Does This Patient Have Medical Decision-Making Capacity?
Does This Patient Have Medical Decision-Making Capacity?
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DOI：
10.1001/jama.2011.1023
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发表时间：
2011-07-27
影响因子：
120.7
通讯作者：
Jackson, Jeffrey L.
中科院分区：
文献类型：
--
作者：
Sessums, Laura L.;Zembrzuska, Hanna;Jackson, Jeffrey L.
对病人作出医疗决定的能力的评估应在考虑到丧失能力的具体医疗决定的情况下进行。目的了解成人医学中无严重精神疾病患者丧失工作能力的发生率及评估的准确性。数据来源MEDLINE和EMBASE（从它们成立到2011年4月）和检索文章的参考书目。研究选择我们纳入了高质量的前瞻性研究（n=43），这些研究采用了评估治疗决策的医疗决策能力的工具。两位作者独立评估研究质量，提取相关数据，并通过共识解决分歧。与住院患者（26%;95% CI, 18%-35%）相比，健康老年对照者（2.8%;95% CI], 1.7%-3.9%）不常见。临床医生准确地诊断出残疾（阳性似然比[LR+]为7.9;95% CI, 2.7-13），尽管他们仅在42% （95% CI, 30%-53%）的受影响患者中识别出残疾。虽然不是用来评估丧失行为能力的，但迷你精神状态检查（MMSE）得分低于20会增加丧失行为能力的可能性（LR, 6.3; 95% CI, 3.7-11），得分在20至24之间没有影响（LR, 0.87; 95% CI, 0.53-1.2），得分高于24会显著降低丧失行为能力的可能性（LR, 0.14; 95% CI, 0.06-0.34）。与金标准相比，9种工具中只有3种易于执行且具有有用的测试特征：能力辅助评估（ACE） （LR+, 8.5; 95% CI, 3.9-19；负LR [LR-]， 0.21; 95% CI, 0.11-0.41），霍普金斯能力评估测试（LR+, 54; 95% CI, 3.5-846; LR-, 0; 95% CI, 0.0-0.52），以及理解治疗披露（LR+, 6.0; 95% CI, 2.1-17; LR-, 0.16; 95% CI, 0.06-0.41）。ACE在最大的研究中得到了验证；它可以在网上免费获得，并包括一个培训模块。结论工作能力丧失是常见的，但往往不被认识到。MMSE只有在极端情况下才有用。ACE是帮助医生评估医疗决策能力的最佳工具。《美国医学协会杂志》上。2011年;306 (4): 420 - 427
Context Evaluation of the capacity of a patient to make medical decisions should occur in the context of specific medical decisions when incapacity is considered.Objective To determine the prevalence of incapacity and assessment accuracy in adult medicine patients without severe mental illnesses.Data Sources MEDLINE and EMBASE (from their inception through April 2011) and bibliographies of retrieved articles.Study Selection We included high-quality prospective studies (n=43) of instruments that evaluated medical decision-making capacity for treatment decisions.Data Extraction Two authors independently appraised study quality, extracted relevant data, and resolved disagreements by consensus.Data Synthesis Incapacity was uncommon in healthy elderly control participants (2.8%; 95% confidence interval [CI], 1.7%-3.9%) compared with medicine inpatients (26%; 95% CI, 18%-35%). Clinicians accurately diagnosed incapacity (positive likelihood ratio [LR+] of 7.9; 95% CI, 2.7-13), although they recognized it in only 42% (95% CI, 30%-53%) of affected patients. Although not designed to assess incapacity, Mini-Mental State Examination (MMSE) scores less than 20 increased the likelihood of incapacity (LR, 6.3; 95% CI, 3.7-11), scores of 20 to 24 had no effect (LR, 0.87; 95% CI, 0.53-1.2), and scores greater than 24 significantly lowered the likelihood of incapacity (LR, 0.14; 95% CI, 0.06-0.34). Of 9 instruments compared with a gold standard, only 3 are easily performed and have useful test characteristics: the Aid to Capacity Evaluation (ACE) (LR+, 8.5; 95% CI, 3.9-19; negative LR [LR-], 0.21; 95% CI, 0.11-0.41), the Hopkins Competency Assessment Test (LR+, 54; 95% CI, 3.5-846; LR-, 0; 95% CI, 0.0-0.52), and the Understanding Treatment Disclosure (LR+, 6.0; 95% CI, 2.1-17; LR-, 0.16; 95% CI, 0.06-0.41). The ACE was validated in the largest study; it is freely available online and includes a training module.Conclusions Incapacity is common and often not recognized. The MMSE is useful only at extreme scores. The ACE is the best available instrument to assist physicians in making assessments of medical decision-making capacity. JAMA. 2011; 306(4): 420-427