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399. Capacity, Consent and Advance Directives9.1. Psychiatric Advance Directives and the Right to Refuse Treatment in CanadaDaniele L. Ambrosini, McGill University (daniele.ambrosini@mail.mcgill.ca)Throughout the 1990s Canadian courts began to abandon traditional and paternalistic views that patientsmust simply conform to treatment by doctors, irrespective of their individual personal rights. The parenspatriae power, traditionally the power of the State to act in the best interests of those unable to provide fortheir own welfare, must be balanced with a patient’s prior wishes, bests interests, and what constitutes theleast intrusive manner of treatment. Legal scholars, psychologists, and psychiatrists have recommendedadvance directives for mental health treatment decisions as a legal method of treatment pre-planning, and toensure that competent persons will have their capable decision-making abilities respected in the event theybecome incapacitated. A Psychiatric Advance Directive (PAD) is an extension of an advance directive, thatapplies to individuals with mental health problems.The article provides a review of jurisprudence, with its development in the right to refusal of medicaltreatment, followed by a discussion of provincial legislative models, and an overview of potentialarguments based on the Charter of Rights and Freedoms and relevant sections of the Criminal Code. Inaddition, issues regarding patient’s psychological perceptions of PADs, their benefits and potentialobstacles in securing psychiatric patient’s rights will be addressed.9.2.Mental Capacity in Psychiatric and Medical In-PatientsMatthew Hotopf, King’s College (m.hotopf@iop.kcl.ac.uk)In this presentation, I will describe three studies supported by the Wellcome Trust Biomedical EthicsProgramme. First, I will present data which suggest that mental capacity can be assessed with excellentinter-rater reliability when using the MacArthur Competence Assessment Tool – Treatment (MacCAT-T).Second, I will describe our general hospital study in which 159 consecutive patients admitted to medicalwards were interviewed, using MacCAT-T. 31% of the interviewed sample lacked capacity; this figurerose when taking into account non-participants who did not complete the interview because of severecognitive impairment or unconsciousness. Mental incapacity was strongly associated with cognitiveimpairment and advancing age, but not with ethnic group, education, or social class. Third, I will describea similar study involving 112 psychiatric inpatients interviewed within one week of admission. In thissample, 43% lacked mental capacity; incapacity in this group was strongly associated with psychotic illnessand with country of birth - those born outside the UK were more likely to be rated as lacking capacity. Ofthe 63 patients who were judge to have mental capacity, 10% had been admitted under the Mental HealthAct; this group perceived their treatment to be more coercive than the remainder of the sample. Of the 49patients who were judged to lack mental capacity, 39% were not admitted under the Mental Health Act, andwould therefore fall in the “Bournewood gap”. This “gap” refers to incapacitated patients who are treatedinformally – that is, without being sectioned under the Mental Health Act, because they accepthospitalisation and treatment "compliantly". The European Court has ruled that such patients should betreated formally, which has major implications for services, patients, and carers.