Assessment of patient competence for making decisions

Palacios, G.J.; Pinto, P.; Marquez, O.; Herreros, B.

doi:10.1016/j.rceng.2019.04.013

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Palacios, P. Pinto, O. Marquez, B. Herreros" "autores" => array:4 [ 0 => array:4 [ "nombre" => "G.J." "apellidos" => "Palacios" "email" => array:1 [ 0 => "goyo.palacios1975@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Pinto" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 2 => array:3 [ "nombre" => "O." "apellidos" => "Marquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "B." "apellidos" => "Herreros" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital U. Fundación Hospital Alcorcón, Alcorcón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina Legal, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Investigación en Ciencias Médicas, Universidad Autónoma del Estado de México, Toluca, Estado de México, Mexico" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Instituto de Ética Clínica Francisco Vallés, Universidad Europea de Madrid, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valoración de la competencia de los pacientes para tomar decisiones" ] ] "textoCompleto" => "CaseAndrea, a 79-year-old woman with acute heart failure, previously unknown iron-deficiency anemia and a hemoglobin level of 6.2g/dL, rejected the transfusion of packed red blood cells. At the time, Andrea was not legally incapacitated and had 6children, 3of whom are Jehovah’s Witnesses. According to one of the children, after the death of her husband a year earlier, Andrea became a Jehovah’s Witness. The daughter acted as the main caregiver (and was not a Jehovah’s witness) and doubted that her mother understood the importance of the decision. The daughter mentioned domestic examples such as how, in the past 9months, her mother had begun to show certain cognitive impairment (frequent lapses of memory, difficulty organizing day-to-day activities, etc.). In the interview, the patient was oriented to person and space but disoriented to time. After telling the patient about the possible consequences of the decision (worsening of symptoms, which could lead to death), she was once again asked about her decision, to which she responded that she “does not want a transfusion” and that “she doesn’t care if she dies”. She was unable to offer reasons (even religious ones) to support this decision. The physicians were uncertain as to whether to respect the patient’s decision.BackgroundThe concepts of freedom and autonomy are based on the respect for individual privacy and have been established as basic rights (individual or subjective) since the 18th century,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> although they have permeated the clinical environment in the 20th century. Respect for autonomy is one of the foundations of the clinical relationship and is put into practice through informed consent, regulated in Spain by Law 41/2002, which governs patient autonomy.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Before accepting a patient’s decision, the patient should be assessed to determine if they are competent to make decisions. If the patient is competent, they can decide with autonomy.Various studies have shown how medical teams detect only a third of cases of incompetence and how competence assessments,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> even when performed, are not usually appropriate.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The aim of this article is to offer guidelines for assessing the competence of patients for whom there are doubts about whether they are able to make decisions concerning their health.Concept of ability and competenceThe terms ability and competence are encompassed by a broader concept: the patient’s autonomy for making decisions. Before analyzing how competence is evaluated, it is worth clarifying the concept of autonomy, ability and competence.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Etymologically, autonomy is the ability to govern oneself, i.e., to self-manage. In medicine, an individual is considered autonomous when they are able to make decisions concerning their health. Autonomy is put into practice through an informed consent: the patient receives information and freely decides. There are a few requirements for a decision to be autonomous<a class="elsevierStyleCrossRef" href="#bib0025">5</a>: 1) the patient must receive appropriate information about the procedure and understand the information<a class="elsevierStyleCrossRefs" href="#bib0010">2,4–9</a>; 2) the patient must be free to choose, which requires the absence of external imposition or coercion; and 3) the patient must be able to volunteer,<a class="elsevierStyleCrossRefs" href="#bib0010">2,10</a> which requires competence or the natural ability to decide, i.e., the intellectual ability to make decisions.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> For a decision to be autonomous (and to grant informed consent), there must be information, understanding, freedom and willingness, with competence a prerequisite for autonomy.</li><li class="elsevierStyleListItem" id="lsti0010">•The legal capacity<a class="elsevierStyleCrossRef" href="#bib0060">12</a> is the legal condition that allows an individual to hold rights and responsibilities. Legal capacity is innate, attributed without restriction to all individuals from birth and equal for everyone, because, in essence, it contains all rights they are entitled to.</li><li class="elsevierStyleListItem" id="lsti0015">•The capacity to exercise one’s rights<a class="elsevierStyleCrossRefs" href="#bib0045">9,12–14</a> is a legal concept and consists of the ability to assert one’s rights and assume responsibilities without authorization by another entity. In Spain, this capacity is generally acquired at 18 years of age, although in the healthcare setting, it is acquired at the age of 16 years. To acquire the capacity to exercise one’s rights, 2aspects must be met: age and maturity (cognitive and volitional skills that enable self-government). The legal capacity allows for degrees (newborns have none, minors have limited legal capacity and adults enjoy the full legal capacity) and changes, given that individuals of legal age can be denied full legal capacity by a court decision (legal incapacitation) (e.g., when faced with advanced dementia). The incapacitation can be total or partial for certain areas (legal-administrative management, medical aspects, right to vote, etc.), with the judge deciding, based on clinical and legal reports, the incapacitation that should be applied and the system of guardianship. The legal guardian will be responsible for making decisions that pertain to the setting of incapacitation.</li><li class="elsevierStyleListItem" id="lsti0020">•The de facto capacity, natural capacity or competence is a clinical concept and refers to the patient’s aptitude for exercising their autonomy and their ability to make decisions.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> It is not a generic concept: competence is linked to the specific decision to be made and refers to the process of understanding the information, appreciating the consequences of the options and assuming the decision. If the patient is competent, they can make, express and defend a decision that is consistent with their set of values.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> In clinical practice, the term “capacity” is often used to refer to competence (to the de facto capacity) or “incapacity” to refer to a lack of competence. An individual can have legal capacity (e.g., a 50-year-old man with alcoholism who has not been incapacitated) but lack competence for making a specific decision (continuing the example, if the man has pneumonia and wants to leave the hospital fully delirious). Legally, the individual is not incapacitated, but at that moment they cannot make that decision.</li></ul>Various formulas and terms have been employed in the literature to describe these concepts: the United Kingdom uses the term “competency” while the United States uses the term “capacity”. However, an indistinct use of both terms has also been observed in clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0020">4,17</a>Assessment of competence: general principlesIn medicine, knowing how to assess competence is essential. If the patient is competent and meets the other requirements for autonomy, the physician must respect the patient’s decision (unless there is a legal exception: injury to a third party, threat to public health, jailed patients with a life-threatening emergency, etc.)<a class="elsevierStyleCrossRef" href="#bib0090">18</a>; if the patient is not competent, consent is not possible. In this assessment, we need to consider the following general principles<a class="elsevierStyleCrossRef" href="#bib0095">19</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">1Who assesses the competence? Although all clinicians should be able to assess competence, the physician responsible for the patient has the obligation to perform the assessment,<a class="elsevierStyleCrossRefs" href="#bib0010">2,9</a> because they know the patient the best. The presence of a medical specialist, typically a psychiatrist (although they can also be a medical examiner or neurologist) is only necessary in cases of special complexity (e.g., when faced with certain mental or neurological diseases).<a class="elsevierStyleCrossRef" href="#bib0020">4</a></li><li class="elsevierStyleListItem" id="lsti0030">2Competency is evaluated by considering the patient’s cognitive abilities at that moment. The aspects to assess are the degree of attention, memory, speech (reasoning) and capacity for introspection or judgment,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> because they are the basis for understanding the information and for reasoning and expressing the decision.</li><li class="elsevierStyleListItem" id="lsti0035">3An individual is not competent in general but rather is competent for a specific task or health decision<a class="elsevierStyleCrossRef" href="#bib0105">21</a>; therefore, competence is bound to the type of decision (severity, type of procedure, risks and consequences of the decision, etc.).<a class="elsevierStyleCrossRef" href="#bib0050">10</a> As proposed by Drane<a class="elsevierStyleCrossRef" href="#bib0110">22</a> with their Sliding Scale (Escala Móvil), the same degree of competence is not required for all decisions, and the larger the risk, the greater the degree of competence demanded.<a class="elsevierStyleCrossRefs" href="#bib0040">8,14,17</a> Buchanan suggested that the necessary competence for accepting (consenting to) a procedure does not have to be the same as that for rejecting the procedure, given that the risks of one option or the other can differ<a class="elsevierStyleCrossRef" href="#bib0030">6</a> (e.g., hemodialysis in the setting of end-stage renal failure).</li><li class="elsevierStyleListItem" id="lsti0040">4Competence is not stable over time and can vary depending on the patient’s clinical condition.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> The assessment process should be continuous, especially when faced with fluctuating and temporary disorders. Competence should be re-evaluated for each specific decision because, in some cases, competence can be recovered.</li><li class="elsevierStyleListItem" id="lsti0045">5There should be a “presumption of capacity”. A patient should only be considered to lack competence when their competence has been evaluated.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Although competence impairment is more frequent in certain disorders (neurological or psychiatric), there should be no prejudice regarding competence in these types of patients.</li></ul>Procedure for assessing competenceIn cases in which reduced competence is suspected, a structured competence assessment should be conducted. When applying this procedure, 2questions need to answered: Is the patient competent for making the decision in play? If competence is reduced, what degree of competence does the patient still maintain and, therefore, what type of decisions can they make?Step one: recognize the situations that require a competence assessmentIn 1998, Grey and Appelbaum described the types of patients who should be suspected of reduced competence and, therefore, those who need a competence assessment (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0045">9,23</a> The authors presented 2types of patients: those who make irrational decisions and those who present clinical signs that suggest cognitive impairment.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Second step: full assessment of competenceAfter identifying the patient who requires a competence assessment, the patient should be informed that this assessment will be performed. Whenever possible, the patient’s consent should be obtained.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The assessment can be performed 2ways<a class="elsevierStyleCrossRef" href="#bib0120">24</a>: systematic clinical assessment or structured clinical interview (using a formal tool, typically a test).<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Any of these methods is reliable and comparable to an expert’s judgment,<a class="elsevierStyleCrossRef" href="#bib0125">25</a> because they help assess the essential criteria of competence: understanding information, appreciating the consequences, having the ability to reason, having the capacity to choose an option and being able to communicate the selection.<a class="elsevierStyleCrossRefs" href="#bib0115">23,26,27</a> The systematic clinical assessment evaluates these criteria and intellectual skills through a series of questions (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#bib0140">28</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The structured clinical interview analyzes the competence criteria using a score, providing a more comprehensive assessment. Specific training is typically required to properly perform the assessment and interpret and extrapolate the results. These tools, typically tests, do not automatically establish whether a patient is competent, because the results should be framed with the overall assessment conducted by the physician. Although there are a considerable number of tests, the most widely employed and for which there is the most evidence<a class="elsevierStyleCrossRefs" href="#bib0040">8,14</a> is the MacArthur Competence Assessment Tool for Treatment (MacCAT-T),<a class="elsevierStyleCrossRef" href="#bib0145">29</a> validated for medical care (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) and research. The tool has a Spanish-validated version<a class="elsevierStyleCrossRef" href="#bib0150">30</a> and has considerable usefulness for nonpsychiatric physicians, because it is simple to perform and interpret. Although MacCAT-T provides guidelines on how it should implemented, it is worth undergoing prior training,<a class="elsevierStyleCrossRefs" href="#bib0020">4,5,8</a> and the approximate assessment time is 15–20min.<a class="elsevierStyleCrossRef" href="#bib0025">5</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>There is no exact range of scores that indicate whether a patient is competent. Patients should be assessed individually, taking into account generically that a medium score in the 4areas would indicate that the patient has sufficient skills for making decisions, while a low test score would mean the patient is not sufficiently competent to consent (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Third step: correlate the degree of competence with the complexity of the decisionOnce the patient’s competence has been assessed with one of the abovementioned methods, the physician has to apply this assessment to the decision to be made, to determine whether the patient can truly make the decision autonomously. For the patient to decide, their degree of competence should be in keeping with the complexity and risks of the proposed procedure. The following possibilities can occur in this situation:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050">1<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055">1The patient has intact competence, can be considered autonomous and can accept decisions with a questionable risk-benefit ratio or reject procedures with a favorable risk-benefit ratio.</li><li class="elsevierStyleListItem" id="lsti0060">2The patient has seriously affected competence and is not autonomous, and a decision by substitution has to be made.</li><li class="elsevierStyleListItem" id="lsti0065">3The patient has mildly affected competence.</li><li class="elsevierStyleListItem" id="lsti0070">4Their decision will be considered if they accept a proposal with a positive risk-benefit balance or if they reject an option with an unfavorable risk-benefit ratio.</li><li class="elsevierStyleListItem" id="lsti0075">5If the risk-benefit balance is intermediate (or unfavorable) and there are questions about the patient’s competence, a second opinion will be requested of a specialist in the competence assessment (psychiatrist).</li></ul></li></ul>Fourth step: try to improve the patient’s competenceIn certain cases, patients have a temporary loss of competence, generally due to acute problems (e.g., acute delirium). If the procedure allows for a delay in the decision (colonoscopy for iron-deficiency anemia), it is advisable to try to improve the patient’s competence, as much as possible, to include the patient in the decision-making process as soon as possible. In these cases, competence should be periodically assessed.Fifth step: establish who will make the decisionIf the patient is competent to make the decision, they will be allowed to decide. If this is not the case, substitution decisions will come into play. Consent by representation will always be in the patient’s favor and will respect their values. Although a patient might not be competent and decision by substitution needs to be made, the patient should participate as much as possible in the decision-making process. The patient should therefore be informed of the procedure and their preferences listened to and respected all much as possible.<a class="elsevierStyleCrossRefs" href="#bib0010">2,17</a> The decisions by substitution are established in the following order:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0080">•What the patient would have established through a living will (previous instructions or advance directives),</li><li class="elsevierStyleListItem" id="lsti0085">•What the patient’s representatives decide (legal guardian, if available, or those closest to the patient, based on the wishes previously expressed by the patient). If the patient’s wishes are not known, the decision should be made by taking into account the greatest benefit for the patient’s life and health.</li><li class="elsevierStyleListItem" id="lsti0090">•If the representatives make a decision that is contrary to the patient’s greatest benefit, the physicians should protect the patient’s interests. The legal authorities should be made aware of the situation, except when, due to reasons of emergency, judicial authorization cannot be obtained, in which case the necessary measures to safeguard the patient’s life and health would be adopted.</li><li class="elsevierStyleListItem" id="lsti0095">•If there is no representative, the responsible physician should make the decision, seeking the greatest benefit for the patient.</li></ul>In questionable or especially controversial cases, it is advisable to consult the center’s healthcare ethics committee because they can advise on the best way to seek the greatest benefit for the patient.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Case resolutionThis case involved a decision to reject a treatment with a clearly beneficial risk-benefit balance; the patient must therefore demonstrate a high level of competence. Several factors could question the patient’s full competence, such as signs indicating incipient cognitive impairment. The responsible physician should therefore assess the patient’s competence for rejecting the transfusion of packed red blood cells. While treatment for heart failure was started, a formal competence assessment was initiated with MacCAT-T, resulting in a score of 10 (low). Given the consequences of rejecting the treatment (clinical severity and high mortality risk), a decision by substitution was considered necessary. The patient had no advance directives or legal guardian. A meeting was convened with Andrea’s children, representatives of her interests at that moment, informing them in detail of the present clinical situation and the potential consequences of rejecting the transfusion. We insisted that the decision should be made according to what Andrea would have wanted. The children requested time to decide. After 30min, they reported their decision: They were not sure what Andrea would really have wanted had she been fully competent. The children therefore considered that the most logical step was for the physicians to seek what is best for Andrea. The transfusion of packed red blood cells was therefore ultimately performed." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1330955" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1226291" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1330954" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1226292" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Background" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Concept of ability and competence" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Assessment of competence: general principles" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Procedure for assessing competence" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Step one: recognize the situations that require a competence assessment" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Second step: full assessment of competence" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Third step: correlate the degree of competence with the complexity of the decision" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Fourth step: try to improve the patient’s competence" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Fifth step: establish who will make the decision" ] ] ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Case resolution" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-02-08" "fechaAceptado" => "2019-04-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1226291" "palabras" => array:5 [ 0 => "Capacity" 1 => "Competence" 2 => "Autonomy" 3 => "Decision making" 4 => "Clinical relationship" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1226292" "palabras" => array:5 [ 0 => "Capacidad" 1 => "Competencia" 2 => "Autonomía" 3 => "Toma de decisiones" 4 => "Relación clínica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "For patients to be able to make decisions autonomously (and to grant informed consent), they must have information, understanding, freedom and willingness, with competence a prerequisite for autonomy. Clinicians are often faced with patients lacking competence to make decisions but detect less than half of such cases and often inadequately assess the patients’ competence. This article offers guidelines for assessing the competence of patients for whom there are doubts about their ability to make decisions concerning their health. The procedure is based on 5 steps: 1) recognising the conditions that require a competence assessment; 2) fully evaluating the competence; 3) correlating the degree of competence with the complexity of the decision; 4) improving the patient’s competence when possible; and 5) establishing who will make the decision." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Para que los enfermos puedan tomar decisiones autónomamente (y que se produzca el consentimiento informado) tiene que haber información, comprensión, libertad y voluntariedad, siendo la competencia un prerrequisito para la autonomía. Los clínicos se enfrentan con frecuencia a pacientes incompetentes para tomar decisiones, pero detectan menos de la mitad de los casos y, además, con frecuencia la evaluación de la competencia no es adecuada. Este artículo ofrece unas pautas para la valoración de la competencia en aquellos pacientes en los que existen dudas sobre si están en condiciones para tomar decisiones sobre su salud. El procedimiento se basa en cinco pasos: 1) Reconocer las situaciones que requieren una valoración de la competencia; 2) Evaluación completa de la competencia; 3) Correlacionar el grado de competencia con la complejidad de la decisión a tomar; 4) Intentar mejorar la competencia del paciente cuando sea posible; y finalmente 5) Establecer quién toma la decisión." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Palacios GJ, Pinto B, Marquez O, Herreros B. Valoración de la competencia de los pacientes para tomar decisiones. Rev Clin Esp. 2020;220:256–262." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Rejection of an indicated procedure without the reasons being clearly explained, when the patient is not willing to discuss or argue the reasons or if these are excessively irrational. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Acceptance of invasive procedures in a strikingly rapid manner and without an apparent assessment of the risks and benefits. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Abrupt changes in mental condition due to acute physical (hypoxia, infection, metabolic disorders, vascular disorders, medication, etc.), psychiatric or neurological disorders. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Some risk factor for causing temporary disability: neurological or psychiatric disease, cultural or language barriers, borderline ages (younger than 18 years or older than 85 years). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2281099.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Situations that require a competence assessment." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Understanding the relevant medical information \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient: should be able to grasp the essential meaning of the information provided by the physician. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Physician: should ask the patient to paraphrase the information given them regarding the patient’s medical condition and treatment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Questions for the clinical assessment (ask the patient to use their own words to repeat the information that was given to them by their physician): \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What do you know about the disease you currently have? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What are the available options for managing your condition? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What do you know about the benefits of the proposed treatment and the likelihood of it being effective? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What are the treatment’s risks, the likelihood that adverse effects might occur and the probability of poor results? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What will happen with your disease if nothing is done? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What are the alternatives to the best treatment proposed, and what are their risks and benefits? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Understanding the condition and its consequences \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient: should be able to assess their medical condition and the consequences of the proposed treatment options. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Physician: should encourage the patient to describe their state of health and what they think of the proposed treatment and the results of the potential treatment options. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Questions for the clinical assessment: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What to you think is causing your health to fail? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do you think you need some type of treatment? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What would be the best treatment for you? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do you think that the treatment or specific surgery is the best treatment for you? Can you explain why or why not? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What do you really think will happen to you if you accept the treatment? What do you think will happen if you don’t? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Why do you think your physician has recommended this treatment? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Thinking about the treatment options \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient: should engage in a rational process of handling the relevant information. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Physician: should invite the patient to compare the treatment options and their consequences, while offering reasons for selecting the best option. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Questions for the clinical assessment: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">What is the basis for accepting or rejecting the treatment recommendation? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Why do you think the information you’ve chosen that goes against the medical recommendation is better than this recommendation? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Communicate and express a choice clearly \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient: should clearly choose a treatment option. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Physician: should ask the patient for the latter’s chosen treatment option. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Questions for the clinical assessment: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Have you decided which medical option is best for you at this time? \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Can you tell us this decision? \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2281098.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical interview for the systematic clinical assessment of competence." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Score: 2: remembers and correctly understands the procedure; 1: remembers or partially understands the procedure, or the explanations are inaccurate or incomplete; 0: does not understand the importance of the procedure, its scope or if their ideas are based on delusions or a distortion of reality." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Areas \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Subcriteria \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Partial score \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="middle">Understanding</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Understanding the disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="middle">0-6</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Understanding the treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Understanding the risks and benefits \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="6" align="left" valign="middle">Appraisal Reasoning</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Appraisal of the disorder \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">0-4</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Appraisal of the general treatment objective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consequential \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle">0-8</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Comparative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Generated consequences \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Logical consistency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expression of a choice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Expression of a choice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0-2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2281101.png" ] ] ] ] "descripcion" => array:1 [ "en" => "MacCAT-T test of competence on performing a medical procedure." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Recognize the situations that require a competence assessment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Full assessment of competence Options: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systematic clinical assessment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Structured clinical interview (competence test). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Correlate the degree of competence with the complexity of the decision. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intact competence (autonomous patient): can accept decisions with questionable risk-benefit ratio or reject procedures with a favorable risk-benefit ratio. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seriously affected competence (nonautonomous patient): decision by substitution. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mildly affected competence (reduced autonomy): \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Their decision is considered if it results in the greatest benefit. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If their decision will not result in the greatest benefit: propose a second opinion from a specialist in the competence assessment (psychiatrist). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Try to improve the patient competence (prior to the decision by substitution) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with temporary/acute impairment of competence. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Establish who will make the decision. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Competent patient: the patient decides. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incompetent patient: decisions by substitution (consent by representation) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advance directives \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Representatives’ decision based on the patient’s expressed wishes; if these wishes are not known, seek the greatest benefit. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Decision by substitution against the greatest benefit for the patient: make the judicial authorities aware of the situation; when faced with an emergency, safeguard the patient’s health. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If there is no representative: seek the greatest benefit for the patient. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2281100.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Steps to follow to assess capacity." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La capacidad de los pacientes para tomar decisiones: Una tarea todavía pendiente" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. 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Appelbaum" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMcp074045" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2007" "volumen" => "357" "paginaInicial" => "1834" "paginaFinal" => "1840" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17978292" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessing patient capacity to consent to treatment: an integrative review of instruments and tools" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Lamont" 1 => "Y.H. Jeon" 2 => "M. 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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case</span><p id="par0005" class="elsevierStylePara elsevierViewall">Andrea&#44; a 79-year-old woman with acute heart failure&#44; previously unknown iron-deficiency anemia and a hemoglobin level of 6&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; rejected the transfusion of packed red blood cells&#46; At the time&#44; Andrea was not legally incapacitated and had 6<span class="elsevierStyleHsp" style=""></span>children&#44; 3<span class="elsevierStyleHsp" style=""></span>of whom are Jehovah&#8217;s Witnesses&#46; According to one of the children&#44; after the death of her husband a year earlier&#44; Andrea became a Jehovah&#8217;s Witness&#46; The daughter acted as the main caregiver &#40;and was not a Jehovah&#8217;s witness&#41; and doubted that her mother understood the importance of the decision&#46; The daughter mentioned domestic examples such as how&#44; in the past 9<span class="elsevierStyleHsp" style=""></span>months&#44; her mother had begun to show certain cognitive impairment &#40;frequent lapses of memory&#44; difficulty organizing day-to-day activities&#44; etc&#46;&#41;&#46; In the interview&#44; the patient was oriented to person and space but disoriented to time&#46; After telling the patient about the possible consequences of the decision &#40;worsening of symptoms&#44; which could lead to death&#41;&#44; she was once again asked about her decision&#44; to which she responded that she &#8220;does not want a transfusion&#8221; and that &#8220;she doesn&#8217;t care if she dies&#8221;&#46; She was unable to offer reasons &#40;even religious ones&#41; to support this decision&#46; The physicians were uncertain as to whether to respect the patient&#8217;s decision&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Background</span><p id="par0010" class="elsevierStylePara elsevierViewall">The concepts of freedom and autonomy are based on the respect for individual privacy and have been established as basic rights &#40;<span class="elsevierStyleItalic">individual</span> or <span class="elsevierStyleItalic">subjective</span>&#41; since the 18<span class="elsevierStyleSup">th</span> century&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although they have permeated the clinical environment in the 20<span class="elsevierStyleSup">th</span> century&#46; Respect for autonomy is one of the foundations of the clinical relationship and is put into practice through informed consent&#44; regulated in Spain by Law 41&#47;2002&#44; which governs patient autonomy&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Before accepting a patient&#8217;s decision&#44; the patient should be assessed to determine if they are competent to make decisions&#46; If the patient is competent&#44; they can decide with autonomy&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Various studies have shown how medical teams detect only a third of cases of incompetence and how competence assessments&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> even when performed&#44; are not usually appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The aim of this article is to offer guidelines for assessing the competence of patients for whom there are doubts about whether they are able to make decisions concerning their health&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Concept of ability and competence</span><p id="par0020" class="elsevierStylePara elsevierViewall">The terms ability and competence are encompassed by a broader concept&#58; the patient&#8217;s autonomy for making decisions&#46; Before analyzing how competence is evaluated&#44; it is worth clarifying the concept of autonomy&#44; ability and competence&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Etymologically&#44; <span class="elsevierStyleItalic">autonomy</span> is the ability to govern oneself&#44; i&#46;e&#46;&#44; to self-manage&#46; In medicine&#44; an individual is considered autonomous when they are able to make decisions concerning their health&#46; Autonomy is put into practice through an informed consent&#58; the patient receives information and freely decides&#46; There are a few requirements for a decision to be autonomous<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#58; 1&#41; the patient must receive appropriate information about the procedure and understand the information<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#8211;9</span></a>&#59; 2&#41; the patient must be free to choose&#44; which requires the absence of external imposition or coercion&#59; and 3&#41; the patient must be able to volunteer&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;10</span></a> which requires competence or the natural ability to decide&#44; i&#46;e&#46;&#44; the intellectual ability to make decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> For a decision to be autonomous &#40;and to grant informed consent&#41;&#44; there must be information&#44; understanding&#44; freedom and willingness&#44; with competence a prerequisite for autonomy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">legal capacity</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> is the legal condition that allows an individual to hold rights and responsibilities&#46; Legal capacity is innate&#44; attributed without restriction to all individuals from birth and equal for everyone&#44; because&#44; in essence&#44; it contains all rights they are entitled to&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">capacity to exercise one&#8217;s rights</span><a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;12&#8211;14</span></a> is a legal concept and consists of the ability to assert one&#8217;s rights and assume responsibilities without authorization by another entity&#46; In Spain&#44; this capacity is generally acquired at 18 years of age&#44; although in the healthcare setting&#44; it is acquired at the age of 16 years&#46; To acquire the capacity to exercise one&#8217;s rights&#44; 2<span class="elsevierStyleHsp" style=""></span>aspects must be met&#58; age and maturity &#40;cognitive and volitional skills that enable self-government&#41;&#46; The legal capacity allows for degrees &#40;newborns have none&#44; minors have limited legal capacity and adults enjoy the full legal capacity&#41; and changes&#44; given that individuals of legal age can be denied full legal capacity by a court decision &#40;<span class="elsevierStyleItalic">legal incapacitation</span>&#41; &#40;e&#46;g&#46;&#44; when faced with advanced dementia&#41;&#46; The <span class="elsevierStyleItalic">incapacitation</span> can be total or partial for certain areas &#40;legal-administrative management&#44; medical aspects&#44; right to vote&#44; etc&#46;&#41;&#44; with the judge deciding&#44; based on clinical and legal reports&#44; the incapacitation that should be applied and the system of guardianship&#46; The legal guardian will be responsible for making decisions that pertain to the setting of incapacitation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">de facto capacity&#44; natural capacity or competence</span> is a clinical concept and refers to the patient&#8217;s aptitude for exercising their autonomy and their ability to make decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> It is not a generic concept&#58; competence is linked to the specific decision to be made and refers to the process of understanding the information&#44; appreciating the consequences of the options and assuming the decision&#46; If the patient is competent&#44; they can make&#44; express and defend a decision that is consistent with their set of values&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In clinical practice&#44; the term &#8220;capacity&#8221; is often used to refer to competence &#40;to the de facto capacity&#41; or &#8220;incapacity&#8221; to refer to a lack of competence&#46; An individual can have legal capacity &#40;e&#46;g&#46;&#44; a 50-year-old man with alcoholism who has not been incapacitated&#41; but lack competence for making a specific decision &#40;continuing the example&#44; if the man has pneumonia and wants to leave the hospital fully delirious&#41;&#46; Legally&#44; the individual is not incapacitated&#44; but at <span class="elsevierStyleItalic">that moment</span> they cannot make <span class="elsevierStyleItalic">that decision</span>&#46;</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Various formulas and terms have been employed in the literature to describe these concepts&#58; the United Kingdom uses the term &#8220;competency&#8221; while the United States uses the term &#8220;capacity&#8221;&#46; However&#44; an indistinct use of both terms has also been observed in clinical practice&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;17</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Assessment of competence&#58; general principles</span><p id="par0050" class="elsevierStylePara elsevierViewall">In medicine&#44; knowing how to assess competence is essential&#46; If the patient is competent and meets the other requirements for autonomy&#44; the physician must respect the patient&#8217;s decision &#40;unless there is a legal exception&#58; injury to a third party&#44; threat to public health&#44; jailed patients with a life-threatening emergency&#44; etc&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#59; if the patient is not competent&#44; consent is not possible&#46; In this assessment&#44; we need to consider the following general principles<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Who assesses the competence&#63;</span> Although all clinicians should be able to assess competence&#44; the physician responsible for the patient has the obligation to perform the assessment&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9</span></a> because they know the patient the best&#46; The presence of a medical specialist&#44; typically a psychiatrist &#40;although they can also be a medical examiner or neurologist&#41; is only necessary in cases of special complexity &#40;e&#46;g&#46;&#44; when faced with certain mental or neurological diseases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2</span><p id="par0060" class="elsevierStylePara elsevierViewall">Competency is evaluated by considering the <span class="elsevierStyleItalic">patient&#8217;s cognitive abilities at that moment</span>&#46; The aspects to assess are the degree of attention&#44; memory&#44; speech &#40;reasoning&#41; and capacity for introspection or judgment&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> because they are the basis for understanding the information and for reasoning and expressing the decision&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3</span><p id="par0065" class="elsevierStylePara elsevierViewall">An individual is not competent in general but rather is competent for a <span class="elsevierStyleItalic">specific task or health decision</span><a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#59; therefore&#44; competence is bound to the type of decision &#40;severity&#44; type of procedure&#44; risks and consequences of the decision&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> As proposed by Drane<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> with their Sliding Scale <span class="elsevierStyleItalic">&#40;Escala M&#243;vil&#41;</span>&#44; the same degree of competence is not required for all decisions&#44; and the larger the risk&#44; the greater the degree of competence demanded&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;14&#44;17</span></a> Buchanan suggested that the necessary competence for accepting &#40;consenting to&#41; a procedure does not have to be the same as that for rejecting the procedure&#44; given that the risks of one option or the other can differ<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;e&#46;g&#46;&#44; hemodialysis in the setting of end-stage renal failure&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">4</span><p id="par0070" class="elsevierStylePara elsevierViewall">Competence is <span class="elsevierStyleItalic">not stable over time</span> and can vary depending on the patient&#8217;s clinical condition&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The assessment process should be continuous&#44; especially when faced with fluctuating and temporary disorders&#46; Competence should be re-evaluated for each specific decision because&#44; in some cases&#44; competence can be recovered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">5</span><p id="par0075" class="elsevierStylePara elsevierViewall">There should be a &#8220;presumption of capacity&#8221;&#46; A patient should only be considered to lack competence when their competence has been evaluated&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Although competence impairment is more frequent in certain disorders &#40;neurological or psychiatric&#41;&#44; there should be no prejudice regarding competence in these types of patients&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Procedure for assessing competence</span><p id="par0080" class="elsevierStylePara elsevierViewall">In cases in which reduced competence is suspected&#44; a structured competence assessment should be conducted&#46; When applying this procedure&#44; 2<span class="elsevierStyleHsp" style=""></span>questions need to answered&#58; Is the patient competent for making the decision in play&#63; If competence is reduced&#44; what degree of competence does the patient still maintain and&#44; therefore&#44; what type of decisions can they make&#63;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Step one&#58; recognize the situations that require a competence assessment</span><p id="par0085" class="elsevierStylePara elsevierViewall">In 1998&#44; Grey and Appelbaum described the types of patients who should be suspected of reduced competence and&#44; therefore&#44; those who need a competence assessment &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;23</span></a> The authors presented 2<span class="elsevierStyleHsp" style=""></span>types of patients&#58; those who make irrational decisions and those who present clinical signs that suggest cognitive impairment&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Second step&#58; full assessment of competence</span><p id="par0090" class="elsevierStylePara elsevierViewall">After identifying the patient who requires a competence assessment&#44; the patient should be informed that this assessment will be performed&#46; Whenever possible&#44; the patient&#8217;s consent should be obtained&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The assessment can be performed 2<span class="elsevierStyleHsp" style=""></span>ways<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#58; systematic clinical assessment or structured clinical interview &#40;using a formal tool&#44; typically a test&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Any of these methods is reliable and comparable to an expert&#8217;s judgment&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> because they help assess the essential criteria of competence&#58; understanding information&#44; appreciating the consequences&#44; having the ability to reason&#44; having the capacity to choose an option and being able to communicate the selection&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;26&#44;27</span></a> The systematic clinical assessment evaluates these criteria and intellectual skills through a series of questions &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">structured clinical interview</span> analyzes the competence criteria using a score&#44; providing a more comprehensive assessment&#46; Specific training is typically required to properly perform the assessment and interpret and extrapolate the results&#46; These tools&#44; typically tests&#44; do not automatically establish whether a patient is competent&#44; because the results should be framed with the overall assessment conducted by the physician&#46; Although there are a considerable number of tests&#44; the most widely employed and for which there is the most evidence<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;14</span></a> is the MacArthur Competence Assessment Tool for Treatment &#40;MacCAT-T&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> validated for medical care &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; and research&#46; The tool has a Spanish-validated version<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and has considerable usefulness for nonpsychiatric physicians&#44; because it is simple to perform and interpret&#46; Although MacCAT-T provides guidelines on how it should implemented&#44; it is worth undergoing prior training&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;8</span></a> and the approximate assessment time is 15&#8211;20<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">There is no exact range of scores that indicate whether a patient is competent&#46; Patients should be assessed individually&#44; taking into account generically that a medium score in the 4<span class="elsevierStyleHsp" style=""></span>areas would indicate that the patient has sufficient skills for making decisions&#44; while a low test score would mean the patient is not sufficiently competent to consent &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Third step&#58; correlate the degree of competence with the complexity of the decision</span><p id="par0105" class="elsevierStylePara elsevierViewall">Once the patient&#8217;s competence has been assessed with one of the abovementioned methods&#44; the physician has to apply this assessment to the decision to be made&#44; to determine whether the patient can truly make the decision autonomously&#46; For the patient to decide&#44; their degree of competence should be in keeping with the complexity and risks of the proposed procedure&#46; The following possibilities can occur in this situation&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">1</span><p id="par0110" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1</span><p id="par0115" class="elsevierStylePara elsevierViewall">The patient has <span class="elsevierStyleItalic">intact competence</span>&#44; can be considered autonomous and can accept decisions with a questionable risk-benefit ratio or reject procedures with a favorable risk-benefit ratio&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2</span><p id="par0120" class="elsevierStylePara elsevierViewall">The patient has <span class="elsevierStyleItalic">seriously affected competence</span> and is not autonomous&#44; and a decision by substitution has to be made&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3</span><p id="par0125" class="elsevierStylePara elsevierViewall">The patient has mildly affected competence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">4</span><p id="par0130" class="elsevierStylePara elsevierViewall">Their decision will be considered if they accept a proposal with a positive risk-benefit balance or if they reject an option with an unfavorable risk-benefit ratio&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">5</span><p id="par0135" class="elsevierStylePara elsevierViewall">If the risk-benefit balance is intermediate &#40;or unfavorable&#41; and there are questions about the patient&#8217;s competence&#44; a second opinion will be requested of a specialist in the competence assessment &#40;psychiatrist&#41;&#46;</p></li></ul></p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Fourth step&#58; try to improve the patient&#8217;s competence</span><p id="par0140" class="elsevierStylePara elsevierViewall">In certain cases&#44; patients have a temporary loss of competence&#44; generally due to acute problems &#40;e&#46;g&#46;&#44; acute delirium&#41;&#46; If the procedure allows for a delay in the decision &#40;colonoscopy for iron-deficiency anemia&#41;&#44; it is advisable to try to improve the patient&#8217;s competence&#44; as much as possible&#44; to include the patient in the decision-making process as soon as possible&#46; In these cases&#44; competence should be periodically assessed&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Fifth step&#58; establish who will make the decision</span><p id="par0145" class="elsevierStylePara elsevierViewall">If the patient is competent to make the decision&#44; they will be allowed to decide&#46; If this is not the case&#44; substitution decisions will come into play&#46; Consent by representation will always be in the patient&#8217;s favor and will respect their values&#46; Although a patient might not be competent and decision by substitution needs to be made&#44; the patient should participate as much as possible in the decision-making process&#46; The patient should therefore be informed of the procedure and their preferences listened to and respected all much as possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;17</span></a> The decisions by substitution are established in the following order&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">What the patient would have established through a living will &#40;previous instructions or advance directives&#41;&#44;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">What the patient&#8217;s representatives decide &#40;legal guardian&#44; if available&#44; or those closest to the patient&#44; based on the wishes previously expressed by the patient&#41;&#46; If the patient&#8217;s wishes are not known&#44; the decision should be made by taking into account the greatest benefit for the patient&#8217;s life and health&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">If the representatives make a decision that is contrary to the patient&#8217;s greatest benefit&#44; the physicians should protect the patient&#8217;s interests&#46; The legal authorities should be made aware of the situation&#44; except when&#44; due to reasons of emergency&#44; judicial authorization cannot be obtained&#44; in which case the necessary measures to safeguard the patient&#8217;s life and health would be adopted&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">If there is no representative&#44; the responsible physician should make the decision&#44; seeking the greatest benefit for the patient&#46;</p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">In questionable or especially controversial cases&#44; it is advisable to consult the center&#8217;s healthcare ethics committee because they can advise on the best way to seek the greatest benefit for the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Case resolution</span><p id="par0175" class="elsevierStylePara elsevierViewall">This case involved a decision to reject a treatment with a clearly beneficial risk-benefit balance&#59; the patient must therefore demonstrate a high level of competence&#46; Several factors could question the patient&#8217;s full competence&#44; such as signs indicating incipient cognitive impairment&#46; The responsible physician should therefore assess the patient&#8217;s competence for rejecting the transfusion of packed red blood cells&#46; While treatment for heart failure was started&#44; a formal competence assessment was initiated with MacCAT-T&#44; resulting in a score of 10 &#40;low&#41;&#46; Given the consequences of rejecting the treatment &#40;clinical severity and high mortality risk&#41;&#44; a decision by substitution was considered necessary&#46; The patient had no advance directives or legal guardian&#46; A meeting was convened with Andrea&#8217;s children&#44; representatives of her interests at that moment&#44; informing them in detail of the present clinical situation and the potential consequences of rejecting the transfusion&#46; We insisted that the decision should be made according to what Andrea would have wanted&#46; The children requested time to decide&#46; After 30<span class="elsevierStyleHsp" style=""></span>min&#44; they reported their decision&#58; They were not sure what Andrea would really have wanted had she been fully competent&#46; The children therefore considered that the most logical step was for the physicians to seek what is best for Andrea&#46; The transfusion of packed red blood cells was therefore ultimately performed&#46;</p></span></span>"
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          "titulo" => "Concept of ability and competence"
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          "titulo" => "Assessment of competence&#58; general principles"
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        8 => array:3 [
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          "titulo" => "Procedure for assessing competence"
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            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Step one&#58; recognize the situations that require a competence assessment"
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            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Second step&#58; full assessment of competence"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Third step&#58; correlate the degree of competence with the complexity of the decision"
            ]
            3 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Fourth step&#58; try to improve the patient&#8217;s competence"
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            4 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Fifth step&#58; establish who will make the decision"
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          "titulo" => "Case resolution"
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          "palabras" => array:5 [
            0 => "Capacity"
            1 => "Competence"
            2 => "Autonomy"
            3 => "Decision making"
            4 => "Clinical relationship"
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      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1226292"
          "palabras" => array:5 [
            0 => "Capacidad"
            1 => "Competencia"
            2 => "Autonom&#237;a"
            3 => "Toma de decisiones"
            4 => "Relaci&#243;n cl&#237;nica"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">For patients to be able to make decisions autonomously &#40;and to grant informed consent&#41;&#44; they must have information&#44; understanding&#44; freedom and willingness&#44; with competence a prerequisite for autonomy&#46; Clinicians are often faced with patients lacking competence to make decisions but detect less than half of such cases and often inadequately assess the patients&#8217; competence&#46; This article offers guidelines for assessing the competence of patients for whom there are doubts about their ability to make decisions concerning their health&#46; The procedure is based on 5 steps&#58; 1&#41; recognising the conditions that require a competence assessment&#59; 2&#41; fully evaluating the competence&#59; 3&#41; correlating the degree of competence with the complexity of the decision&#59; 4&#41; improving the patient&#8217;s competence when possible&#59; and 5&#41; establishing who will make the decision&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Para que los enfermos puedan tomar decisiones aut&#243;nomamente &#40;y que se produzca el consentimiento informado&#41; tiene que haber informaci&#243;n&#44; comprensi&#243;n&#44; libertad y voluntariedad&#44; siendo la competencia un prerrequisito para la autonom&#237;a&#46; Los cl&#237;nicos se enfrentan con frecuencia a pacientes incompetentes para tomar decisiones&#44; pero detectan menos de la mitad de los casos y&#44; adem&#225;s&#44; con frecuencia la evaluaci&#243;n de la competencia no es adecuada&#46; Este art&#237;culo ofrece unas pautas para la valoraci&#243;n de la competencia en aquellos pacientes en los que existen dudas sobre si est&#225;n en condiciones para tomar decisiones sobre su salud&#46; El procedimiento se basa en cinco pasos&#58; 1&#41; Reconocer las situaciones que requieren una valoraci&#243;n de la competencia&#59; 2&#41; Evaluaci&#243;n completa de la competencia&#59; 3&#41; Correlacionar el grado de competencia con la complejidad de la decisi&#243;n a tomar&#59; 4&#41; Intentar mejorar la competencia del paciente cuando sea posible&#59; y finalmente 5&#41; Establecer qui&#233;n toma la decisi&#243;n&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Palacios GJ&#44; Pinto B&#44; Marquez O&#44; Herreros B&#46; Valoraci&#243;n de la competencia de los pacientes para tomar decisiones&#46; Rev Clin Esp&#46; 2020&#59;220&#58;256&#8211;262&#46;</p>"
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                  \t\t\t\t">1&#46; Rejection of an indicated procedure without the reasons being clearly explained&#44; when the patient is not willing to discuss or argue the reasons or if these are excessively irrational&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">2&#46; Acceptance of invasive procedures in a strikingly rapid manner and without an apparent assessment of the risks and benefits&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46; Abrupt changes in mental condition due to acute physical &#40;hypoxia&#44; infection&#44; metabolic disorders&#44; vascular disorders&#44; medication&#44; etc&#46;&#41;&#44; psychiatric or neurological disorders&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#46; Some risk factor for causing temporary disability&#58; neurological or psychiatric disease&#44; cultural or language barriers&#44; borderline ages &#40;younger than 18 years or older than 85 years&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t">1&#46; <span class="elsevierStyleBold">Understanding the relevant medical information</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patient&#58; should be able to grasp the essential meaning of the information provided by the physician&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Physician&#58; should ask the patient to paraphrase the information given them regarding the patient&#8217;s medical condition and treatment&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Questions for the clinical assessment &#40;ask the patient to use their own words to repeat the information that was given to them by their physician&#41;&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">What do you know about the disease you currently have&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">What are the available options for managing your condition&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">What do you know about the benefits of the proposed treatment and the likelihood of it being effective&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">What are the treatment&#8217;s risks&#44; the likelihood that adverse effects might occur and the probability of poor results&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">What will happen with your disease if nothing is done&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">What are the alternatives to the best treatment proposed&#44; and what are their risks and benefits&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46; <span class="elsevierStyleBold">Understanding the condition and its consequences</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patient&#58; should be able to assess their medical condition and the consequences of the proposed treatment options&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Physician&#58; should encourage the patient to describe their state of health and what they think of the proposed treatment and the results of the potential treatment options&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Questions for the clinical assessment&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">What to you think is causing your health to fail&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do you think you need some type of treatment&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">What would be the best treatment for you&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do you think that the treatment or specific surgery is the best treatment for you&#63; Can you explain why or why not&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">What do you really think will happen to you if you accept the treatment&#63; What do you think will happen if you don&#8217;t&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Why do you think your physician has recommended this treatment&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46; <span class="elsevierStyleBold">Thinking about the treatment options</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patient&#58; should engage in a rational process of handling the relevant information&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Physician&#58; should invite the patient to compare the treatment options and their consequences&#44; while offering reasons for selecting the best option&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Questions for the clinical assessment&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">What is the basis for accepting or rejecting the treatment recommendation&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Why do you think the information you&#8217;ve chosen that goes against the medical recommendation is better than this recommendation&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46; <span class="elsevierStyleBold">Communicate and express a choice clearly</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patient&#58; should clearly choose a treatment option&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Physician&#58; should ask the patient for the latter&#8217;s chosen treatment option&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Questions for the clinical assessment&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Have you decided which medical option is best for you at this time&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Can you tell us this decision&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical interview for the systematic clinical assessment of competence&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Score&#58; 2&#58; remembers and correctly understands the procedure&#59; 1&#58; remembers or partially understands the procedure&#44; or the explanations are inaccurate or incomplete&#59; 0&#58; does not understand the importance of the procedure&#44; its scope or if their ideas are based on delusions or a distortion of reality&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Subcriteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Partial score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="middle">Understanding</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Understanding the disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="middle">0-6</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Understanding the treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Understanding the risks and benefits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="6" align="left" valign="middle">Appraisal Reasoning</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Appraisal of the disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="middle">0-4</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Appraisal of the general treatment objective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consequential&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="middle">0-8</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Comparative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Generated consequences&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Logical consistency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Expression of a choice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Expression of a choice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0-2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">MacCAT-T test of competence on performing a medical procedure&#46;</p>"
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        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; <span class="elsevierStyleBold">Recognize the situations that require a competence assessment&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; <span class="elsevierStyleBold">Full assessment of competence Options&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Systematic clinical assessment&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Structured clinical interview &#40;competence test&#41;&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46; <span class="elsevierStyleBold">Correlate the degree of competence with the complexity of the decision&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Intact competence &#40;autonomous patient&#41;&#58; can accept decisions with questionable risk-benefit ratio or reject procedures with a favorable risk-benefit ratio&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seriously affected competence &#40;nonautonomous patient&#41;&#58; decision by substitution&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mildly affected competence &#40;reduced autonomy&#41;&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Their decision is considered if it results in the greatest benefit&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">If their decision will not result in the greatest benefit&#58; propose a second opinion from a specialist in the competence assessment &#40;psychiatrist&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46; <span class="elsevierStyleBold"><span class="elsevierStyleItalic">Try to improve the patient competence &#40;prior to the decision by substitution&#41;</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patients with temporary&#47;acute impairment of competence&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">5&#46; <span class="elsevierStyleBold">Establish who will make the decision&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Competent patient&#58; the patient decides&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Incompetent patient&#58; decisions by substitution &#40;consent by representation&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advance directives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Representatives&#8217; decision based on the patient&#8217;s expressed wishes&#59; if these wishes are not known&#44; seek the greatest benefit&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Decision by substitution against the greatest benefit for the patient&#58; make the judicial authorities aware of the situation&#59; when faced with an emergency&#44; safeguard the patient&#8217;s health&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">If there is no representative&#58; seek the greatest benefit for the patient&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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