Supported Decision Making in Serious Mental Illness

May combine two claims.

No exact count of U.S. guardianship cases exists, since laws vary by state and many states withhold data.

“The precise number of individuals in guardianship in the U.S. is not known, largely because of the state-specific nature of guardianship laws and the fact that many states do not release guardianship data.”

Probably not a substantial claim: may not pass S4 (based).

Whether some SMI patients unable to manage benefits could do so with decisional support, instead of relying fully on a fiduciary, remains unknown.

“Can some people with SMI who demonstrate an inability to manage their benefits, nonetheless manage them effectively with decisional support, rather than full dependence on/deference to the decisions of a fiduciary? The answer to that question is presently unknown”

May combine two claims.

The authors found only three related studies, and each assessed the need for supported decision making rather than its outcomes in people with serious mental illness.

“We found only three related studies; yet, each evaluated the need for, rather than the outcomes of, SDM in persons with SMI.”

May combine two claims.

Decision-making capacity is context-dependent, affected by the complexity of the information and decision and by how the information is communicated.

“decision making capacity is an inherently context-dependent construct – affected by the inherent complexity of the information and decision, as well as the manner in which the information is communicated complexity (Dunn, Palmer, & Karlawish, 2007).”

• cites Dunn, Palmer, & Karlawish, 2007Not checked yet

  Not checked in the free run.

May combine two claims.

Most state laws direct guardians to use a substituted judgment standard, with a best-interest standard allowed when there is insufficient evidence of what the ward would have decided.

“Most state laws argue that a substituted judgment standard should guide guardian decision making, and a best-interest standard is allowable when guardians lack sufficient evidence to determine what decision the ward would have made if s/he had the capacity (Shalowitz, Garrett-Mayer, & Wendler, 2006).”

• cites Shalowitz, Garrett-Mayer, & Wendler, 2006Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

About one million of those guardianships were established in the U.S. after 1995, indicating recent growth in their use.

“This number includes approximately one million people who have been placed under guardianship in the U.S. since 1995, reflecting a recent increase in the application of guardianship (Blanck & Martinis, 2015).”

• cites Blanck & Martinis, 2015Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The capacity needed to choose supporters voluntarily in SDM may not be the same as that needed to appoint them formally by power of attorney or advance directive.

“the legal capacity required to voluntarily designate spporters through such an arrangement may differ from the capacity required to formally appoint supporters through a Power of Attorney or Advanced Directive.”

May combine two claims.

In SMI, decision-making capacity is usually impaired in only some individuals, unlike intellectual/developmental disabilities, and can vary with emotional state.

“Persons with SMI differ from those with intellectual and developmental disabilities in that decision making capacity typically is impaired only in a subset of individuals with SMI (Palmer, Dunn, Depp, Eyler, & Jeste 2007), and it may fluctuate over time, depending on the individual’s emotional state.”

• cites Palmer, Dunn, Depp, Eyler, & Jeste 2007Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Data from four states in 2008 yielded an estimate of about 1.5 million U.S. adults under guardianship at any time.

“based on data released from four states in 2008 (i.e., Vermont, Kansas, Ohio, and the District of Columbia), it is estimated that approximately 1.5 million American adults are under guardianship at any given time (Uekert & Van Duizend, 2011).”

• cites Uekert & Van Duizend, 2011Not checked yet

  Not checked in the free run.

May combine two claims.

Plenary guardianship may be applied too broadly and may have harmful effects, including lowered self-esteem, lowered perceived self-efficacy, behavioral passivity, and potential for guardian abuse.

“Emerging research involving individuals with cognitive (e.g., intellectual and developmental) disabilities suggests that plenary guardianship presently may be applied too broadly and may have potentially harmful effects, such as lowered self-esteem, lowered perceived self-efficacy, behavioral passivity, and the potential for abuse of privilege by appointed guardians (Jameson et al. 2015).”

• cites Jameson et al. 2015Not checked yet

  Not checked in the free run.

May combine two claims.

Studies of young adults with intellectual disabilities indicate that most are under guardianship, full guardianship greatly exceeds partial, and alternatives are seldom considered.

“Research among young adults with intellectual disabilities suggests that a majority of these individuals are placed under guardianship, that plenary guardianship is far more common than partial guardianship, and that alternatives to guardianship are rarely broached (Blanck & Martinis, 2015; Jameson et al., 2015).”

• cites Blanck & Martinis, 2015Not checked yet

  Not checked in the free run.

• cites Jameson et al., 2015Not checked yet

  Not checked in the free run.

May combine two claims.

In law, competence determinations generally consider only the unaided individual, and SDM is not recognized as an alternative to guardianship.

“the current legal framework generally recognizes only the individual/unaided decision maker in determining competence/incompetence, without provisions for SDM as an alternative to guardianship.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The likelihood that decisional capacity changes probably depends on the cause and nature of the underlying impairment.

“but the frequency/likelihood of change, is probably dependent on the cause and nature of the underlying impairment.”

May combine two claims.

Neuropsychological tests can clarify cognitive strengths and deficits and the nature of decision-making impairments, but they cannot replace direct functional evaluation of decisional capacity.

“Neuropsychological testing can be helpful in identifying a patient’s pattern of cognitive strengths and deficits, thereby understanding (and potentially remedying) the underlying nature of any decision making impairments, but cognitive testing does not substitute for direct functional assessment of decision making capacity (Moye et al. 2007).”

• cites Moye et al. 2007Not checked yet

  Not checked in the free run.

May combine two claims.

Many individuals with SMI are placed under full/plenary legal guardianship, with substitute decision makers appointed.

“These individuals have often been placed under legal guardianship, and substitute decision makers have been appointed to make decisions on their behalf.”

• Also stated in: § Conclusions: · plain

  “many of these individuals are placed under full/plenary legal guardianship”

• cites Blanck & Martinis 2015Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Both the patients and their parents were broadly supportive of supported decision making as an appropriate way to achieve independence.

“and both the patients and their parents were broadly supportive of SDM as an appropriate strategy towards achieving this aim.”

• cites Werner and Chabany (2016)Not checked yet

  Not checked in the free run.

May combine two claims.

The support described by those participants varied widely and included clarifying available choices, affirming self-efficacy, and providing non-specific emotional support such as instilling hope.

“The specific nature of this support varied widely, including clarification of available choices, affirmation of self-efficacy, and non-specific emotional support (e.g., instilling hope).”

• cites Amnesty International (2009)Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The NGA stance aligns with most state laws that mandate consideration or trial of less restrictive options before guardianship.

“The NGA’s position is consistent with most state laws, which require that less restrictive alternatives be considered or attempted prior to placing a person under guardianship.”

• AssumptionRests on an assumption: Less restrictive alternatives to guardianship are preferable when feasible.

May combine two claims.

Instructional coursework aimed at improving goal setting, expression of goals, and self-advocacy in educational and transition planning for high school students with intellectual and learning disabilities has shown benefit, including better employment, greater independence, and improved community integration.

“This research has demonstrated a benefit of this coursework, leading to better employment outcomes, greater independence, and improved community integration (Powers, et al. 2012).”

• cites Powers, et al. 2012Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

A VA program for supervised direct payment has features resembling SDM.

“The Veterans Affairs healthcare system has a supervised direct pay system for veterans having difficulties independently managing their benefits that shares some characteristics with SDM.”

May combine two claims.

Supported decision making may increase feelings of self-empowerment and improve functional outcomes for people with serious mental illness, as shown in studies of people with cognitive disabilities.

“Nonetheless, SDM may enhance feelings of self-empowerment and yield improved functional outcomes for persons with SMI, as has been shown in studies involving individuals with cognitive disabilities.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The VA system selects the most effective and least restrictive fiduciary arrangement, considering supervised direct pay before paid fiduciary.

“VA will always select the most effective and least restrictive fiduciary arrangement. This means that VA will first consider whether the beneficiary can manage their VA benefits with limited VA supervision under supervised direct pay.”

• cites http://benefits.va.gov/BENEFITS/factsheets/fiduciary/FiduciaryFactSheet.pdfNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Werner and Chabany reported that people with unspecified mental illnesses and their parents placed high importance on retaining independence.

“Werner and Chabany (2016) reported that individuals with unspecified mental illnesses attached high importance to retaining independence in their lives, as did the parents of these individuals”

• cites Werner and Chabany (2016)Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

Integrating technological platforms such as mobile applications, Skype, and social media may let a person access supports and supporters in real time.

“Integration of technological platforms, such as mobile applications, Skype, and social media, may enable a person to access supports and supporters in real time.”

May combine two claims.

Interventions that target parts of the decision-making process may improve the ability of people with compromised decision-making capacity to control their lives, which may lead to meaningful functional improvements.

“This research, albeit limited at present, suggests that interventions that target aspects of the decision making process may enhance the ability of individuals with compromised decision making capacity to exercise control over their lives, which in turn leads to meaningful functional improvements.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

The risk that supported decision making exposes people with disabilities to undue influence or coercion by supporters is lower when several supporters are involved, unless those supporters collude.

“Of course, this possibility is mitigated when there are a number of supporters involved, unless we imagine they are colluding.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Those groups were concerned about supported decision making during crisis periods when decisional capacity may be compromised.

“However, these groups expressed concern about SDM during crisis periods when individuals’ decisional capacity may be compromised.”

• cites Werner and Chabany (2016)Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

SDM better matches typical everyday decision-making processes.

“Although SDM better matches typical everyday decision-making processes”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Supported decision making could be used too broadly, requiring people who could have decided independently to seek supports during decision making.

“In addition, it is possible that SDM may be applied too broadly and that people who could have made a choice independently will be required to seek supports during the decision making process.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Those participants said that personal support from others was key to enhancing their capacity during acute distress.

“These participants identified the personal support they received from others as key to enhancing their capacity during these times.”

• cites Amnesty International (2009)Not checked yet

  Not checked in the free run.

May combine two claims.

According to those studies, patients and caretakers see SDM as acceptable and possibly better than substitute decision making.

“These studies suggest that SDM is viewed as an acceptable and potentially superior alternative to substitute decision making for patients and their caretakers.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In an Irish Amnesty International study, participants with unspecified mental illnesses said that acute emotional distress can impair decision-making ability.

“Participants acknowledged that periods of acute emotional distress can impair their decision making ability.”

• cites Amnesty International (2009)Not checked yet

  Not checked in the free run.

May combine two claims.

Higher self-determination is associated with better outcomes in quality of life, employment status, health care access, financial independence, and independent living.

“In other studies, higher levels of self-determination have been associated with better outcomes across areas including quality of life, employment status, access to health care, financial independence, and independent living (Wehmeyer & Palmer, 2003).”

• cites Wehmeyer & Palmer, 2003Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Different aspects of decision making, such as sexual consent versus financial or research consent, may have qualitatively distinct consequences that could affect how a supported decision-making model is incorporated.

“It is noted that different aspects of decision making, such as sexual consent versus financial consent or research consent, may have qualitatively distinct ramifications that could impact incorporation of a SDM model.”