OBJECTIVES:Mild cognitive impairment (MCI) is a concept that is steeped in controversy not limited to prognostic uncertainty; it is unclear how patients interpret or attribute meaning to the label, and whether they perceive that being made aware is beneficial.METHODS:A systematic review was conducted, searching ISI Web of Science, PubMed and PsycINFO in accordance with PRISMA guidelines. Search terms were developed to include articles concerning perceptions regarding MCI and experiences and impact of being informed. Thematic synthesis was applied to the findings.RESULTS:Fourteen papers met criteria. Three themes emerged regarding the MCI label: 1) Individual differences relating to living circumstances, personal perceptions and experiences, and coping style affect how patients adjust to the MCI label; 2) Patients' reactions to the MCI label and their perceptions about how useful it was to receive are affected by the nebulous nature of the construct and information available regarding MCI; 3) Care partners are uncertain about what MCI means and how to address and cope with the patient's cognitive difficulties.CONCLUSIONS:Patient and care partner perspectives were affected by the quality of information and support provided, possibly influenced by clinicians' understanding of the concept. Personal perceptions and experiences, living circumstance and coping styles also shaped experiences of being informed.CLINICAL IMPLICATIONS:Clinicians should develop their understanding of MCI to deliver clear information to patients and consider the necessity of applying the label. Offering support tailored to patients' specific needs may improve perceptions about the label's utility, whilst aiding coping and adjustment.
SummaryThis article reviews a 2017 Court of Protection case which assessed and decided issues relating to the Islamic faith and the Mental Capacity Act 2005. The case involved a 39-year-old Muslim man with learning difficulties. It centred on his ability to make decisions about two specific aspects of his faith - capacity for fasting and for the removal of pubic and axillary hair. The judgment describes how s.4 of the Act was applied in deciding these decisions under the doctrine of best interests. In doing so, it elucidates key principles which can be applied to similar cases of this and other faiths.Declaration of interestNone.
The last 15 years has seen clarification of the terminology used to describe prolonged disorders of consciousness within the United Kingdom leading to the emergence of a new diagnosis - minimally conscious state (MCS) in 2002. MCS is distinct from vegetative states, in that a person demonstrates wakefulness with some degree of minimal awareness. The Mental Capacity Act (MCA) 2005 in England and Wales provides a legal framework for assessing an individuals' capacity to make decisions for themselves. The Act also authorizes others to make decisions on behalf of an individual who is assessed as lacking capacity in their best interests. The Act has an accompanying Code of Practice which provides guidance and a best interests "test" to be applied when assessing best interests. Since the advent of the Act, approximately two cases each year go to the Court of Protection for final decisions regarding end-of-life care in people in an MCS. Currently, any decision involving the withdrawal of clinically assisted nutrition and hydration (CANH) for people in an MCS must be referred to the court. In each case, the courts analyze the application of the Act which has become central in the court's decision-making process, particularly when assessing best interests. This article provides an overview of key MCA sections applied in such end-of-life MCS cases and reviews seminal cases elucidating how the Act has been applied. It further describes the evolution of how courts have interpreted the doctrine of best interests when considering withholding or withdrawing CANH and other life-sustaining treatments.
This article reviews a Court of Protection case involving a woman, Ms X, with two severe medical conditions: anorexia nervosa and end-stage liver cirrhosis due to alcohol dependence. Each of these conditions alone warranted end-of-life care planning. When combined, they provided a far more unique and complex presentation because of the way they were intertwined. Ms X's life was in imminent danger. The Court implemented methodically the principles of the Mental Capacity Act 2005. Ms X was assessed as lacking capacity to make decisions in relation to treatment for her anorexia. However, she retained capacity to make decisions regarding treatment for her liver disease and the continued harmful use of alcohol. The Court ruled that it was not in Ms X's best interests to be subject to further compulsory treatment for her anorexia, even though this may have prolonged her life. It was also in her best interests and lawful not to provide nutrition and hydration with which she did not comply.
Sir: Postoperative pain is an important issue with abdominoplasties and flank liposuction procedures. Different anesthetic techniques have been developed to overcome this problem, including the bilateral thoracic paravertebral block, the epidural block, and infiltration of the rectus sheath with local anesthetics. The transversus abdominis plane block was recently introduced for operations that involve the abdominal wall.1 In the plane between the transversus abdominis muscle and the internal oblique muscle travel the intercostal nerves T7 to T11, the subcostal nerve (T12), and the ilioinguinal and iliohypogastric nerves (L1). The local anesthetic injected in the plane blocks the sensory afferents of all these nerves, providing pain relief for the entire anterior abdominal wall. To date, the transversus abdominis plane block has been evaluated in retropubic prostatectomies,1 cesarean deliveries,2 hysterectomies,3 and laparoscopic4 and abdominal surgery.5 In all of them, it reduced the postoperative pain, morphine requirements, and sedation.2,3,5 Since January of 2009, we have assessed the feasibility of this technique in patients undergoing body contouring abdominoplasties with flank liposuction, and prospectively collected data regarding pain medication requirements. All patients were operated on by one surgeon (A.A) with the same technique and standard general anesthesia. Patients chronically consuming pain medication were excluded from the analysis. After the flap resection and before muscle plication, a 2-cm oblique incision is performed on both sides on the muscular fascia, 3 cm medial and 4 to 5 cm superior to the anterior superior iliac spines. The external oblique muscles are identified and the fibers of the external and internal oblique muscles are separated by blunt dissection until the transversus abdominis muscles are visualized (Fig. 1, above). Bupivacaine hydrochloride (0.5%, 5 mg/ml; total dose, 2 mg/kg) is injected bilaterally in the plane between the internal oblique muscles and the transversus abdominis muscles using a blunt needle (Fig. 1, below). The OEM fascia is then repaired and tumescence liposuction with modified Klein solution (without anesthetic) proceeds as normal. Postoperative analgesia is administered, when required, with morphine (5 mg intramuscularly) in the first postoperative hour and with paracetamol-opioid combination tablets (co-codamol: codeine, 30 mg; paracetamol, 500 mg) afterward.Fig. 1.: (Above) Dissection of external and internal oblique muscles with visualization of the transversus abdominis muscle. (Below) Deposition of the local anesthetic in the plane between the oblique internal and the transversus abdominis muscles.Between January of 2009 and June of 2009, 24 women were operated on (Table 1). Five patients (21 percent) required 5 mg of morphine in the first postoperative half hour; none required morphine in the second half. No patients received oral codeine/paracetamol until postoperative hour 6, seven patients (29 percent) received one tablet from hours 7 to 12, three patients (13 percent) received one tablet from hours 13 to 24, and only one patient (4 percent) received one tablet from hours 25 to 48. No intraoperative or postoperative complications related to the anesthetic or surgical technique were recorded.Table 1: Sociodemographic and Clinical Characteristics of Patients Operated onResults confirm that the transversus abdominis plane block is safe for aesthetic abdominal operations. The technique is also simple, as the flap is already elevated and the muscular fibers are easily identified under direct visualization without the need for ultrasonographic guidance. The technique is associated with low postoperative requirements for morphine or other pain medication. Future randomized studies should now compare abdominoplasties with or without the block to confirm the advantages of this technique in abdominal aesthetic operations. Antonino Araco, M.D. Jack Pooney, M.D. Dolan Park Hospital Bromsgrove Birmingham, United Kingdom Luca Memmo, M.D. Department of Surgery Hôpital Erasme Bruxelles, Belgium Gianpiero Gravante, M.D. Department of Hepatobiliary and Pancreatic Surgery University Hospitals of Leicester Leicester, United Kingdom
