Surrogate decision-making for incompetent elderly patients: the role of informal representatives

Informal or unofficial representation refers to the practice (more common in some European jurisdictions than in others), that persons not designed by a court or by the patient himself, make medical decisions on the patient's behalf in case of their incompetence. If the law provides for this, it is usually next of kin (spouse, children, brothers and sisters, etc.) who are allowed to act in such a capacity. Informal representation raises several questions. Are family members always familiar with what their relative would have wished, ready to take responsibility, and not too much reigned by their emotions? The basic legal concern is whether there are sufficient procedural and other safeguards to protect the incompetent patient from representatives who do not serve their best interests. In addressing these issues, after a brief survey of the law in the Netherlands as compared with that in Belgium, Germany and England/Wales, we will argue that informal representation as such is not at variance with international and European standards. However, an 'informal' approach to surrogate decision-making should always go together with sufficient protection of the incompetent patient, including procedural safeguards with regard to the decision that the patient is incompetent, limits to the decision-making power of informal representatives and effective forms of conflict resolution.     

A comparison of civil patients and incompetent defendants: pre and post deinstitutionalization

There has been a great deal of speculation that deinstitutionalization has resulted in the criminalization of the mentally ill. Using two samples of defendants found incompetent to stand trial (IST) and two samples of civil patients randomly selected from five states, pre and post deinstitutionalization, this research compares changes in their mental health and arrest histories. After deinstitutionalization, fewer and less dramatic differences in the arrest and mental health histories were evident between ISTs and civil patients. Both patient samples displayed significant increases in prior hospitalization and arrest histories. Among the civil patients there was a significant increase in the frequency and seriousness of criminal activity. There was no evidence that IST commitments are being expanded to hospitalize the nondangerous mentally ill no longer subject to civil commitment.     

Women in parole: respect and rapport

Although the number of females in law enforcement has increased in recent years, research suggests that the uniquely gendered contributions of females are minimized in favor of traditional modes of law enforcement, emphasizing physical presence, authoritative commands, and demonstrative control. This research examines women in parole, using in-depth interviews with a small convenience sample of female parole agents in California. Participants discussed their experiences as parole agents from the perspective of women in a predominantly male occupation. Overwhelmingly, they emphasized traditionally associated female traits of intuition, verbal communication, and relationships, over physical tactics. Participants emphasized the importance of building respect and rapport with parolees in multiple contexts, including in the parolees' homes, with the families of parolees, and at parolees' places of employment. Participants suggested that this approach ensures their personal safety and enhances parolee compliance, especially when considering their subjective account of experiences by male parole agents.