Etchells E, Darzins P, Silberfeld M, Singer P A, McKenny J, Naglie G, Katz M, Guyatt G H, Molloy D W, Strang D
Department of Medicine, The Toronto Hospital, University of Toronto, Toronto, Ont., Canada.
J Gen Intern Med. 1999 Jan;14(1):27-34. doi: 10.1046/j.1525-1497.1999.00277.x.
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.
Cross-sectional study with independent comparison to expert capacity assessments.
Inpatient medical wards at an academic secondary and tertiary referral hospital.
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.
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 receiver-operating characteristic curves were 0.90 for specific capacity assessment by treating clinician and 0.93 for SMMSE score (2p =.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 2.6, 15); probably capable, 0.39 (95% CI 0.18, 0.81); and definitely capable, 0.05 (95% CI 0.01, 0.29). For the SMMSE, a score of 0 to 16 had a likelihood ratio of 15 (95% CI 5.3, 44), a score of 17 to 23 had a likelihood ratio of 0. 68 (95% CI 0.35, 1.2), and a score of 24 to 30 had a likelihood ratio of 0.05 (95% CI 0.01, 0.26).
Specific capacity assessments by the treating clinician and SMMSE scores agree closely with results of expert assessments of capacity. Clinicians can use these practical, flexible, and evaluated measures as the initial step in the assessment of patient capacity to consent to treatment.
比较主治医生进行的特定能力评估、标准化简易精神状态检查（SMMSE）的结果与患者同意治疗能力的专家评估结果。
与专家能力评估进行独立比较的横断面研究。
一所学术性二级和三级转诊医院的住院内科病房。
连续100名面临重大医疗治疗或侵入性医疗程序决策的住院患者。参与者要么拒绝治疗，要么接受治疗，但根据主治医生的判断，其能力不明确。
主治医生（住院医生或学生）使用一种名为“能力评估辅助工具”的决策辅助工具对每位参与者进行特定能力评估。特定能力评估是对参与者理解相关信息以及认识特定治疗决策的合理可预见后果能力的半结构化评估。参与者还接受了由研究护士进行的SMMSE检查。然后，参与者接受了两次独立的能力专家评估。如果两次专家评估意见不一致，则由一个独立的裁决小组在审查两次专家评估的录像后解决分歧。以两次专家评估和裁决小组的结果作为参考标准，我们计算了受试者工作特征曲线下的面积和似然比。主治医生进行的特定能力评估的受试者工作特征曲线下面积为0.90，SMMSE评分的曲线下面积为0.93（P = 0.48）。对于主治医生的特定能力评估，检测无能力的似然比如下：肯定无能力为20（95%置信区间[CI] 3.6，120）；可能无能力为6.1（95% CI 2.6，15）；可能有能力为0.39（95% CI 0.18，0.81）；肯定有能力为0.05（95% CI 0.01，0.29）。对于SMMSE，0至16分的似然比为15（95% CI 5.3，44），17至23分的似然比为0.68（95% CI 0.35，1.2），24至30分的似然比为0.05（95% CI 0.01，0.26）。
主治医生进行的特定能力评估和SMMSE评分与能力专家评估结果密切一致。临床医生可以将这些实用、灵活且经过评估的措施作为评估患者同意治疗能力的第一步。
