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Review article
Competency: General principles and applicability in dementia
Competencia: conceptos generales y aplicación en la demencia
L.C. Álvaro
Servicio de Neurología y Comité de Ética Asistencial del Hospital de Basurto, Departamento de Neurociencias, Universidad del País Vasco EHU/UPV, Bilbao, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Competency refers to a person&#39;s ability to make responsible decisions on matters that affect different areas of his or her life and involve assuming risks&#46; The individual must make an informed decision freely and without being influenced&#46; While this influence is understood to be external&#44; it can also be internal and result from the person&#39;s mental state&#59; a weakened mental state is a factor limiting the individual&#39;s ability to make decisions entailing risk&#46; It is from this perspective that we will be examining competency in dementia&#46; Cognitive impairment&#44; and the emotional state which frequently accompanies it&#44; involve a type of internal duress which limits a patient&#39;s ability to make decisions entailing risks&#44; including health care decisions having to do with accepting certain diagnostic procedures or treatments&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Informed consent and evaluating capacity or competency</span><p id="par0010" class="elsevierStylePara elsevierViewall">Only an informed and capable individual&#44; meaning one fully aware of the risks involved in making a decision and able to understand the gravity of its consequences&#44; is able to choose responsibly&#46; Therefore&#44; the first step in evaluating competency is assessing informed decision-making&#46; In these matters&#44; we are guided by the principle of autonomy&#58; the rule states that the patient may freely accept or reject a medical option&#44; and this principle only applies in practice if the patient has sufficient information about the procedure&#44; whether diagnostic or therapeutic&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The doctor responsible for the patient must be the one to provide that information so that the patient will be able to accept or refuse the proposed option or options&#44; that is&#44; make use of the power of choice implicit to the autonomy principle&#46; The relationship between one party providing information and the other party&#39;s logical decision based on the information is what precisely defines informed consent&#46; We will therefore address this specific aspect of the doctor&#8211;patient relationship&#44; seen from the perspective of recognising the patient&#39;s own ability to make decisions&#46; The doctor&#39;s position will now be diametrically opposed the paternalistic attitude which was dominant only few years ago&#46; According to the former paradigm&#44; the doctor was responsible for making decisions which the patient would then directly accept as the most appropriate and beneficial&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The history of informed consent is long and convoluted&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The successive events spanning the last 5 centuries have brought us into the modern era&#46; Relationships between individuals are now horizontal&#44; and people in positions of power no longer impose their will on others&#46; Vertical relationships&#44; those in which one party was considered superior based on his medical knowledge&#44; meant that the doctor decided what was best for the patient&#44; who was viewed as a tutored&#44; passive subject&#46; Horizontal relationships&#44; characterised by transmitting information&#44; dialogue&#44; and decision-making by the patient&#44; constitute a leap forward&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain&#44; these ideas only began to arrive in the last 20 years&#44; and they were accepted grudgingly due to their being perceived as a challenge to the doctor&#39;s knowledge and decision-making capacity&#46; This mentality gave rise to a concept of informed consent that is more a legal formality than true transmission of information&#46; This process should be part of the underlying structure of a doctor&#8211;patient relationship&#44; which was and still is essentially based on the spoken word&#58; medical history&#44; examinations&#44; information on diagnostic and treatment procedures&#44; discussion of pros and cons&#44; and the patient&#39;s own reasoned decisions&#46; An informed consent document cannot replace this entire process&#44; even if it might seem faster or more convenient from the standpoint of legal concerns&#44; and even if it is easier to hand over a pamphlet instead of using our limited time to speak with the patient&#46; The fact is that the consent document should only be one part in the process&#46; It could be seen as an outline that summarises and organises the information which the patient should already have heard during direct conversations with the doctor&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The entry of these ideas into our healthcare system was formalised in our codes of ethics<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> and in Spanish legislation&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> especially Law 21&#47;2000 on patients&#8217; right to information and Law 41&#47;2002 on patient autonomy&#46; The latter contains 2 chapters specific to the topic which concerns us&#46; The first covers the right to information and the second&#44; respect for the patient&#39;s autonomy&#46; The second chapter states that the more uncertain the result of the intervention&#44; the greater the doctor&#39;s obligation to obtain the patient&#39;s written consent&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Legislation also addresses the concept of ability or competency from the patient&#39;s point of view&#46; This brings us to the next basic concept&#58; the decision-making capacity of a patient who has been informed&#46; This ability refers to natural or functional capacity&#44; and it must be established before a medical procedure can take place&#46; Legal competence&#44; on the other hand&#44; may only be declared by a judicial authority&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The topic we will be addressing here is therefore natural capacity&#44; which affects daily life events and has consequences for the patient and his&#47;her immediate family&#44; social&#44; employment or economic situation&#46; In fact&#44; a patient&#39;s natural or functional capacity may affect every event of his or her daily life&#44; from signing contracts&#44; marriage&#47;adoption certificates&#44; testaments&#44; etc&#46;&#44; to accepting or refusing treatment or institutionalisation&#46; However&#44; functional capacity as described here is task-specific&#46; This means we must judge whether or not a patient is competent to make a specific decision&#46; Given the limitations caused by the patient&#39;s disease&#44; meaning dementia or cognitive impairment in our case&#44; can he or she understand treatment risks and benefits&#44; refuse institutionalisation&#44; or even vote&#63; These are direct questions&#44; but we will rarely have recourse to a standard tool to provide us with answers&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Declaring legal competence&#8212;and its opposite&#44; legal incompetence&#8212;are the processes in which several judicial bodies intervene&#44; almost always at the request of the patient&#39;s family&#44; in order to protect the patient&#39;s life and property&#46; A legally incompetent person must have a legal guardian who reports periodically to a judicial authority&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Doctors and medical professionals in general do not have the power to declare legal competence&#46; The Office of the Public Prosecutor and the judge normally request medical evaluations and reports upon which to base their decision&#46; In these cases&#44; rulings are all-encompassing&#44; unlike pronouncements on natural or functional capacity&#44; which are task-specific&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The doctor responsible for the patient should be the one to evaluate functional capability&#46; The medical personnel caring for the patient must determine his or her capacity&#44; with recourse to additional evaluations by other colleagues as needed&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Strangely enough&#44; neurologists are absent from this list of consulting colleagues&#44; even during the process of evaluating capacity in dementia patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;16</span></a> We believe that the neurological community should be involved in this process&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evaluating capacity&#58; general principles</span><p id="par0050" class="elsevierStylePara elsevierViewall">Evaluating capacity or competency is a task that entails considerable responsibility&#44; and not just in a strictly clinical sense&#46; Declaring a person incapable&#44; even for specific tasks&#44; means depriving him or her of basic rights and liberties&#46; These rights and liberties are assumed by a third party in order to protect the patient&#46; The task of incapacitating a patient is based on the principle of &#8220;first&#44; do no harm&#8221;&#46; According to Diego Gracia&#44; this principle plus the fairness or justice principle should guide our work as a whole&#44; and that of healthcare administrators as well&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The primary goal is to protect the patient from all harmful activity&#44; while guaranteeing equitable and efficient use of healthcare resources&#46; Applying these principles to determining competency or capacity entails&#44; firstly&#44; preventing harm to the patient&#46; Examples include preventing the patient from making risky decisions beyond his or her capacity&#44; and not depriving the patient of rights through unnecessary incapacitation&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Spanish law states that the doctor responsible for the patient must be the one to define his or her capacity or competency&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Legal dispositions and codes of ethics establish three types of requirements&#58; cognitive&#44; affective&#44; and conative or volitional&#46; In fact&#44; this threefold model is rooted in Hippocratic medicine and the classical schools&#44; which defined three different capabilities of the mind&#58; knowledge&#44; will&#44; and emotion or preference&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Unfortunately&#44; the law neither establishes normal parameters for competency nor defines methods or tools for measuring it&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Doctors in general&#44; and neurologists in particular&#44; routinely establish competency or functional capacity based on a mixture of experience&#44; intuition&#44; and common sense&#46; We have been doing this for some time now&#44; and it would seem that the procedure works&#44; judging by how little we hear about cases requiring a second opinion or generating conflicts&#46; However&#44; more careful analysis reveals that this effect is really a reporting bias&#46; Only cases in which patients refuse highly effective treatments or procedures attract attention and create conflict&#46; The example of Jehovah&#39;s Witnesses who refuse blood transfusions is the most striking&#46; But many other situations also occur in which treatment or diagnostic procedures are initiated without the patient having sufficient competency or capacity to make a decision&#46; When the patient does not refuse the procedure and there are no significant risks or severe consequences&#44; lack of competency goes unnoticed&#46; The fact that sensitivity to lack of competency is low&#44; and that this lack only becomes an issue in grave cases&#44; goes against respect for the principle of autonomy&#46; This provides food for thought&#44; and should lead us to improve our ability to diagnose functional incompetence&#46; Healthcare administrators must be aware of this as well&#44; since this task will require more dedication and more time&#44; which is our scarcest resource due to its high cost&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">If we do not accept and provide case-by-case evaluations of competency&#44; we will come face to face with reality&#46; In fact&#44; cases in which there is a request for assessment of the financial decision-making capacity of a patient with cognitive impairment are increasingly common&#46; Cognitive impairment is not always severe enough for us to be able to state that the patient is obviously incapable&#46; In other cases&#44; patients who refuse to live in a residence may require evaluation&#46; Other patients may accept or refuse risky diagnostic or treatment procedures&#44; and our well-informed society requires that these procedures be used cautiously&#44; in keeping with the patient&#39;s decision-making capability&#46; For these purposes&#44; the general principles used to guide any competency assessment process are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Tools specific to evaluating dementia are listed in the final sections of this study&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">At this point&#44; we should reiterate the important fact that the required degree of capacity or competence is directly proportionate to the level of risk associated with a decision&#46; With this in mind&#44; making a decision entailing great risk &#40;undergoing an emergency carotid endarterectomy&#41; or in turn&#44; refusing a manifestly beneficial procedure or treatment &#40;antibiotics for meningitis&#41; requires a high degree of capacity on the part of the patient&#46; Meanwhile&#44; other clinical situations entail a very low degree of risk&#44; whether the patient opts to refuse a procedure &#40;cranial CT as dementia follow-up&#41; or accept it &#40;vitamins for a non-deficiency-related neuropathy&#41;&#46; Aside from evidence-based benefit considerations&#44; risk in such clinical situations is very low&#44; and the patient&#39;s requisite degree of capability is also low&#46; There are also situations ranging between the two extremes&#44; in which risks or benefits may be significant&#44; but not vitally important&#46; It is likely that most clinical situations fall into this last category&#46; In such cases&#44; the potential benefit of accepting diagnostic tests or treatments&#44; and the resulting risk of refusing them&#44; is moderate&#46; In practical terms&#44; this means that the procedures are neither vital nor urgent&#44; although by refusing them a patient&#39;s quality of life or even life span may be lessened&#46; Examples of decisions regarding treatment include refusing statins used in secondary prevention of cardiovascular disease or drugs used to treat Parkinson disease&#44; dementia&#44; or multiple sclerosis&#46; Examples of decisions regarding diagnostic procedures include accepting non-emergency conventional angiography&#44; refusing a DaTscan to evaluate parkinsonism&#44; or refusing lumbar puncture for a demyelinating disease&#46; Potential risks and lost potential benefits are not negligible&#44; even if they are not of vital importance&#46; This is why we must be more rigorous regarding the patient&#39;s capacity in intermediate cases&#44; while this would be a lesser concern in critical&#44; life-or-death situations&#46; This array of situations is shown in the Drane sliding scale &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;20&#44;21</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">From a purely cognitive viewpoint&#44; the 3 levels for situations also entail different requirements regarding the patient&#39;s understanding and decision-making capacity&#46; For standard 1 situations&#44; it is only necessary for a patient to be aware of the current situation and agree&#44; either explicitly or implicitly&#44; to the procedure&#46; For standard 2 situations&#44; the patient must understand the information and make a choice based on thorough cognitive and emotional evaluation of the options&#46; Lastly&#44; for standard 3&#44; the competent patient must be able to take a reflective and critical view of the disease and available options&#44; and make a logical&#44; reasoned decision based on evaluation of its consequences and his or her personal beliefs&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Instruments for evaluating capacity or competency</span><p id="par0080" class="elsevierStylePara elsevierViewall">We will now focus on evaluating competency specifically&#46; In the most common clinical situation&#44; a doctor transmits information on a diagnostic or therapeutic procedure which implicitly entails potential risks as well as benefits&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the aspects of the procedure which the patient should understand&#46; The same aspects&#44; broken down step by step&#44; also usually appear in the informed consent documents which we manage on a daily basis&#46; The first aspect to be assessed is the patient&#39;s awareness of his or her disease&#46; If the patient does not accept that he&#47;she is ill&#44; as frequently occurs in Alzheimer disease&#44; the patient will probably be unable to evaluate the real risks of the procedure&#44; or will underestimate those risks&#46; It is important for the patient to be aware of and understand particularly serious or critical risks&#44; and these should be explained using direct everyday language without too many suppositions&#46; All other aspects listed in the table should be explained in the same way&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">As stated previously&#44; neither the law nor other disciplines having to do with the study of competency have provided universally accepted tools for assessing competency&#46; Competency criteria and the minimum degree of competence required to make each decision remain undefined&#46; It was the subject of considerable research in the 1980s and early 1990s&#44; particularly among legal experts&#44; bioethicists and psychiatrists&#46; This research resulted in an array of instruments for assessing competency&#46; These tools first evaluate subjects&#8217; ability or capacity to receive&#44; understand and process information&#46; In the next step&#44; they measure the ability to make an appropriate&#44; reasoned decision based on available information&#46; Lastly&#44; they consider a patient&#39;s ability to communicate the decision in an organised and comprehensible way&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> provides a summary of the most systematic and widely-used scales and evaluation methods&#46; The first of those methods is White&#39;s list of criteria for competence &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> a good example of the systematic method to follow when assessing competency&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The ACE Guide &#40;aid to capacity evaluation&#41; prepared by the University of Toronto is a free-use&#44; free-access resource&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> It lists a series of questions intended to evaluate aspects that are decisive when defining functional capacity &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; It includes 8 groups of questions&#44; which must be asked sequentially&#46; Specific tips and guidance are offered for each section containing 3 or 4 questions&#46; These questions may also be substituted by equivalents drawn up when the test is administered&#46; Lastly&#44; the doctor checks &#8220;yes&#8221; &#40;the patient understands&#41;&#44; &#8220;no&#8221; &#40;the patient does not understand&#41; or &#8220;unsure&#8221; after finishing each group of questions&#44; rather than relying on intuition&#46; The final score establishes whether the patient is definitely capable&#44; probably capable&#44; probably incapable or definitely incapable&#46; The test has no cut-off points&#46; Once again&#44; we must recall that the seriousness of the decision at hand will determine the patient&#39;s score requirements&#46; This guide is a good first assessment before proceeding to the final decision&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Another 5 guides&#44; scales and instruments are listed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; They are cited by their acronyms CAT&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> CCTI&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> DAM&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> HCAI<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and MacCAT&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> Of these instruments&#44; the MacArthur Competence Assessment Tool &#40;MacCAT&#41; is the one with the most proven validity&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;14&#8211;16&#44;31</span></a> Three versions of the test are available&#58; one is for considering treatment decisions &#40;MacCAT-T&#41;&#44; another screens clinical research subjects to determine their capacity for consent &#40;MacCAT-CR&#41;&#44; and a third is of interest for determining adjudicative competence in criminal cases &#40;MacCAT-CA&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In daily clinical practice&#44; an interview may be sufficient to determine a patient&#39;s functional capacity&#46; For this to be true&#44; its structure must take into account the basic steps in the responsible decision-making process&#58; understanding the information&#44; making the decision&#44; and clearly communicating the selected option&#46; Guidelines organise&#44; facilitate and quantify this procedure&#44; although the result of the procedure and the final decision will be based on clinical criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;32</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Before moving on to the next section&#44; we should reiterate that all patients must be considered capable by default&#46; If the patient&#39;s history or current clinical situation point to decreased capacity&#44; the doctor must consider that possibility prudently&#44; but transparently&#46; The burden of proof and that of the added workload rest on the doctor who will decide if the patient is able to make the decision in question&#46; Information from family members and close friends may be crucial&#46; Opinions of colleagues&#44; nurses&#44; or bioethics committees may also contribute to the final decision to declare the patient capable or incapable&#46; In any case&#44; recourse to a legal evaluation should only be used when a patient may be legally incompetent&#44; or when conflicts arise&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Dementia&#58; key aspects related to capacity</span><p id="par0115" class="elsevierStylePara elsevierViewall">Dementia is a disorder associated with the ageing population&#44; and its prevalence is increasing&#46; This is the most common disorder in which a patient&#39;s capacity may be questioned&#44; particularly in the early and intermediate phases of the course of the disease corresponding to mild and moderate stages of dementia&#46; Disease progression&#44; which is intrinsic to the disorder&#44; determines the healthcare needs and bioethical conflicts typical of each phase&#46; With this in mind&#44; determining patient capacities and writing advance directives are problems for the early stages&#44; while support provided by the carer&#44; devices to prevent wandering&#44; and institutionalising patients are situations that come up in later stages of the disease&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A list of bioethical problems that may arise in dementia appears in <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;33</span></a> Number 4 on that list &#40;consent and competency&#41; is the one examined by our study&#46; The others are not considered within the sphere of this project&#44; although different problems may overlap&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">As stated previously&#44; capacity or functional competence is task-specific&#44; and this may apply to any of the patient&#39;s life activities&#46; In cases of dementia&#44; the most common situations are decisions regarding treatments and diagnostic tests or other financial or contractual decisions&#46; But many other life activities may be at stake as well&#59; accepting or refusing institutionalisation&#44; the ability to drive and the right to vote are all topics that have been addressed in the literature&#46; With such a wide variety of activities being affected&#44; we run the risk of being asked to assess competence in controversial situations that are not in keeping with our role as dementia experts&#46; To cite an example&#44; the voting ability of Alzheimer patients was called into question during the U&#46;S&#46; presidential election in 2000&#44; in which George Bush&#39;s victory depended on the outcome in Florida&#46; That state has a high percentage of elderly residents&#44; meaning that the prevalence of dementia among Florida&#39;s voters is also likely to be high&#46; This matter was debated in a number of highly visible journals<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#8211;36</span></a> that questioned the legality of the election and the practical applicability of screening tests designed by medical societies and expert panels&#46; Were this debate to reach our country&#44; our role would be superseded by the result of the debate&#44; which is more social than scientific in nature&#46; Presumably&#44; we would then be viewed as advisers rather than as evaluators&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Advance directives are especially relevant in cases of dementia&#46; Where present&#44; they can facilitate care and decision-making in critical moments&#46; The instructions they contain serve to orient the patient&#39;s end-of-life care&#46; They may serve to prevent futile treatments or discontinue enteral feeding&#44; if these approaches are listed&#46; We should be aware that discontinuing feeding does not produce additional suffering&#46; Furthermore&#44; it is coherent with the patient&#39;s own decision&#44; provided that treatments&#44; including feeding and hydration by artificial means&#44; are no longer effective&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;32&#44;33</span></a> Patient participation in studies or clinical trials also should be mentioned&#46; Specific protection must be extended to dementia patients&#46; This means that guarantees must exist that the patient is both informed and capable&#46; With the dual objective of meeting the above requirements on the one hand&#44; and avoiding investigator manipulation and conflicts of interest on the other&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> research and clinical trial committees should make an effort to supervise studies of dementia patients&#46; If the patients have advance directives stating their specific wishes in this regard&#44; this is particularly useful&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Spanish law and healthcare administrations now encourage the preparation of advance directives&#46; However&#44; several unforeseen conflicts have arisen in recent years&#46; Specifically&#44; there have been cases in which the patient&#39;s initial wishes expressed in the advance directive are at odds with the wishes the patient is expressing at the current time&#46; Using advanced dementia as an example&#44; we find cases of patients who had previously expressed the wish to have their feeding tubes removed if they ever reached severe stages of dementia&#46; However&#44; once they do reach that situation&#44; patients may countermand previous instructions and ask to be fed&#46; In such cases&#44; which orders are to be respected&#63; Dworkin states that the initial instructions&#44; written when the patient was still competent&#44; are a better reflection of that person&#39;s identity&#44; values&#44; and convictions&#44; and should therefore be followed&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> However&#44; other authors maintain that identity and being are present even in obviously incompetent patients with severe cognitive decline&#44; and their wishes in that stage should be respected&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Our own opinion is that changing circumstances give rise to different requests that are appropriate and proportional to the patient&#39;s condition and time of life&#46; The patient&#39;s decreased needs make the wishes expressed at this moment of life plausible and respectable&#46; On a practical level&#44; we recommend revising all advance directives periodically&#44; a step which is not stressed enough&#46; It is understandable that a young&#44; healthy individual would be appalled by the perspective of devastating loss entailed by dementia&#44; and would opt to dictate the end of his or her life upon reaching a severe stage of cognitive decline and dependency&#46; At the same time&#44; it is understandable that an elderly person with limited capacities would present radically different&#44; less stringent requirements for his or her well-being and happiness&#46; This individual&#39;s perspective on the same disease might then be more tolerant and relaxed in the end&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results from studies of capacity in dementia &#40;Alzheimer&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">The most widely-studied capacity in dementia patients is competence for making decisions regarding medications&#46; This issue is highly relevant&#44; since a wide array of studies have been devoted to developing treatments&#44; especially for Alzheimer disease&#44; for more than a decade&#46; The appearance of new drugs is accompanied by risks which have not necessarily been foreseen&#46; As an example&#44; we could cite tacrine-induced liver damage&#44; which led to recall of the drug&#44; or even more severe cases of meningoencephalitis during the trial phase of immunisation with Abeta42 peptide&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The patient must understand these risks&#44; be able to relate them to his or her own condition&#44; decide whether or not to undergo treatment&#44; and explain that choice logically&#46; Essentially&#44; the patient must demonstrate his or her decision-making capacity for a situation entailing risk&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Drugs approved for use in Alzheimer have more precise and quantifiable risks&#44; but they must still be explained&#46; Different tools have been developed for evaluating this type of capacity&#46; The MacCAT-T scale for treatment is the most widely-used example&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> With this aim in mind&#44; a simple design study<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> used that tool to evaluate 48 patients with mild or moderate Alzheimer and 102 carers as controls&#46; Only 40&#37; of the patients were competent&#46; Lack of understanding of their own limitations and the disease itself&#8212;a frequent symptom in these patients&#8212;was linked to the presence of incapacity&#46; The Mini-Mental State Examination &#40;MMSE&#41; had a limited discriminatory ability since it does not distinguish between patients scoring between 19 and 23&#46; Patients with mild dementia fall into this precise interval&#44; and decisions about their competence tend to be the most urgent&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The ability to detect incapacity has also been studied for other tools apart from the MMSE that measure cognitive decline&#46; One study of 88 patients with mild or moderate dementia employed 11 neuropsychological tests &#40;auditory&#44; visuospatial&#44; attention&#44; memory&#44; abstraction&#44; language&#44; and executive function tests&#41;&#46; These tests were correlated with other tests specifically measuring capacity&#44; including MacCAT-T&#44; White&#39;s criteria and the HCAI &#40;see <a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#41;&#46; They found good predictive ability &#40;77&#46;8&#41; for the initial phase of competence&#44; referring to simple comprehension of information&#46; However&#44; predictive ability was lower for more complicated phases of competence&#58; self-reference &#40;39&#46;4&#37;&#41;&#44; reasoned decision-making &#40;24&#46;6&#37;&#41; and appropriate communication of the choice &#40;10&#46;2&#37;&#41;&#46; These results support the general hypothesis of there being a direct correlation between the degree of cognitive decline and capacity for treatment decision-making&#46; Unfortunately&#44; inter-individual variability is high and results have no direct clinical applicability&#46; On the other hand&#44; the same study shows that verbal evocation ability was the variable with the greatest correlation to competency&#44; in all stages of competence&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> This only reflects the fact that most of the information used in the tests was verbal&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In stark contrast to the complexity of the study described above&#44; analysis in another study was limited to detecting the most basic risks in treatment decisions for cases of dementia&#46; To do so&#44; it used a battery of 10 true&#47;false questions&#46; The cut-off point was set at 8 correct responses&#46; Analysis of 250 patients with differing levels of dementia and 165 controls showed that 95&#37; of patients with mild dementia were above the competence threshold&#44; compared to only 67&#37; of patients with moderate Alzheimer&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> This test battery has direct clinical value due to its simplicity and high predictive ability&#46; There is no available data referring to its use in the Spanish-speaking world&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Complex qualitative analyses have also been published analysing capacity in Alzheimer patients with regard to different levels of competence&#46; These have been established as legal standards of competence &#40;LS&#41;&#46; Ranging from LS1 to LS5&#44; these levels range from simply understanding that treatment is being offered &#40;LS1&#41; to making a reasoned decision and explaining it appropriately and coherently &#40;LS5&#41;&#46; These legal standards have been researched in studies that blur the lines between neurology and legal medicine&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;45</span></a> The test presents two vignettes&#46; The subject is asked to envision a case of cancer with two treatment alternatives&#44; and a case of heart disease with two treatment options&#46; The subject listens as information written in a simple style is read aloud&#46; The purpose is to measure capacity for decision-making according to each of the 5 legal standards of competence&#46; The vignettes are good simulations of a clinical situation in which a patient must make rational decisions regarding risk-filled diagnostic and treatment options&#46; In the first study&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> these vignettes were described to 15 elderly control subjects and 29 Alzheimer patients &#40;14 in mild stages and 15 in moderate stages&#41;&#46; For less stringent standards&#44; such as those measuring simple understanding of the choice and making the reasonable choice &#40;LS1 and LS2&#41;&#44; there were no differences between the control and Alzheimer groups&#46; However&#44; those in mild stages were already limited with regard to appreciating consequences of the choice &#40;LS3&#41;&#46; Subjects in moderate stages of Alzheimer showed a marked lack of competence upon trying to justify choices &#40;LS4&#41; or understand the significance of each option &#40;LS5&#41;&#46; These vignettes are comparable to clinical situations involving withdrawing treatment&#44; do-not-resuscitate orders&#44; and participation in clinical trials&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The level of cognitive decline is directly related to loss of competency&#46; However&#44; we have already mentioned that test batteries such as the MMSE provide little specific information&#46; For that reason&#44; experts have attempted to correlate lack of competency with other markers of cognitive decline&#46; For example&#44; the legal standards of competence have been compared to neuropsychological test batteries evaluating a range of different capacities&#58; language&#44; attention&#44; memory&#44; reasoning&#44; visuospatial functions&#44; and executive functions&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> The same authors conducted the study&#44; presumably with the same 44 subjects used in the study described above<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> since distribution was the same &#40;control&#44; 15&#59; mild Alzheimer&#44; 15&#59; moderate Alzheimer&#44; 14&#41;&#46; They found that only those subjects with severe receptive aphasia or anomia had difficulty with the LS1 decision-making level &#40;understanding that options exist&#41;&#46; On the other hand&#44; executive dysfunction predicted incompetence on the level of understanding consequences of a choice &#40;LS3&#41;&#44; while other frontal functions &#40;semantic memory&#44; conceptualisation&#44; and verbal evocation&#41; had to be preserved for the LS5 level of maximum competence&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Executive dysfunction is therefore a key factor in determining competency&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In another study using qualitative methodology&#44; doctors analysed the consequences of errors in LS decisions&#46; They designed a test battery measuring 16 qualitative errors in the areas of language&#44; executive dysfunction&#44; affective dysfunction&#44; and compensatory responses&#46; Answers indicative of loss of task&#44; non-response and loss of detachment were key predictors of executive dysfunction and declining competence&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">One simple competency model categorised lack of competency as either operational or general&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Operational incompetence results from an alteration in a single cognitive sphere&#44; usually in the area of language&#46; General incompetence&#44; on the other hand&#44; would affect more than one cognitive domain or area among the seven listed here&#58; attention&#44; memory&#44; language&#44; orientation&#44; perception&#44; reasoning and emotion&#46; Reasoning capacity&#44; affective dysfunction&#44; memory disorders and attention disorder&#44; in that order&#44; were the most commonly affected areas in the sample of 92 patients assessed over 18 months in one neurobehavioural unit&#46; This study&#39;s methodology is imprecise considering the tests used to evaluate each cognitive sphere and the definitions of dysfunction in those spheres&#46; Its strength lies in its clinical applicability and suitability for widespread use&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Lastly&#44; before declaring a patient incompetent&#44; we should analyse any possibility of his having preserved intellectual areas that may compensate for other defective areas&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> To this end&#44; another new simple cognitive model is available that analyses attention&#44; language&#44; memory and frontal function &#40;consciousness of the disease and decision-making ability&#41;&#46; The evaluator should be aware of the area responsible for the patient&#39;s specific limitation or lack of competence and check if other preserved areas could compensate when making the decision in question&#46; The most typical example is that of a patient with a language disorder who may try to compensate by means of gestures&#44; drawings&#44; etc&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Other types of dementia</span><p id="par0185" class="elsevierStylePara elsevierViewall">The above results are potentially applicable to other types of dementias&#44; given that the cognitive decline determining incompetence depends on a lesion&#39;s location&#44; not on its cause or type&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Dysexecutive syndromes are the distinguishing feature of frontal lobe lesions&#44; and their presence in cognitive decline is a strong predictor of incapacity or incompetence&#44; as stated previously&#46; Executive functions comprise all capabilities permitting us to manage simple ideas and actions in order to transform them into complex activities&#44; referring to our own goals and daily life activities&#46; To achieve these ends&#44; we require motivation or drive&#44; emotional control&#44; and planning and abstract thought&#46; If any of these 3 components is altered&#44; an executive dysfunction appears&#44; with its own specific frontal lesion profile&#46; Apathy and lack of initiative or drive appear with anterior cingulate and medial frontal cortex lesions&#59; changes in personality&#44; erratic behaviour and loss of emotional control with orbitofrontal lesions&#59; and lastly&#44; direct alterations in abstract thinking with dorsolateral prefrontal lesions&#46; Translating this schema to the field of functional competence obliges us to restate the basic idea that being competent to make a decision means understanding information&#44; weighing the pros and cons and making a final reasoned decision&#46; If executive dysfunction is present&#44; the patient is likely to lack initiative&#44; or even insight or awareness of his or her disease and its limitations&#46; In addition&#44; it is likely that the patient will have lost planning and organisational capacity&#46; This translates to rigid behaviours and extreme difficulty adapting to change or to unforeseen situations that disturb daily routines&#46; Making decisions&#44; whether related to healthcare and its risks&#44; financial matters&#44; or a simple change of residence&#44; becomes a challenge&#44; as the complex planning processes these decisions entail will probably exceed these patients&#8217; abilities&#46; This occurs in patients whose other cortex functions&#44; such as language&#44; visuospatial abilities and reasoning skills&#44; remain intact&#46; It creates a loss of autonomy&#46; This may be a loss of independent decision-making capacity&#44; based on simple conceptual and emotional understanding&#44; or a loss of executive autonomy&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> which reflects the ability to act upon deliberately prepared plans&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Executive dysfunction&#44; which is common in Alzheimer disease&#44; is even more typical in other types of dementia&#46; Parkinson disease is a typical example of functional incompetence resulting from executive dysfunction&#46; This was demonstrated by a study of 20 patients with Parkinson and cognitive decline and 20 control subjects&#46; Capacity was measured using CCTI &#40;capacity to consent to treatment instrument&#59; see <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; and segmented according to intervals LS1 to LS5&#46; We found significant alterations at all levels&#44; from legal standard LS1 to LS5&#46; This finding was directly correlated to executive dysfunction and difficulties with abstract reasoning&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">We have not found specific literature on capacity in other common forms of dementia&#44; such as dementia with Lewy bodies or vascular dementia&#46; However&#44; there are recently published articles on the topic of MCI&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;51</span></a> Since this diagnosis is very common&#44; and up to 25&#37; of all cases progress to dementia in the first 3 years&#44; these patients are involved in a number of clinical trials&#46; For this reason&#44; there is considerable interest in verifying their competence for understanding healthcare-related risks and choosing treatment alternatives&#46; One study has been published on this topic&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> It analyses medical decision-making ability in 60 patients diagnosed with MCI&#44; compared to 31 patients with mild Alzheimer and 56 control subjects&#46; The study also makes use of the CCTI and legal standards&#46; Findings were that the group of MCI patients had better results than those with mild Alzheimer for all legal standards&#46; However&#44; for LS3 &#40;risk comprehension&#41;&#44; LS4 &#40;reasoned assessment of risks&#41; and LS5 &#40;making a reasoned choice&#41;&#44; the MCI patient group&#39;s results were significantly poorer than those of the control group&#46; Participation of these patients in clinical trials should therefore be considered and evaluated in a framework that considers the possibility of their being incapable of making treatment decisions entailing risk&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Financial capacity is a basic skill in daily life&#44; which makes it an important research topic in studies on capacity and dementia&#46; One study<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> analysed financial capacity over 1 year in 66 control subjects&#44; 25 patients with amnesic MCI that progressed to dementia in the follow-up period&#44; and 62 cases of non-progressive MCI&#46; The Financial Capacity Instrument is a tool that evaluates different financial activities ranked in order of increasing complexity&#44; including basic monetary skills&#44; bank statement management and paying bills&#46; The study found that the progressive MCI group scored significantly lower from the start of the study&#46; The loss of financial capacity was more evident for more complex activities &#40;managing bank statements&#41;&#44; and it was fundamentally caused by procedural or arithmetic errors rather than conceptual limitations&#46; As a result&#44; MCI patients may show decreased capacity for financial matters&#46; In addition&#44; if this symptom is present&#44; it is an indicator of unfavourable disease progression&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0210" class="elsevierStylePara elsevierViewall">Competency in dementia is a hot topic with implications for daily clinical practice&#46; Deciding that a patient is competent or capable involves making decisions&#44; which may be critical&#44; regarding multiple facets of that patient&#39;s daily life&#46; Neurologists have made important contributions to this research&#44; and the Spanish medical community in particular has produced a valuable multidisciplinary informative guide &#40;<span class="elsevierStyleItalic">Documento de Sitges</span>&#44; 2009&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> Unfortunately&#44; neurologists are not listed by the international literature as specialists of reference or expert advisers in this field&#46; We are convinced that this should change&#46; To this end&#44; we must raise awareness throughout our specialist community&#44; and follow up on that step by updating and distributing the available tools&#46; Only in this way will we join the ranks of the psychiatrists&#44; clinical psychologists and legal doctors who evaluate capacity&#46; This will be true both in clinical practice&#44; in which we are often not called upon to evaluate competency&#44; and in the field of research&#44; in which many discoveries must still be made&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The present article touches on all of these topics&#46; It presents basic concepts such as the link between competency&#47;capacity and bioethics through the principle of autonomy&#44; and the direct relationship between level of competence required and the seriousness of the decision to be made&#46; The article describes several easily accessible tools used in this area&#46; In conclusion&#44; it describes basic research on Alzheimer disease and other forms of dementia&#44; mentioning critical cortex functions and useful methodological constructs such as the legal standards or LS&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres169853"
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            0 => "Abstract"
            1 => "Introduction"
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          "identificador" => "xpalclavsec157927"
          "titulo" => "Keywords"
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            1 => "Introducci&#243;n"
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          "titulo" => "Palabras clave"
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          "identificador" => "sec0005"
          "titulo" => "Informed consent and evaluating capacity or competency"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Evaluating capacity&#58; general principles"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Instruments for evaluating capacity or competency"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Dementia&#58; key aspects related to capacity"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Results from studies of capacity in dementia &#40;Alzheimer&#41;"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Other types of dementia"
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          "identificador" => "sec0035"
          "titulo" => "Conclusions"
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        10 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conflicts of interest"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2011-09-08"
    "fechaAceptado" => "2011-12-17"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec157927"
          "palabras" => array:5 [
            0 => "Alzheimer"
            1 => "Assessment"
            2 => "Capacity"
            3 => "Competence"
            4 => "Dementia"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec157926"
          "palabras" => array:5 [
            0 => "Alzheimer"
            1 => "Capacidad"
            2 => "Competencia"
            3 => "Demencia"
            4 => "Evaluaci&#243;n"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Competency means the capacity to make responsible and balanced decisions&#46; This may be performed in clinical settings &#40;decision-making abilities on treatment or risky diagnostic procedures&#41; and also in daily-life activities &#40;financial matters&#44; nursing home admittance&#44; contracts&#44; etc&#46;&#41;&#46; Competency is linked to the ethical principle of autonomy and to a horizontal doctor&#8211;patient interaction&#44; far from ancient paternalistic relationships&#46; It is contemplated in the Spanish law as the patient&#39;s right to be informed and to make free choices&#44; particularly in cases of dementia&#46;</p> <span class="elsevierStyleSectionTitle">Development</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The competency that we assess is the so-called natural or working capacity&#46; It is specific for an action or task&#46; The level of required capacity depends on the decision&#58; higher for critical ones&#44; lower for low-risk decisions&#46; The assessment process requires noting the patient&#39;s capacity to understand&#44; analyse&#44; self-refer and apply the information&#46; There are some guides available that may be useful in competency assessments&#44; but nevertheless the final statement must be defined by the physician in charge of the patient and clinical judgment&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Capacity is directly related to the level of cognitive deterioration&#46; Nevertheless&#44; specific cognitive tests such as MMSE &#40;mini-mental&#41; have a low predictive value&#46; The loss of competency is more associated with the so-called legal standards of incapacity &#40;LS&#41;&#46; These encompass a range of five steps &#40;LS1&#8211;LS5&#41;&#44; which may detect the incapacity from the mild levels of dementia&#46; The cortical functions that are the best predictors of incapacity are language and executive dysfunctions&#46; These explain the incapacity in the cases of Alzheimer&#39;s and Parkinson&#39;s diseases&#44; and have been studied more&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Incapacity is common and it influences the clinical decision-making process&#46; We must be particularly cautious with clinical trials of dementia&#46; It also involves other areas of daily life&#44; particularly financially related ones&#44; where limitations are present from the mild cognitive impairment &#40;MCI&#41; level&#46; The neurological community has already produced specific and invaluable documents like the one from Sitges&#44; although in our opinion this community has to increase its awareness&#44; and also its involvement as much in the clinical as in the research sides of this field&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Competencia significa capacidad o aptitud para tomar decisiones responsables y razonadas&#46; Puede verse comprometida en acciones de la vida diaria &#40;asuntos econ&#243;micos&#44; de residencia&#44; contratos&#44; etc&#46;&#41; o en escenarios cl&#237;nicos &#40;decisiones sobre tratamientos o pruebas diagn&#243;sticas de riesgo&#41;&#46; Emana del principio de autonom&#237;a y de una relaci&#243;n m&#233;dico-enfermo horizontal y no paternalista&#46; Reconocida en la legislaci&#243;n espa&#241;ola como parte del derecho a la informaci&#243;n y libre elecci&#243;n del paciente&#44; estamos obligados a determinarla&#44; particularmente en demencias&#46;</p> <span class="elsevierStyleSectionTitle">Desarrollo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La competencia que evaluamos es la natural o de obrar&#46; Es espec&#237;fica de tarea&#46; El nivel de capacidad exigido var&#237;a con la decisi&#243;n&#44; muy alto en las cr&#237;ticas&#44; bajo en las de escaso riesgo&#46; El proceso requiere perfilar las capacidades de comprensi&#243;n&#44; de an&#225;lisis y de aplicaci&#243;n de la informaci&#243;n&#46; Existen gu&#237;as que facilitan la valoraci&#243;n&#44; aunque la decisi&#243;n final recae en el m&#233;dico responsable y depende de su juicio cl&#237;nico&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La capacidad se relaciona directamente con el nivel de deterioro cognitivo&#46; No obstante&#44; bater&#237;as espec&#237;ficas o test como el Minimental tiene muy escaso valor predictivo&#46; La p&#233;rdida de competencia se correlaciona mejor con medidores como los llamados niveles legales de competencia &#40;LS&#41;&#44; que con 5 grados &#40;LS1-LS5&#41; detectan incapacidades desde estadios leves de demencia&#46; Las funciones corticales mejor predictoras de incapacidad son el lenguaje y sobre todo las disfunciones ejecutivas&#46; Estas explican la incapacidad de muchos casos de Alzheimer y Parkinson&#44; los m&#225;s estudiados&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La incapacidad es frecuente y tiene implicaciones en decisiones cl&#237;nicas&#46; Se debe ser especialmente cauteloso con los ensayos cl&#237;nicos en demencia&#46; La demanda alcanza m&#250;ltiples esferas de vida diaria&#44; sobre todo las econ&#243;micas&#44; donde se detectan limitaciones desde el deterioro cognitivo leve&#46; La comunidad neurol&#243;gica ha elaborado documentos espec&#237;ficos de alto valor como el de Sitges&#44; aunque creemos ineludible aumentar su concienciaci&#243;n y participaci&#243;n&#8212;asistencial e investigadora&#8212;en este campo&#46;</p>"
      ]
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; &#193;lvaro LC&#46; Competencia&#58; conceptos generales y aplicaci&#243;n en la demencia&#46; Neurolog&#237;a&#46; 2012&#59;27&#58;290&#8211;300&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
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        "fuente" => "Modified from Sim&#243;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and Sim&#243;n and J&#250;dez&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>"
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                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" 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">1&#46; Incapacity is not pronounced based on diagnosis of a specific pathology &#40;drug addiction&#44; dementia&#44; psychosis&#44; etc&#46;&#41;&#44; but rather from individual evaluation of each case&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">2&#46; Evaluation must always be task-specific&#44; since some tasks may be affected while others remain completely unaltered&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">3&#46; Competency may fluctuate&#44; and evaluations must therefore be continuous&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">4&#46; The seriousness of the decision determines the required level of competence&#44; which must be higher if the choice may entail severe consequences &#40;Drane&#39;s sliding scale model&#44; see text&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">5&#46; The decision itself constitutes no basis for declaring a patient incapable&#44; even if its seems absurd&#46; Autonomy includes the right to refuse life-saving treatment &#40;if the patient is informed&#44; capable and under no duress&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">6&#46; Assessing capacity is based on the decision-making process &#40;receiving and understanding information&#44; implications for the patient&#44; reasoned decision&#44; communicating the decision&#41;&#44; and not on the choice itself&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">7&#46; Cognitive evaluation tools &#40;MMSE&#41; must be used in conjunction with specific tests of capacity &#40;see &#8220;Tests&#8221; section&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">General principles in evaluating capacity&#46;</p>"
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      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Modified from Drane&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>"
        "tabla" => array:1 [
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            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"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Decisions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Competence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Standard 1&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">1&#46; Consent where risk&#47;benefit balance is favourable&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">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">2&#46; Refusal where risk&#47;benefit balance is unfavourable&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Standard 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">Consent or refusal where risk&#47;benefit balance is unclear&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">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Standard 3&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">1&#46; Acceptance where risk&#47;benefit balance is unfavourable&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">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">2&#46; Refusal where risk&#47;benefit balance is favourable&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab264870.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Drane&#39;s sliding scale of competency&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "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" 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">1&#46; Nature of the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">2&#46; Purpose of the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">3&#46; Risks and benefits associated with the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">4&#46; Risks associated with refusing the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">5&#46; Available alternatives and their risks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab264867.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Aspects of a medical procedure which must be understood&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "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=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">Guide or protocol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Name&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Competence to consent&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">White&#39;s criteria&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">Semi-structured interview&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Aid to capacity evaluation&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">ACE&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Capacity assessment tool&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">CAT&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Decision assessment measure&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">CCTI&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Hopemont capacity Assessment interview&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">HCAI&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">MacArthur competence assessment tool&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">MacCAT-T&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">MacCAT-CR&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">MacCAT-CA&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab264865.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Guides for evaluating competence&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Modified from Sim&#243;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Sim&#243;n and J&#250;dez&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and White&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>"
        "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" 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"><span class="elsevierStyleItalic">A&#46; Informability</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">1&#46; Capacity to receive information&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">2&#46; Capacity to recognise relevant information as information&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">3&#46; Capacity to remember information&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">B&#46; Cognitive and affective capabilities</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">1&#46; Capacity to relate situations to oneself&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">2&#46; Capacity to reason about alternatives&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">3&#46; Capacity to rank alternatives&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">C&#46; Ability to choose</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">1&#46; Capacity to select an option&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">2&#46; Capacity to resign oneself to the choice&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleItalic">D&#46; Critical review of the process</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">1&#46; Ability to recount one&#39;s decision-making process&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab264871.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">White&#39;s competence criteria&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Modified from Etchells et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>"
        "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" 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">1&#46; Able to understand medical problem&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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">2&#46; Able to understand proposed 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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">3&#46; Able to understand alternatives to proposed treatment &#40;if any&#41;&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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">4&#46; Able to understand option of refusing proposed 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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">5&#46; Able to appreciate reasonably foreseeable consequences of accepting proposed 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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">6&#46; Able to appreciate reasonably foreseeable consequences of refusing proposed 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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">7&#46; Consent is given freely and willingly&#44; with no external duress&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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">8a&#46; Decision not affected by depression&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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">8b&#46; Decision not affected by delusion or psychosis&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">Yes&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">No&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Overall impression&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">Capable&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">Probably&#58;&#8211; capable&#8211; incapable&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">Unsure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <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" 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">1&#46; Doctor&#8211;patient relationship&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">2&#46; Explaining the diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">3&#46; Age as a limit on patient care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">4&#46; Consent and competence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">5&#46; The carer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">6&#46; Residence admission and care&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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#46; End-of-life care&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&#46; Research on dementia&nbsp;\t\t\t\t\t\t\n
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                  """
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                    0 => array:1 [
                      "titulo" => "Ethical practice"
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                        "titulo" => "Ethical issues in neurology"
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                        "serieFecha" => "2008"
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                      "titulo" => "Diez mitos en torno al consentimiento informado"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "P&#46; Sim&#243;n"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "An Sist San Navar"
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                        "volumen" => "29"
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                        "paginaFinal" => "40"
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                    0 => array:2 [
                      "titulo" => "A history and a theory of informed consent"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46; Faden"
                            1 => "T&#46;L&#46; Beauchamp"
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                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "1986"
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              "identificador" => "bib0020"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "La crisis del antiguo r&#233;gimen"
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                    0 => array:1 [
                      "Libro" => array:4 [
                        "titulo" => "Historia de la Espa&#241;a contempor&#225;nea"
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                        "editorial" => "Editorial Ariel SA"
                        "editorialLocalizacion" => "Barcelona"
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                    0 => array:2 [
                      "titulo" => "Principles of biomedical ethics"
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                          "etal" => false
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                            0 => "T&#46;L&#46; Beauchamp"
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                      "titulo" => "Two models of implementing informed consent"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3377623"
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                  "referenciaCompleta" => "C&#243;digo deontol&#243;gico&#46; Normas de &#233;tica m&#233;dica&#46; Barcelona&#58; Consell de Collegis de Metges de Catalunya&#59; 1998&#46; Available from&#58; <a class="elsevierStyleInterRef" href="http://www.comb.es/cast/passeig/deonto/home.htm">http&#58;&#47;&#47;www&#46;comb&#46;es&#47;cast&#47;passeig&#47;deonto&#47;home&#46;htm</a> &#91;accessed 24&#46;07&#46;11&#93;&#46;"
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                    0 => array:2 [
                      "titulo" => "Convenio para la protecci&#243;n de los derechos humanos y la dignidad del ser humano con respecto a las aplicaciones de la biolog&#237;a y la medicina"
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ISSN: 21735808
Original language: English
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2017 August 16 4 20
2017 July 13 4 17
2017 June 21 13 34
2017 May 31 2 33
2017 April 14 29 43
2017 March 15 13 28
2017 February 17 2 19
2017 January 11 3 14
2016 December 24 8 32
2016 November 28 4 32
2016 October 41 12 53
2016 September 32 8 40
2016 August 16 3 19
2016 July 23 3 26
2016 June 40 2 42
2016 May 28 10 38
2016 April 21 12 33
2016 March 29 12 41
2016 February 30 16 46
2016 January 22 12 34
2015 December 17 1 18
2015 November 19 7 26
2015 October 31 6 37
2015 September 26 6 32
2015 August 25 13 38
2015 July 12 3 15
2015 June 8 1 9
2015 May 20 10 30
2015 April 35 12 47
2015 March 42 4 46
2015 February 33 2 35
2015 January 43 6 49
2014 December 68 10 78
2014 November 39 6 45
2014 October 48 4 52
2014 September 39 4 43
2014 August 57 7 64
2014 July 52 4 56
2014 June 46 4 50
2014 May 35 7 42
2014 April 23 4 27
2014 March 36 8 44
2014 February 23 7 30
2014 January 17 6 23
2013 December 44 2 46
2013 November 61 9 70
2013 October 58 6 64
2013 September 45 6 51
2013 August 36 8 44
2013 July 30 0 30
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos