Allen Rebecca S, DeLaine Shermetra R, Chaplin William F, Marson Daniel C, Bourgeois Michelle S, Dijkstra Katinka, Burgio Louis D
Department of Psychology, The University of Alabama, Tuscaloosa 35487, USA.
Gerontologist. 2003 Jun;43(3):309-17. doi: 10.1093/geront/43.3.309.
The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity.
The authors used cross-sectional, cohort study between 1997 and 1999. Seventy-eight residents (M age = 83.97, SD = 8.2) and their proxies (M age = 59.23, SD = 11.77) were included across five nursing homes. The authors obtained data via chart review, proxy interviews, resident assessments, survey completion by certified nursing assistants, and direct observation of residents' daily behaviors.
Capacity assessments revealed that most residents could state a simple treatment preference (82.4%), but a sizable number did not retain capacity to understand treatment alternatives or appreciate the consequences of their choice. Global cognitive ability (Mini-Mental State Examination score) was related to understanding and appreciation. When the authors removed the effects of global cognitive ability, understanding and appreciation were related to time spent by residents in verbal interaction with others. Residents were more likely to possess advance directives when proxies possessed advance directives, proxies were less religious, and residents were socially engaged.
Assessment of proxy beliefs and direct determination of residents' decisional capacity and social engagement may help nursing home staff identify families who may participate in advance planning for end-of-life medical care. Measures of global cognitive ability offer limited information about resident capacity for decision making. Decisional capacity assessments should enhance the verbal ability of individuals with dementia by reducing reliance on memory in the assessment process. Interventions to engage residents and families in structured discussions for end-of-life planning are needed.
确定能够继续参与临终护理预立医疗计划的养老院居民是一个关键的临床和生物伦理问题。本研究采用高质量的观察性研究来确定养老院中预立医疗计划的相关因素，包括对能力的客观测量。
作者在1997年至1999年期间进行了横断面队列研究。纳入了五家养老院的78名居民（平均年龄=83.97岁，标准差=8.2）及其代理人（平均年龄=59.23岁，标准差=11.77）。作者通过病历审查、代理人访谈、居民评估、注册护理助理完成的调查以及对居民日常行为的直接观察来获取数据。
能力评估显示，大多数居民能够说出简单的治疗偏好（82.4%），但相当一部分居民没有理解治疗选择或认识到其选择后果的能力。整体认知能力（简易精神状态检查表得分）与理解和认识有关。当作者消除整体认知能力的影响后，理解和认识与居民与他人进行言语互动所花费的时间有关。当代理人有预立医疗指示、代理人宗教信仰较弱且居民参与社交活动时，居民更有可能拥有预立医疗指示。
评估代理人的信念以及直接确定居民的决策能力和社交参与度可能有助于养老院工作人员识别那些可能参与临终医疗护理预立计划的家庭。整体认知能力的测量提供的关于居民决策能力的信息有限。决策能力评估应通过减少评估过程中对记忆的依赖来提高痴呆症患者的言语能力。需要采取干预措施，让居民和家庭参与关于临终计划的结构化讨论。
