Assessment of competence to complete advance directives: validation of a patient centred approach

Abstract

Results This patient centred approach for assessing competence to complete advance directives can discriminate between elderly persons living in the community and elderly patients with dementia. The procedure has good interrater (r = 0.95) and test-retest (r = 0.97) reliability. Validity was examined by relating this approach with a global assessment of competence to complete an advance directive made by two of us (both specialising in old age psychiatry). The data were also used to determine the best threshold score for discriminating between those competent and those incompetent to complete an advance directive. Conclusion A patient centred approach to assess competence to complete advance directives can be reliably and validly used in routine clinical practice.

Appréciation de la capacité de discernement des patients: procédure d'aide à l'usage des médecins

“…La littérature est relativement pauvre sur le sujet et centrée sur deux aspects: le consentement du patient au traitement [7] et la rédaction de directives anticipées [3,4]. Même si ces deux sujets sont relativement différents, ils présentent une importante similitude, la capacité du patient de se positionner face à une situation dans laquelle une décision peut avoir des conséquences importantes et même engager son avenir.…”

“…Le discernement est défini par l'article 16 du Code Civil [2] comme suit: «Toute personne qui n'est pas dépourvue de la faculté d'agir raisonnablement à cause de son jeune âge, ou qui n'en est pas privée par suite de maladie mentale, de faiblesse d'esprit, d'ivresse ou d'autres causes semblables, est capable de discernement dans le sens de la présente loi.» Le discernement comprend deux aspects principaux [3]: -Prise de conscience: le patient doit pouvoir comprendre l'information fournie, manipuler cette information rationnellement, et se rendre compte des conséquences de ses actes. -Manifestation de sa volonté: le patient doit pouvoir communiquer ses choix et résister de manière adéquate à la pression exercée par autrui sur lui-même.…”

Diretivas antecipadas de vontade: benefícios, obstáculos e limites

“…Assim, diante de tais possibilidades as diretivas antecipadas são consideradas um meio proeminente de estender a autonomia do paciente em situações em que se encontra impossibilitado de exercê-la 30 . Niebrój 31 argumenta que durante os 40 anos da história da bioética como disciplina de conhecimento com especificidade própria as discussões sobre o princípio da autonomia têm evoluído.…”

“…Um premente problema ético no uso da DAV é que pessoas competentes podem nem sempre estar aptas para tomar decisões a respeito de seu futuro quando inopinadamente se deparam com o "seu eu incapacitado" 30 ; em consequência, existe a preocupação com a autenticidade e estabilidade da decisão, visto que na elaboração do documento o paciente se baseia em uma reconstrução imaginária de como seria sua vida em determinada condição nunca antes experimentada. Essa reconstrução é altamente problemática pela dificuldade de prever fatos futuros.…”

‘Not in perfect mind’ – the complexity of clinical capacity assessment

“…There are a number in the literature, including semistructured interviews largely based on the Lord Chancellor's criteria (Draper & Dawson, 1990) recognition tests -subjects are asked questions about a short essay on treatment rights (Hopkins Competency Assessment Test; Janofsky et al, 1992) and questions based on patient-centred clinical vignettes (Fazel et al, 1999). It should be borne in mind that verbal disabilities have been found to correlate with lack of capacity in both schizophrenia (Rosenfeld et al, 1992) and Alzheimer's disease (Marson et al, 1995), and so recognition rather than recall of information may be preferable in capacity assessment.…”