PubMed Health⌕ Search

Biomedical subjects

M Silberfeld

Publications and source records attributed to M Silberfeld.

At least 19 recordsLinked to original sources
PubMed1996

Mental competence and the question of beneficent intervention.

The authors examine recent arguments purporting to show that mental incompetence (lack of decision-making capacity) is not a necessary condition for intervention in a person's best interests without consent. It is concluded that these arguments fail to show that competent wishes could justifiably be overturned. Nonetheless, it remains an open question whether accounts of decision-making capacity based solely on the notion of understanding and appreciation can adequately deal with various complexities. Different possible ways of resolving these complexities are outlined, all of which need further exploration.

Beneficence↗
PubMed1996

Competency and practical judgment.

At least four different frameworks--psychiatric, cognitive, functional and decision-making--are used in the evaluation of competence, all of which remain more or less unrelated in the literature. In the first section of this paper we consider various meanings of "competence," in order to arrive at a definition of the term relevant to the medical and legal setting. Patient or client "competence," we conclude, refers to the practical abilities that individuals employ in pursuing their own autonomous goals in life. We then show how a systematic categorization of these practical abilities--which we call a taxonomy of practical judgment--allows us to show when the traditional frameworks for the evaluation of competence may or may not be useful in the evaluation of a particular competence. In the final section we explore some of the normative considerations underlying the taxonomy. For instance, competence is not only related to intrinsic abilities but to resources available in the community. Here we touch on questions related to the fair distribution of community resources.

Aged↗
PubMed1996

Measuring capacity to complete an advance directive.

OBJECTIVE: To validate reference standards for the assessment of capacity to complete an advance directive and to develop and test three simple screening instruments. METHODS: We administered five measures of capacity to 96 older subjects from nursing homes, retirement homes, and homes for the aged. The measures included two reference standard evaluations: an assessment by a specially trained nurse in collaboration with a multidisciplinary team (Competency Clinic assessment) and geriatrician assessment using a decisional aid. Three screening instruments were also included: a Generic Instrument designed for any advance directive, a Specific Instrument designed for the "Let Me Decide" advance directive, and the Standardized Mini-Mental Status Examination (SMMSE). The screening instruments and the geriatrician's assessment were administered twice to half of the respondents to determine interrater agreement. RESULTS: The chance-corrected agreement for the assessment by two geriatricians was 0.78, and for agreement between the geriatricians and Competency Clinic assessments it was 0.82. Agreement for the Generic and Specific screening instrument assessments by two observers was 0.77 and 0.90, respectively. The areas under the Receiver Operating Characteristic curve relating the results of the three screening instruments to the Competency Clinic assessment were 0.82 for the Generic Instrument, 0.90 for the Specific Instrument, and 0.94 for the SMMSE; chance is an unlikely explanation for the difference between these three values (P < or = .01). CONCLUSIONS: Using rigorous methods, health workers can make reproducible and valid assessments of capacity to complete an advance directive. The SMMSE accurately differentiates people who can learn about and ultimately complete advance directives from those who cannot.

Advance Directives↗
PubMed1996

Competency assessments: perceptions at follow-up.

OBJECTIVES: To report on the perceptions of assessment of competency and its consequences on a group of clients and significant others at follow-up. METHODS: Ninety-five interviews were conducted using a carefully developed semistructured telephone interview of 24 clients and 71 family/caregivers, representing the perceptions of about 80 clients. RESULTS: There was general satisfaction in the competency assessment process. There was a perception that interests and rights were protected. Clients were seen to be less involved in all spheres of decision making regardless of capacity outcome. Clients and families were satisfied with how decisions were made. CONCLUSIONS: Follow-up study of competency assessment does not support the conclusions previously drawn based on court record studies that assessments are deleterious and frequently result in violations of rights.

Adolescent↗
PubMed1996

Permissible errors in managing property: an approach to the threshold of capacity.

OBJECTIVE: To demonstrate a practical approach to describing the threshold of mental capacity. METHOD: A retrospective analysis of 62 cases of assessments for capacity to manage property was carried out to record the type and frequency of errors. RESULTS: For items on the Mini-Mental State Examination (MMSE), there was no clear demarcation of items associated with a judgement of capable. On the clinical criteria, several items almost completely distinguished capable from incapable subjects. CONCLUSIONS: The permissible error approach makes the threshold of capacity explicit. It is well suited to the emphasis put on functional performance in the evaluation of mental capacity.

Canada↗
PubMed1995

Reflections on segregating and assessing areas of competence.

Various complexities that arise in the application of legal and/or clinical criteria to the actual assessment of competence/capacity are discussed, and a particular way of understanding the nature of such criteria is recommended.

Activities of Daily Living↗
PubMed1995

Agreement between professions on ethical decisions: an empirical demonstration.

The decisions of a multidisciplinary competency panel at the Baycrest Centre for Geriatric Care, Toronto, Canada, were studied to try to explain the high level of agreement on individual cases when determining mental capacity. The panel assessed its own judgments on a standardized form developed to capture the process of coming to a capacity determination. Though the relative weights given to decision-making variables varied with discipline, there was agreement on a group of criteria most relevant to capacity. Three alternative explanations are given for these results.

Aged↗
PubMed1994

Presumptions respecting mental competence.

This paper addresses the role(s) played by presumptions regarding mental competence in the context of clinical assessment of decision-making capacity. In particular, the issue of whether or not the usual common law presumption of competence is appropriate and applicable in cases of reassessment of persons previously found incompetent is discussed. Arguments can be made for either retaining a presumption of competence or adopting a presumption of incompetence in reassessment cases. In addressing the issue and the arguments, the authors conclude that the question is really a public policy issue which requires legislative resolution. In writing this paper, the authors have drawn on their joint clinical experience at the Baycrest Competency Clinic. Though the authors' jurisdiction is the province of Ontario, their intent is to raise awareness and to prompt consideration of this issue both inside and outside Ontario.

Commitment of Persons with Psychiatric Disorders↗
PubMed1993

A randomized trial of a decisional aid for mental capacity assessments.

The objective of this study was to evaluate the clinical utility of a decisional aid for mental capacity assessments which was developed using a group judgment methodology. This was carried out by a randomized, controlled trial. The subjects comprised 64 University of Toronto psychiatry residents in postgraduate years 1 through 4. Residents were randomized to carry out mental capacity assessments on simulated cases with, or without, the use of the decisional aid. The main outcome measure was the extent of agreement between the mental capacity determinations of residents and those of experts. There was no difference between the intervention and control groups with respect to the overall mean level of agreement with experts (0.87 vs 0.86, p = 0.88; 95% confidence interval for the difference between the study groups, -0.07 to +0.08). A logistic regression analysis, which adjusted for imbalances between the groups, also revealed no difference between the groups in their agreement with experts. The mean time per competency assessment was significantly longer in the intervention group (19.1 vs 10.8 min; p < 0.001). It was concluded that the decisional aid did not improve the ability of the psychiatry residents to make mental capacity assessments on simulated cases. Despite relatively limited formal training, the psychiatry residents had a high level of agreement with experts.

Adult↗
PubMed1992

Psychiatric services: a survey of nursing homes and homes for the aged in Ontario.

A survey was conducted to determine perceptions and attitudes of psychiatric services available to nursing homes and homes for the aged across Ontario. A questionnaire was sent by mail to medical and nursing directors separately. Thirty-six point eight percent of responders reported that the nursing home residents never receive psychiatric care, and 88.2% of responders estimated the total psychiatric care received by all of their residents per month was five hours or less. Almost three-quarters of the responders stated that they require more psychiatric services. Significantly more nursing directors than medical directors wanted more psychiatric services. Southwestern Ontario, followed by Northern Ontario, had the least perceived availability of a visiting psychiatrist. Perceived availability was greatest in larger urban areas and least in rural areas. The mean percentage of residents perceived to have psychiatric or behavioural problems was 30.5%, while the mean percentage perceived to require psychotropic medication was 37.4%. Physical aggression, wandering and agitation were identified as the behavioural problems of greatest concern to staff. When a visiting psychiatrist is not available, residents sometimes have to travel long distances for psychiatric evaluation. Planning is required to facilitate and encourage the development of efficient and effective psychiatric services for long term care facilities for the elderly.

Aged↗
PubMed1992

A preliminary report on the discrepancy between clinical and test evaluations of competence.

This report demonstrates the discrepancy that can occur between clinical and test evaluations of competence. It presents retrospective examination of 35 assessments of competence performed on 24 subjects by a multidisciplinary competency panel. The findings of the panel are compared with the subjects' results on the Cognitive Competency Test and on the Mini-Mental State Examination. The results show that the multidisciplinary competency panel will more often find subjects competent than indicated by their psychometric test scores. A process approach to the use of tests is recommended. Reliance on tests to decide the outcome of difficult cases does not appear to be warranted.

Adult↗
PubMed1991

Heterogeneity in responses to cancer. Part I: Psychiatric symptoms.

Heterogeneity in psychiatric responses to disease specific diagnosis is demonstrated for two groups of cancer patients who are comparable in prognosis and treatment intensity. Implications of this heterogeneity are drawn for etiological study and for planning psychiatric interventions.

Adaptation, Psychological↗
PubMed1991

Heterogeneity in responses to cancer. Part II: Sexual responses.

Heterogeneity in psychosexual responses to disease-specific diagnosis is demonstrated for two groups of cancer patients with testis cancer and Hodgkin's disease who are comparable in prognosis and treatment intensity. The two groups of patients and their partners are shown to differ in their ability to recover from psychiatric problems associated with the diagnosis and/or treatment of cancer.

Adaptation, Psychological↗
PubMed1988

Psychiatric consultation services in an oncology hospital.

Psychosocial oncology has become an area of considerable interest over the past ten to fifteen years. There has been little written about the development of psychiatric services or the profile of such services to this population. This paper describes the historical evolution of a psychiatric consultation service in a cancer hospital and provides a statistical analysis of the patient population and services provided. The special need for continuity of care and a comprehensive biopsychosocial approach is elaborated and clinical examples are reported. Finally, directions for the future development of this kind of service are suggested.

Adaptation, Psychological↗