Group dynamics in forensic pretrial decision-making.

This study examines how forensic evaluators' opinions that pertain to diagnosis, competency to stand trial, and criminal responsibility (Maryland's version of the not guilty by reason of insanity plea) are rendered at a state forensic hospital for defendants pleading not criminally responsible. Pretrial evaluations completed independently by a psychiatrist, a psychologist, and a social worker were presented at a forensic staff conference where psychiatrist and psychologists openly "voted" on diagnosis, competency to stand trial, and criminal responsibility. These results were then sent to the court. The purpose of this study was to assess the clinicians' level of agreement and the role that conformity played in the decision-making process. A sample of twenty court-ordered pretrial evaluations of defendants examined at the hospital between March and June 1991, with evaluators' opinions generated by a secret ballot, were compared with a matched control group from an earlier time, when opinions were generated by open ballot. The study was designed to compare the opinions of forensic evaluators in the issues of diagnosis, competency to stand trial, and criminal responsibility between the two samples. The defendants in the experimental group and the control group were matched on the basis of age, race, sex, and offense. It was hypothesized that with secret ballot voting there would be a greater disparity of agreement regarding diagnosis, competency to stand trial, and criminal responsibility opinions compared with the open method of voting. However, the results of this study did not support that hypothesis. There was little disparity on forensic opinions rated either by secret or open voting.

Insanity defense pleas in Baltimore City: an analysis of outcome.

OBJECTIVE: The authors studied all defendants in Baltimore City's circuit and district courts who pleaded not criminally responsible, Maryland's version of the not guilty by reason of insanity plea, during a 1-year period. The study was designed to compare the perception that the insanity plea is misused to actual outcome data. METHOD: The cohort of defendants who pleaded not criminally responsible in both the circuit and district courts during calendar year 1991 was identified. Data on demographic characteristics, crimes committed, diagnoses, and psychiatrists' opinions on criminal responsibility were collected. Trial outcome data were obtained through a search of the circuit and district court computer systems. RESULTS: Of the 60,432 indictments filed in the two courts, 190 defendants (0.31 per 100 indictments) entered a plea of not criminally responsible. All but eight defendants (0.013 per 100 indictments) dropped this plea before trial. For these eight cases, both the state and the defense agreed that the defendant should be found not criminally responsible, and the plea was uncontested at trial. The remaining defendants had their charges dropped before trial, remained not competent to stand trial at the time of the study, or withdrew their pleas of not criminally responsible before trial. CONCLUSIONS: There were no trials that contested the plea of not criminally responsible. The state and defense agreed with each other for all of the defendants who actually retained the plea at trial. The perception that the insanity defense is overused and misused is not borne out by data.

Clinicians' judgement of capacity of nursing home patients to give informed consent.

OBJECTIVE: The study determined the rate of incapacity to give informed consent for medical treatment among patients admitted to a nursing home and assessed whether clinical staff members recognized this incapacity and whether they used alternative means to provide surrogate decision making for their patients' treatment. METHODS: After 44 patients admitted to a nursing home affiliated with a major teaching hospital gave oral consent, two standardized tests, the Hopkins Competency Assessment Test (HCAT) and the Mini Mental State Examination (MMSE) were administered to them. Later a researcher blind to the test results reviewed subjects' clinical records to determine whether staff recognized any incapacity in giving informed consent for medical treatment. RESULTS: Twenty of 44 subjects were identified by the HCAT as incompetent to give informed consent for medical treatment. Clinical staff had identified 13 of those subjects as clinically incompetent. None of the subjects whom clinical staff identified as clinically incompetent was provided with surrogate decision makers in accordance with procedures outlined in state law. CONCLUSIONS: The prevalence of incapacity to give informed consent in the nursing home population was high. Clinical screening by staff did not identify all clinically incompetent patients, and staff had unresolved conflicting opinions about individual patients' capacity to give informed consent. Even when staff recognized a patient's incapacity to give informed consent, proper legal procedures for appointing surrogate decision makers were not followed.

Competency assessment of medical and psychiatric patients under Maryland's Health Care Decisions Act.

The Health Care Decisions Act provides considerable flexibility and autonomy for patients regarding advance directives and surrogate decision making and clarifies how patients can tell their physicians and the world in general what they would like to have happen if they become incapable of making their own health care decisions. The law, however, is complex. This article provides help for physicians in interpreting some of the Act's clinical and legal ramifications.

The Munchausen syndrome in civil forensic psychiatry.

The diagnosis of Munchausen syndrome requires that a patient intentionally produce or feign physical symptoms with a psychological need to assume the sick role. To differentiate the disorder from malingering one must document the absence of an external incentive for the patient's behavior. Although malingering is a major topic of interest in forensic psychiatry, there has been no literature that looks at the Munchausen syndrome presenting in the civil forensic setting. This paper reports on two cases of the Munchausen syndrome that occurred in the areas of medical malpractice and workers' compensation. The cases highlight how the psychiatrist should approach these cases in the civil forensic setting. The malpractice case also illustrates how the disorder is viewed by an appellate court.

The request for assistance in dying. The need for psychiatric consultation.

BACKGROUND: Public initiatives and legislative proposals have increased the likelihood that some states will legalize euthanasia and assisted suicide as a means of ending the suffering of patients with terminal illness. However, suggested safeguards that would guide physicians in such cases have not properly addressed the need to evaluate psychosocial factors that could motivate patients' requests for premature death. METHODS: Four cases of patients with cancer who expressed a wish to end their lives prematurely are described. These cases were evaluated with regard to mental and emotional functioning. RESULTS: Pain and suffering, organic mental disease, depression, and personality issues play significant roles in patients' requests for assistance in dying. CONCLUSION: Comprehensive psychosocial assessment is needed when evaluating requests for assistance in dying. This assessment may reveal hidden problems or conflicts that affect rational decision making, a prerequisite to informed consent for any procedure or intervention.

Prevalence of advance directives and guardianship in nursing home patients.

The Patient Self-Determination Act (PSDA) now requires federally funded nursing homes to inform newly admitted patients of their right to determine their future medical care. Many nursing home patients may not be able to understand these rights, given the high prevalence of mental disorders, particularly dementia, in this population, and well need family members for assistance. Prior to the onset of the PSDA we surveyed the families of all residents of a large, proprietary nursing home to determine whether family members understood the concept of advance directives and guardianship. We also ascertained the rate of use of these instruments in the population studied. We found that the majority of family member respondents understood these concepts, but that substantial proportions of both competent and incompetent patients lacked surrogate decision-making authority, either in the form of a court-appointed guardian or a written advance-directive instrument. Informing newly admitted patients and their families about advance directives is warranted because many lack these plans. However, the high proportion of incompetent patients among nursing home patients indicates the need to encourage currently competent patients to formulate advance directives prior to nursing home placement.

The Hopkins Competency Assessment Test: a brief method for evaluating patients' capacity to give informed consent.

The Hopkins Competency Assessment Test (HCAT), a brief instrument for evaluating the competency of patients to give informed consent or write advance directives, consists of a short essay and a questionnaire for determining patients' understanding of the essay. In a study to validate the instrument, 41 medical and psychiatric inpatients answered the questionnaire after reading the essay while bearing it read aloud. A forensic psychiatrist who was blind to the HCAT scores later examined the patients for competency. A subject's number of correct answers to the HCAT questionnaire was an accurate indicator of clinical competency as assessed by the psychiatrist. The results suggest that the HCAT is a useful tool for rapidly screening patients for competency to make treatment decisions.

Assessing competency in the elderly.

The doctrine of informed consent requires that a patient understand the medical procedure being proposed, that consent be voluntary, and that the patient be competent to give consent. Because of declining cognitive functioning, elderly patients are at significant risk of becoming incompetent and, therefore, unable in the eyes of the law to give informed consent. Advance directives allow competent patients to tell their doctors and the world in general what their health care choices are should they not be able to make their choices clear in the future. The living will and durable power of attorney are two types of advance directives that are legally binding in most states.

The emergency petition process in Maryland.

Maryland's Emergency Petition statute allows a violent or suicidal person with a mental disorder to be brought to an emergency facility for rapid evaluation regarding the need for emergency treatment. Although many states have similar laws, little has been written in the psychiatric literature about the emergency petition process. The investigators evaluated emergency petition documents, demographic data, and the adequacy of emergency room records for all patients brought to a large county hospital in Prince Georges County, Maryland, by emergency petition during a one-month period. All emergency petition patients in Prince Georges County are brought to this hospital site. Of 94 petitioned patients examined during the study period, 92 records were available for review. The emergency petition was found to meet appropriate legal criteria in 94 percent of cases. More than half of all patients evaluated were intoxicated on alcohol or illicit drugs, and the majority of these patients were released from the emergency room as no longer dangerous after their acute intoxication resolved. In contrast to previous studies most of the patients evaluated were affluent, had health insurance, and were employed.

Defendants pleading insanity: an analysis of outcome.

The authors examined the cohort of all defendants pleading not guilty by reason of insanity over a 12-month period in Baltimore City's superior trial court. During that time, 143 of the 11,497 defendants indicted (1.2%) pled not criminally responsible. Fourteen of those defendants (10%) were subsequently found not guilty by reason of insanity. The authors found marked agreement between the prosecution and defense with only two cases leading to full trials where the issue of insanity was argued. The evaluating physician's opinion as to criminal responsibility and Axis I diagnosis, and the most serious underlying charge discriminated between those defendants found not guilty by reason of insanity and those defendants found guilty or not guilty by the court. Other demographic factors such as age, number of dependents, educational level, severity of illness, and criminal background did not discriminate between the two groups.

Psychiatrists' accuracy in predicting violent behavior on an inpatient unit.

Courts and legislators continue to assume psychiatrists are able to predict dangerousness, but research has shown they have no special ability to do so. In this study, two psychiatrists examined 47 new inpatient admissions to a short-term psychiatric treatment unit and predicted whether they would commit battery or demonstrate threatening or suicidal behavior within seven days. The psychiatrists were not accurate in predicting battery or suicidal behavior but had some efficacy in predicting threatening behaviors. The presence of assaultive or threatening behavior on admission, hallucinations on mental status examination, and a discharge diagnosis of mania were useful for predicting battery. A discharge diagnosis of mania was useful for predicting threatening behavior. The use of likelihood ratios to conceptualize predictive data is described.

Munchausen syndrome in a mother and daughter: an unusual presentation of folie à deux.

The author describes a mother and daughter, both admitted to a major medical center on the same day to the same room, and both with a clinical presentation consistent with Munchausen syndrome. To the author's knowledge, this is the first report of Munchausen syndrome presenting as a folie à deux.