For patient and proxy ratings, the EQ-5D had the best combination of measurement properties, although it had a substantial ceiling effect for patient ratings. Proxy QOL ratings did not accurately reflect patients' ratings.

OBJECTIVE:To compare results of a specific capacity assessment administered by the treating clinician, and a Standardized Mini-Mental Status Examination (SMMSE), with the results of expert assessments of patient capacity to consent to treatment. DESIGN:Cross-sectional study with independent comparison to expert capacity assessments. SETTING:Inpatient medical wards at an academic secondary and tertiary referral hospital. PARTICIPANTS:One hundred consecutive inpatients facing a decision about a major medical treatment or an invasive medical procedure. Participants either were refusing treatment, or were accepting treatment but were not clearly capable according to the treating clinician. MEASUREMENTS AND MAIN RESULTS:The treating clinician (medical resident or student) conducted a specific capacity assessment on each participant, using a decisional aid called the Aid to Capacity Evaluation. A specific capacity assessment is a semistructured evaluation of the participant's ability to understand relevant information and appreciate reasonably foreseeable consequences with regard to the specific treatment decision. Participants also received a SMMSE administered by a research nurse. Participants then had two independent expert assessments of capacity. If the two expert assessments disagreed, then an independent adjudication panel resolved the disagreement after reviewing videotapes of both expert assessments. Using the two expert assessments and the adjudication panel as the reference standard, we calculated areas under the receiver-operating characteristic curves and likelihood ratios. The areas under the receiveroperating characteristic curves were 0.90 for specific capacity assessment by treating clinician and 0.93 for SMMSE score (2 p ‫؍‬ .48). For the treating clinician's specific capacity assessment, likelihood ratios for detecting incapacity were as follows: definitely incapable, 20 (95% confidence interval [CI] 3.6, 120); probably incapable, 6.1 (95% CI 2.

Using rigorous methods, health workers can make reproducible and valid assessments of capacity to complete an advance directive. The SMMSE accurately differentiates people who can learn about and ultimately complete advance directives from those who cannot.

The Mini-Mental State Examination (MMSE) is widely used to detect dementia, but the diagnosis of dementia also depends on a decline in the level of daily functioning. Little is known about the relationship between performance on the MMSE and daily living abilities. This relationship was investigated in this study of an elderly population by comparing scores on the MMSE with those on both a direct assessment of everyday tasks and an indirect questionnaire about activities of daily living and physical self-maintenance. Forty-five subjects with varying mental abilities participated in the study. A significant correlation was found between MMSE scores and the measures of functional abilities; but the specificity and sensitivity to the diagnosis of dementia would be increased by assessing functional status, even indirectly, as well as cognitive ability.

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This report demonstrates the discrepancy that can occur between clinical and test evaluations of competence. It presents retrospective examination of 35 assessments of competence performed on 24 subjects by a multidisciplinary competency panel. The findings of the panel are compared with the subjects' results on the Cognitive Competency Test and on the Mini-Mental State Examination. The results show that the multidisciplinary competency panel will more often find subjects competent than indicated by their psychometric test scores. A process approach to the use of tests is recommended. Reliance on tests to decide the outcome of difficult cases does not appear to be warranted.

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