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The rest An MMSE score of under 24 is consistent with moderate to severe impairment, and was recorded in In order to evaluate the stress factors, we selected 6 of the items of the original scale. Five of them were chosen due to their relationship with the information process, while the sixth offered a global view of the level of stress.

The mean general stress score was 2. The descriptive analysis of the variables anxiety and depression showed Evaluation of the level of anxiety and depression in critical patients. The results are expressed as percentages.. In the descriptive analysis of the results obtained with the CITD, we grouped the items of the latter into 6 categories—each identifying the role which the patient considered should be played by those implicated in the information process and in decision taking.. Regarding the role assigned by the patients to their relatives, the mean total items score was 2.

Regarding the role which the patients consider they should play in the information process and in decision taking, the mean total items score was 2. The mean total items score referred to the role assigned by the critical patient to the physician was 3. On examining whether the last word in deciding corresponds to the physician, the mean score was found to be 2. It should be noted that On the other hand, the mean score referred to the role assigned by the critical patient to the psychologist was 2. According to A total of Table 1 shows the results of the analysis of the influence of the sociodemographic variables upon the cognitive, emotional, and subjective variables referred to the decision taking process.

Questionnaire for subjective evaluation of the information process and decision taking in the hospital setting.. In order to analyze these differences between groups of individuals with high and low cognitive capacity, referred to subjective variables associated with the decision taking process CITD , two groups of patients were established according to the MMSE score obtained. On examining the observation of patient competence in clinical practice, we find that there are no guidelines—though a number of practical principles have been established, such as definition of the source of authority, the securing of effective communication, the prompt availability of reliable information referred to the patient wishes, and respect for the patient rights.

Considering that competence refers to how a capacity is applied to a given situation, and that this is more closely related to skill than to any stable cognitive characteristic, 21 we have evaluated both the cognitive capacity of the patients and their skills in evaluating the surroundings or environment, and the roles which in their opinion are played by those implicated in the process.. The results of the CITD questionnaire indicate that the critical patient is in clear agreement with the idea that the family should receive full information on the patient condition, treatment, and prognosis.

However, patients show only limited agreement with the idea that the family should have the last word or should be in charge of informing the patient of bad news. In some cases both the relatives and the clinicians underestimate the wishes of the patient, and this conclusion, drawn from the study published by Ciroldi et al.

Almost two-thirds of the participants fully agreed with the idea that they should be notified in advance if death is expected to occur. A study conducted in the primary care setting, using questionnaires similar to those contemplated by the CITD, has yielded similar results. With regard to the role which patients assign to the physician, three-quarters fully agree that it is preferable for bad news to be conveyed by the physician.

Patients continue to attribute physicians with an important role in the communication process and in decision taking. The results of our study suggest that the relationship based on confidence that has always existed between patients and their physicians should be reinforced, and that this decision does not mean that the patient wishes and beliefs are no longer respected; rather, emphasis is placed on communication, mutual respect, and sincerity.

According to the CITD findings, over one-half of the participants are quite or fully agreed with the availability of psychologist support in decision taking. Clinical psychologists are increasingly needed particularly in the ICU, due to the extreme situations facing patients, their relatives, and even the healthcare professionals. The studies published by Jorm et al. These studies differ from our own in terms of the type of patients involved, though our results nevertheless coincide.

In effect, we observed a negative correlation between age and the MMSE score, and a positive correlation between educational level and the MMSE score—a higher educational level being associated with improved cognitive capacity. The results obtained referred to the relationship among the emotional variables, the MMSE score, and the subjective variables related to decision taking point to an association between increased anxiety and depression and lessened cognitive capacity.

Preventing and minimizing the causes of stress and providing the patient with comfortable conditions are effective measures for favoring a stable emotional state, which in turn facilitates decision taking. Although the anxiety and depression levels in our series were not very high, the literature reports that critical patients can suffer a range of psychological problems. In this context, anxiety, stress, and despair are cited as the main affective disorders—the expressed main need being the sensation of safety. In the CoBaTrICE study, 33 the patients considered it more important than their relatives to participate in decision taking and to be informed in detail, while for the relatives giving bad news with gentleness, and individualized treatment, were taken to be more important than for the patients.

Aspects considered to be improvable and related to previous experiences were especially the continuity of care by the same physician, and intercommunication among physicians.. Lastly, the professionals who attend critical cases have become accustomed to dealing with sedated and unconscious patients, with relatives who are scared and overwhelmed by incomprehensible situations that destabilize their lives, and in which decisions must be made quickly, since the life of the patient depends on them. To speak of humanization is easy, though putting it into practice is a challenge.

By using the available instruments we must accept the possibility of scientific, technical and ethical error. Our results indicate that the critical patient wishes to take part in the decision taking process, wants to be informed by the physician of any bad news, and wishes to have the last word regarding his or her disease process.. Our conclusions allow the following recommendations referred to clinical practice: 1. Evaluate the decision taking process, not the result.. Evaluate whether the patient understands all the relevant aspects of the decision and issues voluntary and informed consent..

Improve our communication skills, respect the patient decisions, and implicate the relatives in patient care.. Avoid making decisions in situations of crisis..

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Plan sessions on ethical discussions, identify the roles of those involved, develop coping strategies, and review the criteria used to resolve each situation.. Improve the environment within the ICU, minimizing stressors and creating a comfortable setting for the patient.. The authors declare no conflicts of interest.. Please cite this article as: Bernat-Adell MD, et al. Med Intensiva. ISSN: Previous article Next article.

Issue 6. Pages August - September More article options. Is the critical patient competent for decision taking? Psychological and psychopathological reasons of cognitive impairment.

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Download PDF. Bernat-Adell a ,?? Corresponding author. This item has received. Article information. Table 1. Table 2. Table 3. Show more Show less. Background Emotional factors may lead to cognitive impairment that can adversely affect the capacity of patients to reason, and thereby, limit their participation in decision taking. Purposes To analyze critical patient aptitude for decision taking, and to identify variables that may influence competence. Design An observational descriptive study was carried out. Patients Participants were 29 critically ill patients.

Main variables Social, demographic and psychological variables were analyzed.

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Functional capacities and psychological reactions during stay in the ICU were assessed. Results The patients are of the firm opinion that they should have the last word in the taking of decisions; they prefer bad news to be given by the physician; and feel that the presence of a psychologist would make the process easier. The anxiety and depression variables are significantly related to decision taking capacity. Critically ill patients. Palabras clave:. Introduction As admitted by Drane, 1,2 from the start the doctrine of consent has posed a series of dilemmas, since in order for a consent document not to become a mere defensive instrument, it is necessary for the patient to be competent, act autonomously, without coercion, and with sufficient cognitive capacity to be able to evaluate the illness and the benefits or consequences of treatment.

When the patient shows a sudden change in mental state. When the patient rejects a treatment that is clearly indicated, without offering a clear argument or reasons, or basing the reasons on irrational assumptions or ideas. When the patient freely accepts bothersome procedures without weighing the risks and benefits. When the patient suffers some background neurological or psychiatric disorder that may give rise to transient incapacitation.

Furthermore, the assessment of competence is particularly relevant in such patients, because decision taking in these cases is typically done in very stressful situations. The work dynamics, the patient condition, the quickness of response demanded of the professionals, and the difficulties in minimizing noise and illumination all cause the ICU to be a stressing environment.

As pointed out by Drane, 8 competence can be dependent upon the physical and mental situation, and on the environment, and as such may change over time. Instruments The following instruments were used for evaluative purposes: - Biological parameters. The CITD comprises 26 items, scored from 1 fully disagree to 4 fully agree. Procedure The interviews were carried out on a personalized basis, in a closed room in order to preserve patient privacy and confidentiality. Informed consent was previously obtained from the participants.

Data analysis The statistical analysis was divided into two phases. Lastly, the patients were divided according to cognitive capacity, and the Student t -test was applied to the CITD scores. Results The descriptive analysis of the biological parameters revealed mean values above those considered normal, and outside the ranges established as reference. The results are expressed as percentages. Figure 1. Minimental test. Hospital anxiety and depression scale.

Questionnaire for subjective evaluation of the information process and decision taking in the hospital setting. Hastings Cent Rep, , pp. Making health care decisions: the ethical and legal implications of informed consent in the patient—practitioner relationship. US Government Printing Office, ,. Rodriguez, A. Martinez, R. La capacidad de los pacientes para tomar decisiones. Med Clin, , pp. Stewart, J. Brown, W. Weston, I. McWhinney, C. McWilliam, T. Patient-centered medicine: transforming the clinical method. Sage Publications, ,. Saralegui, R. Abizanda, L.

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Iribarren, M. Med Intensiva, 32 , pp. Solsona, M. Med Intensiva, 29 , pp. Roca, J. Colmenero, H. Med Intensiva, 31 , pp. JAMA, , pp. Criteria for assessment of patient competence: a conceptual analysis from the legal, psychological and ethical perspectives. Fidlar Doubleday Inc. Parker, B. Decision-making competence: external validation through an individual-differences approach.

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