van den Bosch Arne, Marijnissen Radboud M, Hanssen Denise J C, Oude Voshaar Richard C
Department of Psychiatry (CC74), University Medical Center Groningen, Groningen, The Netherlands.
J Am Geriatr Soc. 2025 Jan;73(1):112-122. doi: 10.1111/jgs.19218. Epub 2024 Oct 21.
The number of patients with dementia who are granted euthanasia or assisted suicide (EAS) increases yearly in the Netherlands. By law, patients need to be decisionally competent or have an advance directive. Assessment of decisional capacity is challenging as dementia progressively affects cognitive performance. We aimed to assess qualitatively which factors, and how, influence the judgment of decisional capacity in EAS cases with dementia.
We performed a qualitative study of 60 dementia EAS case summaries published by the Dutch regional euthanasia review committees between 2012 and 2021. Included reports were evaluated using the grounded theory approach. All quotes related to decisional capacity were coded independently by two researchers and compared in an iterative process to formulate an overarching framework on the assessment of decisional capacity. We selected 20 patients who had an advance directive and were judged to be decisionally compromised, as well as a selection of 40 EAS cases judged to be decisionally competent, half of which also had an advance directive (purposive sampling).
Decisional capacity was present in every case report. Predefined, external criteria were rarely described explicitly, but physicians indirectly referred to the (cognitive) criteria set by Appelbaum and Grisso. Whether the thresholds for these dimensional criteria were met was influenced by six supporting factors (level of communication, psychiatric comorbidity, personality, presence of an advance directive, consistency of the request, and, finally, the patient-physician relationship) that also directly contributed to the judgment of capacity. The involved physicians and executed investigations were the two contextual factors providing a background.
Decisional capacity regarding euthanasia is a multidimensional construct, often implicitly assessed and influenced by supporting and contextual factors. The subjectivity of the final judgment poses ethical and legal issues and argues for continuous quality improvement processes.
在荷兰，获准实施安乐死或协助自杀（EAS）的痴呆症患者数量逐年增加。根据法律规定，患者必须具备决策能力或有预先指示。由于痴呆症会逐渐影响认知能力，因此评估决策能力具有挑战性。我们旨在定性评估哪些因素以及如何影响痴呆症患者EAS案例中的决策能力判断。
我们对荷兰地区安乐死审查委员会在2012年至2021年期间发布的60例痴呆症EAS案例摘要进行了定性研究。纳入的报告采用扎根理论方法进行评估。所有与决策能力相关的引述均由两名研究人员独立编码，并在迭代过程中进行比较，以制定关于决策能力评估的总体框架。我们选择了20名有预先指示且被判定决策能力受损的患者，以及40例被判定具有决策能力的EAS案例，其中一半患者也有预先指示（目的抽样）。
每份案例报告中均存在决策能力。预先定义的外部标准很少被明确描述，但医生间接提及了阿佩尔鲍姆和格里索设定的（认知）标准。这些维度标准的阈值是否得到满足受到六个支持因素（沟通水平、精神疾病共病、性格、预先指示的存在、请求的一致性，以及最后患者与医生的关系）的影响，这些因素也直接影响了能力判断。参与的医生和所进行的调查是提供背景的两个背景因素。
安乐死的决策能力是一个多维概念，通常是隐性评估，并受到支持因素和背景因素的影响。最终判断的主观性带来了伦理和法律问题，并主张持续改进质量。
