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Decision-making capacity of elderly patients assessed through the vignette method: imagination or reality?
- Authors:
- VELLINGA A., et al
- Journal article citation:
- Aging and Mental Health, 9(1), January 2005, pp.40-48.
- Publisher:
- Taylor and Francis
This article evaluates whether providing hypothetical or realistic information influences the assessment of decision-making capacity in elderly patients with (and without) cognitive impairment. Decision-making capacity was assessed by means of a clinical vignette that presented a choice about whether to undergo an endoscopic procedure. The following standards of decision-making capacity were evaluated quantitatively and qualitatively: ability to evidence a choice, to understand, to reason, and to appreciate a situation. The vignette was presented to patients in either a hypothetical or real situation. In the hypothetical situation cognitively impaired patients performed significantly poorer than cognitively non-impaired patients on all abilities associated with decision-making capacity (with the exception of evidencing a choice). The realistic situation showed the same pattern among cognitively impaired and non-impaired patients in their ability to understand and in the total vignette score. Both types of patients reasoned about and appreciated the realistic situation equally well. Qualitative analysis revealed that patients gave comparable answers in both hypothetical and realistic situations. The answers were not related to standards of decision-making capacity. Moreover, personal circumstances were taken as a reference point for making a decision, regardless of the situation. We did not find any major differences between the hypothetical and realistic situation. Our findings do raise questions about the validity of hypothetical vignettes, however, especially when used with cognitively impaired persons.
Competence to consent to treatment of geriatric patients: judgements of physicians, family members and the vignette method
- Authors:
- VELLINGA A., et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 19(7), July 2004, pp.645-654.
- Publisher:
- Wiley
In absence of a gold standard of methods to assess competence, three judgements of competency of geriatric patients are evaluated: the judgements of a physician, the judgement of a family member, and the judgement of an instrument. Competence of 80 geriatric patients was judged both by a physician and a family member. Decision making capacity was assessed with a vignette. A vignette describes a treatment choice, after which the following abilities are evaluated: evidencing a choice, understanding, reasoning and appreciating a situation. Cognitive functioning was measured with the Mini-Mental State Examination. Most of the geriatric patients were judged competent by all three methods. Disagreement between the three judgements was found for 25 patients. Agreement about incompetence was only reached for one patient. Physicians appeared to be most lenient in their incompetency judgement: only three patients were judged incompetent. These patients scored significantly lower than competent patients on cognitive functioning, the decisional ability of understanding, and the total vignette score. Family members appeared to be most stringent in their judgement: they considered 22 patients incompetent. Incompetent patients scored significantly lower than competent patients on cognitive functioning, reasoning and the total vignette score. The disagreement between the judgements suggests a difference in factors given emphasis by the three methods. The finding that both the judgement of physicians and family members are associated with the assessment of the vignette, suggests that the vignette method has more than a legal theoretical base and is associated with daily life experience and knowledge as well. Physicians can be helped to assess competence by the vignette method to evaluate decisional abilities and by family members who can provide more information about patients' values.