BMJ 1999;318:493-497 ( 20 February )

Papers

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

Seena Fazel, Wellcome research registrar,  Tony Hope, reader in medicine,  Robin Jacoby, professor. 

Section of Old Age Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX

Correspondence to: Dr Fazel seena.fazel{at}psychiatry.ox.ac.uk

Objective: To develop a patient centred approach for the assessment of competence to complete advance directives ("living wills") of elderly people with cognitive impairment.
Design: Semistructured interviews.
Setting: Oxfordshire.
Subjects: 50 elderly volunteers living in the community, and 50 patients with dementia on first referral from primary care.
Main outcome measures: Psychometric properties of competence assessment.
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.


Key messages

  • Advance directives could potentially be useful for patients with dementia as a means of extending their autonomy when they become incompetent

  • Competence to complete an advance directive involves understanding possible future clinical situations

  • Vignettes presenting hypothetical medical problems were tested in 100 elderly people, and were found to validly and reliably discriminate between volunteers living in the community and patients with dementia

  • We suggest that two clinical vignettes, each followed by a semistructured interview comprising 10 points, can aid in the assessment of competence to complete advance directives




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Rapid Responses:

Read all Rapid Responses

Showing competence in the cognitively impaired
Trevor Thompson
bmj.com, 27 Feb 1999 [Full text]
Competence to complete advance directives
Adrian Treloar
bmj.com, 5 Mar 1999 [Full text]
The test may have face validity only!
S Teunisse
bmj.com, 23 Mar 1999 [Full text]
Authors' reply: Competence to complete advance directives
Seena Fazel
bmj.com, 9 Apr 1999 [Full text]
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