Variability of judgments of capacity: experience of capacity evaluators in a study of research consent capacity.

BACKGROUND: Assessment of decision-making capacity is a common and important function of psychiatric consultants. However, the sources of variability in evaluators' judgments have not been well characterized. OBJECTIVE: To examine the degree and potential sources of variability in the categorical capacity judgments of experienced psychiatrists. METHOD: The setting was a study comparing the decision-making capacities of 188 persons with Alzheimer's disease to appoint a research proxy and to consent to two hypothetical randomized controlled trials for dementia (a new drug RCT and a neurosurgical RCT). We compared five experienced consultation psychiatrists' capacity judgments for 555 videotaped capacity interviews. Both quantitative and qualitative data were used. RESULTS: Pair wise kappa statistics ranged from slight agreement (0.17) to substantial agreement (0.64) with group kappa statistics ranging from fair to moderate agreement (0.40 to 0.45) for the psychiatrists' judgments regarding the three capacities. The sources of variability included varying "strictness" among judges, moderate test-retest reliability within judges, the relative novelty of assessing decision-making capacity for research participation decisions, as well as the limitations of the methods used to obtain capacity judgments in the study. DISCUSSION: There is considerable variability in capacity judgments of experienced consultation psychiatrists regarding the capacities to appoint a research proxy and to consent to research. The potential sources of variability identified in this study may provide starting points for more effective training in capacity assessment.

Depression and suicidal ideation in patients who discontinue the life-support treatment of dialysis.

OBJECTIVE: The objective of this study was to determine the prevalence of major depression and suicidal ideation in patients who stop the life-support treatment of dialysis. METHODS: The authors prospectively studied 79 subjects who discontinued maintenance dialysis at eight facilities in North America. Structured interviews were conducted with 23 patients and 76 families. RESULTS: The prevalence of major depression in the sample was between 5% and 25%, and only 1 of 22 patients considered himself to have the illness of depression. Approximately 12% of the respondents were unsure or believed that discontinuing dialysis was the equivalent of suicide. This belief did not correlate with measures of depression. In comparison with the general population there seemed to be an increased prevalence of past suicide attempts. CONCLUSIONS: Most patients who decide to stop dialysis do not seem to be influenced by major depression or ordinary suicidal ideation. Although the sample size was small, these results highlight the need to further examine the theoretical framework and terminology of depression and suicide in the context of terminal illness.

Liver transplantation for patients on methadone maintenance.

Most transplant programs require abstinence of at least 6 months from alcohol and illicit drugs before orthotopic liver transplantation (OLT). However, there are no published data regarding OLT outcomes in patients who are currently on methadone maintenance treatment (MMT) as part of the treatment of their heroin addiction at the time of OLT. The objective of this study is to evaluate our experience regarding the outcome of OLT in patients with end-stage liver disease (ESLD) who were on MMT at the time of OLT. Between March 1993 and May 1999, a total of 185 patients with ESLD underwent OLT at our center. Five transplant recipients (2.7%) had a history of heroin abuse and had undergone drug and alcohol rehabilitation, but could not be weaned off methadone. Pre-OLT status, drug history, perioperative course, compliance with medical therapy, post-OLT follow-up, and patient and allograft survival were analyzed in detail in these patients. All patients on MMT underwent uneventful OLTs. Their compliance with medications and follow-up was excellent. One patient was weaned completely off methadone after OLT. Post-OLT mean hospital stay in this group was 43 +/- 25 days. Although the number of patients was small, long-term outcome of liver transplant recipients on MMT appears similar to that of patients not on MMT who underwent OLT during this period. Our results suggest cirrhotic patients on MMT should be considered for OLT if they meet the same psychosocial requirements as patients with alcohol abuse. Furthermore, it is not necessary for patients to be weaned off methadone before OLT.