luz del nuevo sistema penal acusatorio en Colombia. Luego se discuten las medidas de seguridad asignadas a los enfermos mentales nominados insanos mentales e inimputables.

This reflection paper presents relevant aspects of the legal concept of Mental Insanity Defense, from the viewpoint of forensic psychiatry, based on the analysis of the Colombian criminal legislation in this regard. As an introduction examples of the concept of criminal responsibility in regulation of some countries and legal aspects are showed and discussed. The concept of liability is defined; forensic psychiatric legal associations correlated to the most frequent psychopathological findings are showed and it is explained that they determine the mental insanity defense in light of the new accusatory penal system in Colombia. Then, we discuss the security measures assigned to mentally ills, named mentally ills or insanes.

Education and Training in Disaster Medicine / 한양의대학술지

Education and training of disaster medicine are the most important part of disaster management. There are so many training and education curriculum all over the world. However education courses based upon core competencies of disaster medicine are lacking. There is still a need to define the specific knowledge, skills, and attitudes that must be mastered by specialized professionals. Standardized core competencies for acute care medical personnel such as emergency department nurses, emergency physicians, and out-of-hospital emergency medical services personnel are needed to ensure that effective emergency medical response can be provided efficiently during all types of disasters. Therefore education and training curriculum of other countries were reviewed in this article.

The Effects of Multidisciplinary Approach for Children with Feeding Disorder and Failure to Thrive on Their Mothers

OBJECTIVES: The aim of this study was to determine whether intervention using a multidisciplinary approach affects maternal mental health, parenting stress, and sense of parenting competence in children with feeding disorder and failure to thrive (FTT). METHODS: Children with feeding disorder and FTT were randomized to the intervention group (N=11) or control group (N=8). We administered the Korean standardization of Parent Temperament Questionnaire for Children (K-PTQ) in both groups before intervention, and the Korean version of the Parenting Stress Index-Short Form (K-PSI-SF), Korean version of the Parenting Sense of Competence (K-PSOC), Korean version of the Beck's Depression Inventory (K-BDI), Korean version of the Beck Anxiety Inventory (K-BAI), and Korean version of the Mood Disorder Questionnaire (K-MDQ) in both groups before and after the intervention. RESULTS: In the intervention group, the K-BDI (p=.068), K-BAI (p=.068), and K-MDQ (p=.066) scores tended to show a decline, the K-PSI-SF scores for stress related to child learning showed a significant decline, and the K-PSOC scores for sense of parenting competence showed significant improvement. However, no significant changes were observed in the control group. CONCLUSION: Use of a multidisciplinary approach improved maternal mental health, parenting stress, and sense of competence. Comparison of these results with those of normal control will be necessary in a future study.

Consentimento informado em cirurgia plástica: avaliação da transferência de informação / Model of informed consent in plastic surgery with evaluation and attestation of the transferred information

Informed consent is an indispensable tool in the doctorpatient relationship. Aims broadly and unrestrictedly clarify the patient about the procedure, which he/she will be submitted, including all stages of treatment and possible complications. As for the professional who will perform the procedure it's importance goes beyond the precise information to the patient, and also relevance in the legal scope for any grievances that may arise from the committed act. However for the purpose of consent is reached, one should do it in a way in which the physician has the conviction that his informations and explanations about all stages of treatment were in fact understood by the patient. Method: In order to confirm the transfer of information for the informed consent in an objective manner the authors have developed a method using a test administered to the patient after the clarification on the procedure Results: We observed a greater satisfaction by patients regarding explanations because they felt more secure about the treatment's knowledge to be carried out, taking the chance of further clarification if necessary. Conclusions: This model of consent present itself as evidence that the information about the procedure was conveyed unequivocally, ensuring tranquility and safety for the patient and the professional...

O consentimento informado é uma ferramenta indispensável na relação médico-paciente. Tem como objetivo o esclarecimento amplo e irrestrito pelo paciente a respeito do procedimento ao qual será submetido, incluindo todas as etapas do tratamento, bem como as possíveis complicações. Já para o profissional que executará o procedimento, sua importância vai além da informação precisa ao paciente, tendo também relevância no escopo jurídico por eventuais insatisfações que possam advir do ato praticado. Contudo, para que o objetivo do consentimento seja atingido, há de se fazê-lo de uma forma na qual o médico tenha convicção de que suas informações e explicações sobre todas as etapas do tratamento foram de fato compreendidas pelo paciente. Método: Com o objetivo de confirmar a transferência de informação do consentimento informado de forma objetiva, os autores desenvolveramum método que utiliza um teste aplicado ao paciente após os esclarecimentos sobre o procedimento. Resultados: Foi observada satisfação maior pelos pacientes, pois, estes se sentiram mais seguros quanto ao entendimento das explicações realizadas pelo médico, tendo a chance de novos esclarecimentos caso necessário, eliminando a alegação de desconhecimento do ato a ser praticado, inclusive provando de forma objetiva, na possibilidade de demanda judicial, a transferência inequívoca de informação. Conclusão: Este modelo de consentimento é uma opção mais didática no esclarecimento de dúvidas pelos pacientes, além de eliminar a dúvida do profissional em relação à compreensão que o paciente teve de suas explicações sobre o procedimento a ser realizado...

Comparative study about the influence of cognitive behavioral intervention on the cognitive function of hospitalized patients with schizophrenia / 中国基层医药

ObjectiveTo explore the influence of cognitive behavioral intervention on hospitalized patients with schizophrenia.Methods100 hospitalized schizophrenia patients were randomly divided into experimental group and the control group.Routine treatment given to the patients in the control group and cognitive behavioral intervention was applied to the patients at the same time based on routine treatment in experimental group.The patients were assessed with the mini-mental state examination( MMSE),activities of daily living(ADL) and WHO battery of cognitive assessment instrument(WHO-BCAI) pre-and post-cognitive behavioral intervention.ResultsThe expenrentcl geoup and ntrol group before and after the intervention the average MMSE score was(21.8 ± 3.9),(24.4 ± 4.7 ),(21.5 ±3.4),(22.9 ±3.8) ;ADL score an average of(28.8 ±7.9),(25.1 ±4.5),(27.9 ±7.1),(25.2 ±4.8) (t =6.89,11.13,all P ＜ 0.05 ) ; cognitive function in the auditory vocabulary learning,language skills,visual identification,the connection test and cancellation tests were different ( P ＜ 0.05 or P ＜ 0.01 ).ConclusionCognitive behavioral intervention had positive influence on cognitive function in hospitalized patients with schizophrenia.

Dignidade, autonomia do paciente e doença mental / Dignity, patient's autonomy and mental illness

A dignidade humana, intrinsecamente vinculada à autonomia, fica comprometida em situações de distúrbio mental grave, quer para participação em pesquisas médicas quer para opinar sobre as prescrições de caráter terapêutico. O artigo discute o conceito de dignidade, o princípio da autonomia e o consentimento informado e, com base em revisão da literatura, preconiza que o agir ético é o constante exercício de identificar quando e como é mais fácil desrespeitar a dignidade e evitar fazê-lo. Conclui asseverando que negar autonomia a outrem, porque simplesmente se está em posição que assim permite, é desrespeitar-lhe a dignidade. Deve-se atentar para o fato de que paternalismo e beneficência nem sempre são boas soluções para o doente mental.

El consentimiento informado en el área clínica: ¿qué es? / Informed consent in clinical area: ¿what is it?

El consentimiento informado ha llegado a la medicina desde la ética con un importante soporte en el derecho. Es un presupuesto y elemento integrante de la lex artis y, por lo tanto, es un acto clínico cuyo incumplimiento puede generar responsabilidad, es no solo un derecho fundamental del paciente, sino también una exigencia ética y legal para el médico. El presente artículo hace una aproximación a la teoría actual del consentimiento informado y desglosa sus elementos constitutivos: voluntariedad, información en cantidad y con calidad suficiente y competencia. Realiza un análisis de cada uno de estos así como de sus definiciones, alcances y conflictos. Finalmente se recoge una presentación acerca de quiénes son incompetentes y se realiza una reseña la luz de la jurisprudencia colombiana de los casos que atañen con menores. [Quintero E. El consentimiento informado en el área clínica: ¿qué es?. MedUNAB 2009; 12:27-32].

The informed consent has been coming from the ethics to the medicine based on the law. It's a presupposed and important element of the lex artis, and it's a clinical act that went it hasn't been completed can generate responsibility. It's not only a patient's fundamental right, it's also an ethical and legal imperative to the health professional. This review presents the actual theory of informed consent and his constitutive elements: self-determination, information in quality and quantity sufficient and competence. Finally defines who's an incompetent patient and show the Colombian law about the informed consent in cases of children. [Quintero E. Informed consent in clinical area: ¿what is it? MedUNAB 2009; 12:27-32].