SOPSI 17th Annual Scientific Meeting Roma, febbraio F. Carabellese, D. La Tegola, F. La Mura, G. Gallo, R. Catanesi

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1 SOPSI 17th Annual Scientific Meeting Roma, febbraio 2013 F. Carabellese, D. La Tegola, F. La Mura, G. Gallo, R. Catanesi Sezione di Criminologia e Psichiatria Forense Coordinatore: Prof. R. Catanesi D.I.M. University of Bari ITALIA

2 Premise INFORMED CONSENT prerequisite for any diagnostic therapeutic intervention key element of the doctor patient relationship Faden RR, Beauchamp TL, King NMP. A History and Theory of Informed Consent. New York, Oxford University Press, competence or capacity to consent Appelbaum PS, Grisso T. Assessing patients' Capacities to consent to treatment. N Engl J Med 1988; 319: even patients with severe mental illness retain capacity levels valid with respect to some or all decisions about their treatment Appelbaum PS: Decisional capacity of patients with schizophrenia to consent to research: taking stock. Schizophr Bull 2006; 32: The relation of this to the specific proposed treatment must also be examined Palmer BW, Dunn LB, Appelbaum PS, Jeste DV. Correlates of Treatment Related Decision Making Capacity among Middle Aged and Older Patients With Schizophrenia. January Arch Psychiatry 2004; 61: ; Raymont V, Bingley W, Buchanan A, David AS, Hayward P, Wessely S, Hotopf M. Prevalence of mental incapacity in medical in patients and associated risk factors: cross sectional study. Lancet 2004, 364:

3 Extreme clinical se1ngs Patients in the final stages of life using pain medication. Alzheimer's patients taking antipsychotics with off label indications for this type of disease. Patients waiting for organ transplants with severe physical ailments. Chronics psychotics patients

4 Law no. 39 of National Programme for the construction of facilities for palliative care, which identified the residential centers, hospices in fact, able to facilitate people facing the end of life in accordance with the directives of National Health Plan 1998/2000. The Region of Puglia approved the law and now in Bisceglie there is a Hospice with 20 beds.

5 Hospices Place of refuge in the proposed organization for palliative care identified by the Law no. 39. Article 2: We define residential palliative care facilities, which are part of the support network for terminal patients, to assist in the temporary admission of patients with progressive disease and in advanced stage, fast moving and poor prognosis, for whom any therapy aimed at healing or stabilization of the disease is not possible or appropriate and, primarily, for patients with terminal malignancy who require palliative care support.

6 The purpose of a hospice Essential health and social care for patients with chronic terminal diseases. Reduction or elimination of pain and relief from difficulty in breathing to relieve the patient of the pain disorder and slow down the deterioration of the quality of life of those affected.

7 Hospice ObjecFves 1. Improving the quality of life of terminally ill patients 2. Improving the quality of clinical care to the terminally ill 3. Improving integration within the network of General Practitioners and the NHS

8 Routes of access to hospices General practitioner Specialist doctor

9 Drugs used in hospices Starting with an appropriate assessment and following recommended guidelines on the use of analgesics, family physicians can achieve successful pain relief in nearly 90 percent of dying patients. The physical, psychological, social and spiritual needs of dying patients are best managed with a team approach Am Fam Physician 2000;61:755 64

10 Survey Methodology 12 month period starting in October 2012 primary school education good knowledge of the Italian language consent to participate in the study excluded patients are those with MMSE <18

11 Informed consent Survey Methodology In the first 72 hours of admission MMSE Folstein M, Folstein S, McHugh P. Mini Mental State: a practical guide for grading the cognitive state of the patient for the physician. J. Psychiatr Res 1975; 12: Medical history interview Clinical trial: State -Trait Anxiety Inventory - Form Y MacCAT T - Beck Depression Inventory II

12 Our research objecfves To analyse possible associations between COMPETENCE IN PALLIATIVE TREATMENT and COGNITIVE FUNCTIONING/EMOTIONAL

13 Our sample 50 patients were admitted to the hospice 37 of whom died in the same reporting period 28 patients agreed to participate in the survey and have become part of our sample

14 Average age: 71 years Primary school education: > 90% Our sample All affected by cancer with metastases All patients before entering the hospice had been informed of their status as terminally ill All were taking Morphine, in addition to other drugs of support Use of the MacCAT T is limited to the evaluation of steps 1 (Understanding) and 2 (Appreciation) of the interview All demonstrated high levels of understanding of the risks and benefits of palliative care taken and were able to appropriately evaluate (appreciate) the information received in this regard (MacCAT T = 4)

15 Age / MacCAT T Age > 70: lowest scores (0 to 2) the scale of the understanding of the MacCAT T (1/3 of the sample) Age <60: full understanding (score = 4 6).

16 MMSE / MacCAT T MMSE > 18: first match of the MacCAT T between 4 and 6 in 83.3% of cases MMSE < 18: qqbetween 2 and 4 MacCAT T in 66% of cases and between 4 and 6 in the remaining 33% of subjects. Among those who reported a very low score in the MacCAT T (between 0 and 2) in 15% of cases had a score of > 18 in the MMSE 1/3 of people with levels of understanding in full force at the scale 1 in the MacCAT T (between 4 and 6) have reported an MMSE score of <18 Patients with intra cerebral metastases had a valid capacity for comprehension (4 6 to MacCAT T) and values> 18 in the MMSE.

17 Schooling / MacCAT T The scores between 4 and 6 in the MacCAT T are largely represented (66%) from subjects with a number of years of school> 5 years in total For a number of <5years of school understanding (0 2 scale 1 of the MacCAT T). minors level of

18 BDI II/MacCAT T Scores above 91 to BDI II low score on step 1 of the MacCAT T (12.5%) 83.3%: score between 4 and 6 in MacCAT T

19 STAI Y/MacCAT T The presence of anxiety symptoms is completely irrelevant to the ability to understand

20 Conclusions Uncertain levels of understanding (comprehension) than the primary diagnosis Inadequate capacity to understand their condition as terminally ill patients (scores of 4 on the scale of the MacCAT T 2) There was also understanding of the risks and benefits of palliative care taken and were able to appropriately evaluate (appreciation) information received in this regard.

21 Conclusions Factors most likely to affect the outcome of the MacCAT T 1: age, cognitive abilities, the level of schooling Little relevance mental condition clinically appreciated with BDI II and STAI Y It necessary to continue research in this specific field of research, especially in light of the ethical and medico legal implications Giampieri M. Communication and Informed Consent in Elderly People. Anestesiologica Minerva, 2012, 78. 2:236 42

22 Many Thanks for your ATTENTION!