Supported decision making: a review of the international literature

Supported decision making (SDM) refers to the process of supporting people, whose decision making ability may be impaired, to make decisions and so promote autonomy and prevent the need for substitute decision making. There have been developments in SDM but mainly in the areas of intellectual disabilities and end-of-life care rather than in mental health. The main aim of this review was to provide an overview of the available evidence relevant to SDM and so facilitate discussion of how this aspect of law, policy and practice may be further developed in mental health services. The method used for this review was a Rapid Evidence Assessment which involved: developing appropriate search strategies; searching relevant databases and grey literature; then assessing, including and reviewing relevant studies. Included studies were grouped into four main themes: studies reporting stakeholders’ views on SDM; studies identifying barriers to the implementation of SDM; studies highlighting ways to improve implementation; and studies on the impact of SDM. The available evidence on implementation and impact, identified by this review, is limited but there are important rights-based, effectiveness and pragmatic arguments for further developing and researching SDM for people with mental health problems.

Shared decision making in patients at risk of cancer: The role of domain and numeracy

Background
Shared decision making has become an integral part of medical consultation. Research has, however, reported wide differences in individuals' desires to be involved in the decision-making process, and these differences in preferences are likely to be the result of a number of factors including age, education and numeracy.

Objective
To investigate whether patients at genetic risk for cancer had preferences for shared decision making that differed depending on medical domain (general health vs. cancer) and whether decision preferences are linked to numeracy abilities.

Methods
Four hundred and seventy-six women who consented to participate in response to an email sent by a local branch of the U.S.-based Cancer Genetics Network (CGN) to its members. Participants completed the Control Preference Scale, as well as an objective and subjective numeracy scales.

Results
Decision domain (cancer vs. general health) was not associated with women's preferences for involvement in decision making. Objective and subjective numeracy predicted a preference for decision involvement in general, and only objective numeracy was predictive with regard to cancer.

Conclusion
Participants were equally likely to state they wanted to play an active, collaborative or passive role in both medical domains (general and cancer). High-numeracy participants were more likely to express a desire for an active role in general and in case they were diagnosed with cancer.

Practice implications
Health authorities' recommendations to clinicians to include patients in their medical decisions are supported by patients' desires, and clinicians should be cognizant of their patients' preferences as well as their numeracy skills.

An international comparison of legal frameworks for supported and substitute decision-making in mental health services

There have been important recent developments in law, research, policy and practice relating to supporting people with decision-making impairments, in particular when a person’s wishes and preferences are unclear or inaccessible. A driver in this respect is the United Nations Convention on the Rights of Persons with Disabilities (CRPD); the implications of the CRPD for policy and professional practices are currently debated. This article reviews and compares four legal frameworks for supported and substitute decision-making for people whose decision-making ability is impaired. In particular, it explores how these frameworks may apply to people with mental health problems. The four jurisdictions are: Ontario, Canada; Victoria, Australia; England and Wales, United Kingdom (UK); and Northern Ireland, UK. Comparisons and contrasts are made in the key areas of: the legal framework for supported and substitute decision-making; the criteria for intervention; the assessment process; the safeguards; and issues in practice. Thus Ontario has developed a relatively comprehensive, progressive and influential legal framework over the past thirty years but there remain concerns about the standardisation of decision-making ability assessments and how the laws work together. In Australia, the Victorian Law Reform Commission (2012) has recommended that the six different types of substitute decision-making under the three laws in that jurisdiction, need to be simplified, and integrated into a spectrum that includes supported decision-making. In England and Wales the Mental Capacity Act 2005 has a complex interface with mental health law. In Northern Ireland it is proposed to introduce a new Mental Capacity (Health, Welfare and Finance) Bill that will provide a unified structure for all substitute decision-making. The discussion will consider the key strengths and limitations of the approaches in each jurisdiction and identify possible ways that further progress can be made in law, policy and practice.

Regret and adaptive decision making in young children

In line with the claim that regret plays a role in decision making, O’Connor, McCormack, and Feeney (2014) found that children who reported feeling sadder on discovering they had made a non-optimal choice were more likely to make a different choice next time round. We examined two issues of interpretation regarding this finding: whether the emotion measured was indeed regret, and whether it was the experience of this emotion rather than the ability to anticipate it that impacted on decision making. To address the first issue, we varied the degree to which children aged 6-7 were responsible for an outcome, assuming that responsibility is a necessary condition for regret. The second was addressed by examining whether children could accurately anticipate that they would feel worse on discovering they had made a non-optimal choice. Children were more likely to feel sad if they were responsible for the outcome; however even if they were not responsible, children were more likely than chance to report feeling sadder. Moreover, across all conditions feeling sadder was associated with making a better subsequent choice. In a separate task, we demonstrated that children of this age cannot accurately anticipate feeling sadder on discovering that they had not made the best choice. These findings suggest that although children may feel regret following a non-optimal choice, even if they were not responsible for an outcome they may experience another negative emotion such as frustration. Experiencing either of these emotions seems to be sufficient to support better decision making.

Decision Making by Credal Nets

Credal nets are probabilistic graphical models which extend Bayesian nets to cope with sets of distributions. This feature makes the model particularly suited for the implementation of classifiers and knowledge-based systems. When working with sets of (instead of single) probability distributions, the identification of the optimal option can be based on different criteria, some of them eventually leading to multiple choices. Yet, most of the inference algorithms for credal nets are designed to compute only the bounds of the posterior probabilities. This prevents some of the existing criteria from being used. To overcome this limitation, we present two simple transformations for credal nets which make it possible to compute decisions based on the maximality and E-admissibility criteria without any modification in the inference algorithms. We also prove that these decision problems have the same complexity of standard inference, being NP^PP-hard for general credal nets and NP-hard for polytrees.