ASSESSING THE COMPETENCE OF PATIENTS WITH ALZHEIMERS-DISEASE UNDER DIFFERENT LEGAL STANDARDS - A PROTOTYPE INSTRUMENT
ASSESSING THE COMPETENCE OF PATIENTS WITH ALZHEIMERS-DISEASE UNDER DIFFERENT LEGAL STANDARDS - A PROTOTYPE INSTRUMENT
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DOI：
10.1001/archneur.1995.00540340029010
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发表时间：
1995-10-01
影响因子：
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通讯作者：
HARRELL, LE
中科院分区：
文献类型：
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作者：
MARSON, DC;INGRAM, KK;HARRELL, LE
目的：对不同法律标准下阿尔茨海默病（AD）患者的同意治疗能力进行实证评价。设计：比较正常老年受试者和AD患者对医疗同意能力的测量。地点：大学医疗中心。研究对象：正常老年对照（n = 15）和疑似AD患者（n = 29[轻度AD 15例，中度AD 14例]）。主要结果测量：开发了两个专门的临床小测试，测试受试者在五种既定的基本原则下同意接受治疗的能力：基本原则1，证明治疗选择；LS2，做出合理的选择；LS3，欣赏选择的结果；LS4，提供合理的选择理由；LS5，了解治疗情况和选择。使用Student's t检验、chi(2)和方差分析比较对照组和AD组在LSs上的表现。通过使用正常对照表现得出的截止分数，痴呆受试者在每个LS下被分为胜任、勉强胜任或不胜任。结果：LS1和LS2组间无差异。对照组在LS4和LS5上的表现明显好于轻度AD患者，在LS3、LS4和LS5上的表现明显好于中度AD患者。轻度AD患者在LS4和LS5上的表现明显好于中度AD患者。在能力状态方面，AD患者表现出与痴呆严重程度和LS严格程度相关的一致和渐进的妥协模式（边际能力或无能）。结论：一种可靠的原型工具能够有效地区分对照者和轻、中度AD患者在五种LSs下的同意治疗能力表现，并对其能力状态进行分类。虽然两组在仅要求一种治疗选择（LS1）或合理治疗选择（LS2）的最低标准上表现相同，但轻度AD患者在要求合理原因（LS4）和理解治疗信息（LS5）的更困难的标准上存在困难，中度AD患者在理解后果（LS3）、合理原因（LS4）和理解治疗（LS5）方面存在困难。研究结果引起了人们的关注，即许多轻度阿尔茨海默病患者可能没有能力同意治疗，并支持了标准化临床小插曲对痴呆症能力评估的价值。
Objective: To assess empirically the competency of patients with Alzheimer's disease (AD) to consent to medical treatment under different legal standards (LSs).Design: Comparison of normal older subjects and patients with AD on measures of competency to consent to medical treatment.Setting: University medical center.Subjects: Normal older control subjects (n = 15) and patients with probable AD (n = 29 [15 with mild and 14 with moderate AD]).Main Outcome Measures: Two specialized clinical vignettes were developed that test a subject's capacity to consent to medical treatment under five well-established LSs for this competency: LS1, evidencing treatment choice; LS2, making the reasonable choice; LS3, appreciating consequences of choice; LS4, providing rational reasons for choice; and LS5, understanding treatment situation and choices. Performance on the LSs was compared across control and AD groups using Student's t test, chi(2), and analysis of variance. Demented subjects were categorized as competent, marginally competent, or incompetent under each LS by using a cutoff score derived from normal control performance. Results: No differences between groups emerged for LS1 and LS2. Control subjects performed significantly better than patients with mild AD on LS4 and LS5, and significantly better than patients with moderate AD on LS3, LS4, and LS5. Patients with mild AD performed significantly better than patients with moderate AD on LS4 and LS5. With respect to competency status, patients with AD showed a consistent and progressive pattern of compromise (marginal competence or incompetence) related to dementia severity and stringency of the LS.Conclusions: A reliable prototype instrument validly discriminated the competency performance and classified the competency status of control subjects and patients with mild and moderate AD under five LSs for competency to consent to medical treatment. While the groups performed equivalently on minimal standards requiring merely a treatment choice (LS1) or the reasonable treatment choice (LS2), patients with mild AD had difficulty with more difficult standards requiring rational reasons (LS4) and understanding treatment information (LS5), and patients with moderate AD had difficulty with appreciation of consequences (LS3), rational reasons (LS4), and understanding treatment (LS5). The results raised the concern that many patients with mild AD may not be competent to consent to treatment and supported the value of standardized clinical vignettes for assessment of competency in dementia.