Decision-Making Capacity Among Elderly People: A Mapping of Health Professionals’ and Laypeople’s Views

Abstract

The views of laypeople and professionals (nurses, occupational therapists, psychologists, and physicians) on the capacity to make informed decisions of elderly people with depression or dementia were examined. Participants were presented with vignettes created by varying the levels of three factors: (a) the type of decision (e.g., agreeing to surgery), (b) the health problem (e.g., slight depression), and (c) the availability of social support. Through cluster analysis, four different positions were found. Seventeen percent of the participants considered that even persons suffering from slight depression were already quite incapacitated. In contrast, 24% considered that only elderly people suffering from moderate or severe dementia were impaired. The majority of participants (59%) expressed positions that can be considered as pragmatic. Level of impairment was viewed as a function of severity of illness or type of illness. No significant differences were found between health professional and laypeople.

Keywords

decision-making capacity elderly depression dementia lay opinion France

Determining the decision-making capacity of elderly people with depression, dementia, or other cognitive or emotional impairments has always been a significant issue for family caregivers and health professionals (American Bar Association Commission on Law and Aging, 2008). Although most elderly people have, after retirement, left professional responsibilities in other peoples’ hands, and although their family obligations have usually lessened, they still have, at least from time to time, important decisions to make. These decisions include, to quote only a few, whether to sell the home in which they have lived for many years, whom to put in their will, and whether to undergo surgical interventions.

Findings support the proposition that elderly people sometimes make inappropriate decisions (Meinow, Parker, & Thorslund, 2011; Schmand, Gouwenberg, Smit, & Jonker, 1999). For example, Finucane et al. (2002) showed that, as age increases, people experience greater difficulties to evaluate health plans options and to choose the most appropriate one, in particular because they make more comprehension errors than younger adults. Lambert-Pandraud, Laurent, Mullet, and Yoon (2017) have suggested that older consumers may have a biased view of the market; they usually suffer from a lack of knowledge regarding recently appeared brands, which can lead them to ignore new products that could fit their needs at lower cost (Cole et al., 2008). More generally, elderly people are often the victims of financial fraud or health-related scams (U.S. Securities and Exchange Commission, 2013). In France, the country in which this study was conducted, the Liliane Bettencourt affair has recently attracted the attention of the public. This rich widow—the top female billionaire in the world—was placed under the guardianship of her grandson in 2011 after she made a series of unjustified cash donations to friends and to politicians. Bettencourt’s name was also cited when the Madoff scandal surfaced: She was one of the main investor and as a result one of the main victims of Madoff’s scheme (Sancton, 2017).

Determining the ability to make decisions is not an easy task. A number of psychometric tools are available, and they are sometimes implemented in clinical settings, for example, the Weschler Adult Intelligence Scale-Revised, the Mini-Mental State Exam (Folstein, Folstein, & McHugh, 1975), the Cognitive Competency Test and Community Competence Scales (Moye, 1996), or the Hopkins Competency Assessment Test (Janofsky, McCarthy, & Folstein, 1992). These psychometric tools have, however, been criticized on the grounds that they do not account for heterogeneity among elderly people (Anastasi & Urbina, 1997) or that they lack accuracy because of the ill-defined nature of the concept of decision-making ability (Skelton, Kunik, Regev, & Naik, 2010).

For practical reasons, elderly people’s decision-making ability is, most of the time, assessed clinically (Moye & Marson, 2007). Professionals usually focus on components of this ability: (a) understanding the information relevant to the decision at hand, (b) appreciating the significance of this information as regard the present situation, (c) processing the information (e.g., by weighing the pros and the cons), and (d) expressing a choice (Grisso & Appelbaum, 1998; see also Marson, Earnst, Jamil, Bartolucci, & Harrell, 2000). Mukherjee and Shah (2001) have shown, however, that concordance between consultant psychiatrists’ assessments and those of an independent researcher using a standardized tool was only modest. Understandably, health professionals may err by underestimating or overestimating an elderly patient’s ability to make decisions. In particular, when a patient agrees with the psychiatrist’s suggestion of a treatment, the psychiatrist would naturally be inclined to have a positive view of the patient’s cognitive ability. When the patient disagrees, the psychiatrist would be inclined to have a negative view.

Volicer and Ganzini (2003) have shown that, in determining decision-making ability, a majority of members of four expert groups—chairs of Ethics Advisory Committees in the medical centers of the U.S. Department of Veterans Affairs, members of the Academy for Psychosomatic Medicine, and members of the Gerontological Society of America (who were either geriatricians or psychologists)—endorsed five basic elements as necessary: the ability to appreciate the consequences of the decision for oneself (98%); the ability to answer yes or no to a question (87%); the ability to provide rational reasons for the decision (80%); the ability to explain the treatment’s alternatives, risks, and benefits (79%); and the making of decisions that seem reasonable (57%).

Laypeople’s views regarding decision-making ability among elderly people, either healthy or suffering from cognitive and emotional impairment, are largely unknown. The only related study is by Pescosolido, Monahan, Link, Stueve, and Kikuzawa (1999), who examined laypeople’s views of the competence of persons with mental health problems such as alcohol or drug dependence, major depression, and schizophrenia. Thirty-six percent of their participants considered that a depressed person is not very able or not able at all to make treatment decisions and 30% considered that this person is not very able or not able at all to make financial decisions. In cases of substance dependence and schizophrenia, these percentages were still higher, ranging from 62% to 76%. Participants’ age was negatively associated with competence ratings: Older participants reported less confidence in troubled individuals’ ability to correctly manage their important affairs than younger participants.

This Study

This study aimed to complement the study by Pescosolido et al. (1999). It was motivated by these authors’ suggestion that if “public views regarding persons with mental illness motivate legal statutes and social practices involving those perceived as disordered, then an examination of public opinion is critical to ongoing debates” (p. 1339). This may be especially true when the persons with mental illness are elderly people. This study examined and mapped the views of laypeople and professionals (professionals who usually work with elderly people: nurses, occupational therapists, psychologists, and physicians) on elderly people’s ability to make informed decisions.

Three factors were considered: the type of decision to be made, the type and severity of the trouble, and the availability of social support at the time of decision-making. The type of decision factor involved, as in Pescosolido et al. (1999), a financial decision (selling the home) and a treatment decision (undergoing surgery). It also involved three additional types of decisions—accepting dietary changes, writing a will, and writing advanced directives—in order to cover a wide range of settings (American Bar Association Commission on Law and Aging, 2008). Kuther (2000) suggested that the type of decision to be made affects judgments of capacity as competency is highly domain-specific. Findings by Pescosolido et al. (1999) at least partly supported this view.

The type of trouble factor involved depression, as in Pescosolido et al. (1999), and dementia. Dementia was introduced in this study because it is the most frequently encountered mental problem among elderly people (American Bar Association Commission on Law and Aging, 2008). The type of trouble factor had five levels: slight depression, severe depression, slight dementia, moderate dementia, and severe dementia. Depression has been shown to be associated with loss in cognitive functioning (e.g., Di Schiena, Luminet, Chang, & Philippot, 2013; Hindmarch, Hotopf, & Owen, 2013). Dementia has been repeatedly shown to be a major determinant of capacity, even before it can be reliably diagnosed (Boyle et al., 2013).

Finally, the social support factor was introduced because experts have suggested that noncognitive factors, such as spouse’s help or friends’ advice, might have a positive effect on decision-making ability, even among demented persons (Sherod et al., 2009; see also Boyle et al., 2013). Knowing the extent to which people are aware that elderly people’s decision-making abilities can be enhanced if additional information and explanations regarding the task are provided, if the set of possible options is adequately framed, and if informal exchanges of viewpoints with members of the family or with friends can take place before deciding is important.

Hypotheses

We expected to find at least three distinct positions among laypeople and professionals. The first one would be a relatively pessimistic position. Participants holding this position would, like a nonnegligible (19%) proportion of participants in the study by Pescosolido et al. (1999), judge decision-making capacity as always impaired, irrespective of type of illness and severity of illness and irrespective of social support.

The second expected position would be a relatively optimistic position. People holding this position would, like another non-negligible (21%) proportion of participants in the study by Pescosolido et al. (1999), judge decision-making capacity as never severely impaired, irrespective of circumstances.

The third expected position could be called “Depends on Circumstances,” a position frequently observed in previous studies in empirical ethics (e.g., Lhermite, Munoz Sastre, Sorum, & Mullet, 2015). People holding this position would judge ability to make informed decisions as a function of the type of illness and the availability of social support, and possibly as a function of the type of decision to be taken.

We also expected that these positions would be associated with certain demographic characteristics, namely, personal experience with elderly people suffering from mental illness: Experienced people and professionals would be more optimistic about patients’ decision-making capacity than people lacking experience or expertise.

Method

Participants

The 170 participants were unpaid volunteers who were informed about the goals of the study and gave their consent. Their mean age was 36.29 years (standard deviation = 13.58, range = 18–81). Ninety-nine participants were laypeople, and 71 were health professionals. The demographic characteristics of the sample are indicated in Table 1.

Table 1.
Demographic Characteristics of the Sample and Composition of the Clusters.

Characteristic Level
Cluster

Often impaired Depends on trouble Depends on degree Not often impaired Total

Gender Female 18 (13)^a 55 (41) 30 (22) 32 (24) 135

Male 10 (29)^a 10 (29) 6 (17) 9 (26) 35

Age 18–26 Years 12 (19) 14 (23)^a,b 17 (27) 19 (31) 62

27–39 Years 5 (10) 25 (51)^a 8 (16) 11 (22) 49

40+ Years 11 (19) 26 (44)^b 11 (19) 11 (19) 59

Experience No 13 (23) 16 (29) 16 (29) 11 (20) 56

Yes 15 (13) 49 (43) 20 (18) 30 (26) 114

Status Laypeople 15 (15) 34 (35) 23 (23) 26 (27) 98

Health professionals 13 (18) 31 (43) 13 (18) 15 (21) 72

Nurses 6 (22) 13 (48) 3 (11) 5 (19) 27

Occupational therapists 0 (0) 6 (60) 3 (30) 1 (10) 10

Psychologists 3 (14) 7 (33) 3 (14) 8 (38) 21

Physicians 4 (29) 5 (36) 4 (29) 1 (7) 14

Total 28 (17) 65 (38) 36 (21) 41 (24) 170

Note. Figures with the same superscript are significantly different, p < .05.

The laypeople were approached by three trained research assistants while they were walking along the main sidewalks of a large city in Southern France. Overall, 255 persons were contacted, and after having received a full explanation of the procedure, 66% of them agreed to participate. The professionals were contacted at their office or at nursing homes: 71% agreed to participate. Among the laypeople, 52% had been directly confronted at least once with this kind of problem in their family.

Material

The material consisted of 50 cards containing a scenario of a few lines, a question, and a response scale. The scenarios were composed according to a three within-subject factor design: (a) the availability (or not) of social support at the time of making an important decision, (b) the type of decision to be taken (agreeing to surgery, selling her personal home, making a will, indicating advance directives, or changing her diet), and (c) the type of problem (slight depression, severe depression, slight dementia, moderate dementia, or severe dementia).

The statement used to indicate slight depression was, “For some time, Mrs. X. has seemed depressed. The staff notices that she stands back a little, that she is taking less pleasure in her usual activities and seems sad.” The statement describing severe depression was, “For some time, Mrs. Y. has seemed very depressed. The staff notices that she completely isolates herself, that she often cries; she has even formulated thoughts of death.” The statement indicating slight dementia was, “For some time, the staff has observed memory troubles in Mrs. Z. For example, she often forgets the place where she has just left her glasses or she forgets important appointments.” The statement for moderate dementia was,
Mrs. Q. is more and more disoriented. She no longer comes by herself to the dining room; the staff has to let her know about meals because she forgets meal times and gets lost in the corridors. Mrs. Q. has to hunt for words more and more, and her speech is not always understandable.

The statement used to indicate severe dementia was, “Mrs. R. is completely disoriented about time; she confuses morning and evening, and get up in middle of the night. She is also disoriented about space; she is unable to find her room by herself.” Age and gender were held constant: All the persons were 82 years old and identified as “Mrs.” A female character was chosen because elderly females over 80 years are more numerous than elderly males (Mazuy, Barbieri, Breton, d’Albis, & Reeve, 2015).

Under each scenario were a question and a response scale. The question was, “To what extent do you think that Mrs. [the name of the person] is capable of making this decision?” The response scale was an 11-point scale (0–10) with a left-hand anchor of Not at all capable and a right-hand anchor of Completely capable. The cards were arranged by chance and in a different order for each participant.

Procedure

The site was a vacant room in the nursing home, in the university, or in the participant’s home. Each person was tested individually according to the procedure recommended by Anderson (2008, 2018). The experimenters routinely made certain that each participant, regardless of age or educational level, was able to grasp all the necessary information before making a rating. The participants took 20 to 40 minutes to complete the ratings. The participants knew in advance how long the experiment would last. None of them complained about the number of vignettes they were required to evaluate. The research was approved by the laboratory of ethics of the Institute of Advanced Studies, and informed consent was obtained from all participants in the study.

Results

A cluster analysis was performed on the raw data using the procedure advocated by Hofmans and Mullet (2013). Four clusters were identified. They are shown in Figure 1. Analyses of variance were performed on the data from each cluster. Their design was Social Support × Type of Decision × Type of Trouble, 2 × 5 × 5. The main results are shown in Table 2. Owing to the multiple comparisons done, the significance threshold was set at .001.

Figure 1.
Pattern of results observed for the four clusters pooled across the four tasks. In each panel, the y-axis corresponds to the capacity judgments, the x-axis bears the five levels of cognitive trouble, and the two curves correspond to the two levels of social support. Sl. Dep. = slight depression; Sev. Dep. = severe depression; Sl. Dem. = slight dementia; Mod. Dem. = moderate dementia; Sev. Dem. = severe dementia.

Table 2.
Main Results of the Analyses of Variance Performed at the Cluster Level and at the Sample Level.

Cluster and factor df MS F p $η_{p}^{2}$

Often impaired

Social support (S) 1 260.58 34.0983 .001 .56

Type of decision (D) 4 17.71 3.8274 .01 .12

Trouble (T) 4 766.71 50.6882 .001 .65

Depends on trouble

Social support (S) 1 295.51 26.428 .001 .29

Type of decision (D) 4 6.00 1.384 .24 .02

Trouble (T) 4 6,748.16 623.845 .001 .91

Depends on degree

Social support (S) 1 894.65 27.129 .001 .44

Type of decision (D) 4 15.63 2.293 .07 .06

Trouble (T) 4 1,109.88 65.756 .001 .65

D × T 16 6.33 3.455 .001 .09

Often impaired

Social support (S) 1 166.4 19.190 .001 .32

Type of decision (D) 4 14.9 3.604 .01 .08

Trouble (T) 4 1,204.6 106.052 .001 .73

Whole sample

Group 2 97.08 0.67 .41 .00

Social support (S) 1 1,363.03 86.41 .001 .34

Type of decision (D) 4 24.15 4.87 .001 .03

Trouble (T) 4 8,412.07 409.65 .001 .71

Note. MS = Mean square

The first cluster (N = 28) was termed Often Impaired as for participants in this cluster, ability to decide was, most of the time, low (M = 2.70). Ability to decide was judged higher in the case of slight depression (M = 5.13) than in the case of severe depression (M = 3.38), slight dementia (M = 2.61), moderate dementia (M = 1.34) or severe dementia (M = 1.06). It was also judged higher when social support was available (M = 3.14) than when it was not available (M = 2.27). As shown in Table 1, male participants were more frequently members of this cluster than female participants.

The second cluster (N = 65) was termed Depends on Type of Trouble as the most important factor was the type of trouble. Ability to decide was judged high in the case of slight depression (M = 8.84) and severe depression (M = 7.20). It was judged lower in case of slight dementia (M = 5.36), moderate dementia (M = 2.57), and severe dementia (M = 1.02). It was judged slightly higher when social support was available (M = 5.30) than when it was not available (M = 4.70). Older participants (27+) were more frequently members of this cluster than younger participants.

The third cluster (N = 65) was termed Depends on Degree of Trouble. As in the second cluster, the most important factor was type of trouble, but the direction of the effect was different. Ability to decide was judged relatively high in the case of slight depression (M = 7.39) and slight dementia (M = 6.25). It was judged lower in the case of severe depression (M = 4.75), moderate dementia (M = 3.94), and severe dementia (M = 3.03). It was judged notably higher when social support was available (M = 5.78) than when it was not available (M = 4.37).

The fourth cluster (N = 65) was termed Not Often Impaired as for participants in this cluster, ability to decide was, most of the time, high (M = 7.47). Ability to decide was judged high in the case of slight depression (M = 9.33), severe depression (M = 8.35), and slight dementia (M = 8.19). It was judged lower in the case of moderate dementia (M = 6.47) and severe dementia (M = 5.03). It was judged slightly higher when social support was available (M = 7.76) than when it was not available (M = 7.19).

A global analysis of variance comparing the two groups of participants was also performed. The design was Group (laypeople vs. health professionals) × Social Support × Type of decision × Type of Trouble, 2 × 2 × 5 × 5. Main results are shown in Table 2 (bottom part). The Group factor was not significant, and no interaction involving the Group factor was significant. The mean ratings were 5.32 (laypeople) and 5.11 (health professionals). For each of the four subgroups of professionals, the mean ratings were 4.94 (nurses), 5.47 (occupational therapists), 5.49 (psychologists), and 4.61 (physicians).

The composition of each cluster is indicated in Table 1. From the four χ² tests that were performed, only the one involving personal experience was close to being significant (at p = .05), χ²(3) = 7.20, p = .066. People without experience with this type of problem tended to be more frequently found in the Often Impaired and Depending on Severity clusters than those with experience.

Discussion

We examined and mapped the views of laypeople, nurses, occupational therapists, psychologists, and physicians on elderly people’s ability to make informed decisions. As hypothesized, several different positions were found. The first one—Often Impaired (17% of the participants)—was to consider that even persons suffering from slight depression were already relatively incapable of making decisions such as a change in diet or the writing of advanced directives. This result was consistent with previous findings by Pescosolido et al. (1999) showing that, for a nonnegligible proportion of participants, depressed people’s decision-making capacity was considered as always impaired. It was consistent with findings by Guedj, Sorum, and Mullet (2012) showing that 15% of participants were of the view that psychiatric patients might be hospitalized, even against their will. Finally, it was consistent with findings by Igier, Munoz Sastre, Sorum, and Mullet (2015) showing that, in the context of breaking bad news to patients, telling the full truth to an elderly person was for some people not appropriate. In all four situations, patients were considered as too impaired to understand the information or to make sound decisions. In other words, the benevolence principle of bioethics (Beauchamp & Childress, 2008) was considered as taking precedence, in these cases, over the autonomy principle so that decision-making would have to be delegated to a third party.

This first cluster strongly contrasted with the fourth one that was called Not Often Impaired (24%). Participants in this cluster considered that only elderly people suffering from moderate or severe dementia were too impaired to make decisions. This result was consistent with previous findings by Pescosolido et al. (1999) showing that, for another proportion of participants, depressed people’s decision-making capacity was considered as not impaired. It was consistent with findings by Guedj et al. (2012) showing that 5% of participants were of the view that psychiatric patients must never be hospitalized against their will. Finally, it was consistent with findings by Igier, Munoz Sastre, Sorum, and Mullet (2014) showing that, for a majority of their sample, telling the full truth to an elderly person was always the most appropriate course of action. In all four situations, patients were considered as never impaired to the point of not being able, possibly with the help of relatives, to understand the information or make sound decisions. In other words, in these participants’ views, the autonomy principle must, in these cases, take precedence over the benevolence principle so that the patient’s decision must be respected by caregivers, even if different from the one they would have recommended or made for themselves.

A majority of participants in this study (59%), however, expressed a position that can be considered as intermediate (the second and third clusters). In their views, impairment was a function of the severity of the illness or the type of illness. This result was consistent with previous findings by Guedj et al. (2012) that a majority of participants thought that the only psychiatric patients who could be hospitalized against their will were those likely to put their life or someone else’s life at risk. It was also consistent with findings by Igier et al. (2015) that, for one quarter of their sample, telling the full truth to a patient must be conditional on the patient’s expectations and on the physician’s perception of the situation. This third viewpoint is a pragmatic one. In all three situations, patients were considered as more or less impaired depending on their symptoms. In the best cases, the autonomy principle would take precedence over the benevolence principle. In the worse cases, the benevolence principle would take precedence over the autonomy principle.

The type of decision to be made was never taken into account by the participants in their judgments about capability. This means that decision-making ability was conceived of as task-independent. This is apparently contrary to Kuther’s (2000) suggestion that competency is task-specific. The discrepancy can be, however, explained. Most people would agree that some decisions are easier to make than others and that the ease of decision-making largely depends on training and previous experience (Phillips, Klein, & Sieck, 2004). The types of decisions in this study were decisions about which the elderly persons would have no training and little previous experience. Undergoing surgery and selling one’s home are too infrequent for most people to gain experience in deciding about them. This may explain why participants did not make any distinction between them. If an easier task had been considered in the scenarios (e.g., choosing between coffee and tea with breakfast), a task effect would probably have been observed but would have been trivial; it is the difficult and unfamiliar decisions that are important.

Although social support was seen as having positive effects on decision-making ability, the impact of this factor was always very modest. This is understandable as participants would also not expect the elderly person’s family and friends to have much training or previous experience in dealing with the problems of old age (American Bar Association Commission on Law and Aging, 2008). If help from professionals (e.g., by geriatric psychologists) had been considered in the scenarios, in addition to help from relatives and friends, a larger effect of social support might have been observed.

Implications

First, we found several clusters, that is, groups of individuals who held a similar and distinctive set of beliefs about the relation of depression and dementia to capacity to make decisions. This pluralism of views about ethical issues is typical of people in ideologically diverse societies like France (Guedj et al., 2012; Lhermite et al., 2015).

Second, participants in all clusters ordered the conditions in a reasonable fashion—the more demented or depressed the patient was, the less degree of capacity was attributed to her. This suggests that they understood the task and responded coherently to the stories.

Third, the vast majority was not absolutist, but instead had nuanced views, taking into account the various circumstances. This has been found for other ethical, even highly contentious, issues such as abortion and ending patients’ lives (Mullet et al., 2014; Munoz Sastre, Petitfils, Sorum, & Mullet, 2015). This implies that, to achieve the agreement of most people, whether health professionals or laypeople, laws and policies regarding this and many other issues should not be all-or-nothing but should be formulated to allow judgments that differ according to circumstances.

Fourth, most participants thought that depression, even severe depression, does not interfere as much with decision-making as does dementia, even slight dementia. This is of clinical importance as these participants would, it appears, allow even severely depressed persons to make major life choices in spite of the considerable evidence that depression impairs decision-making (Hindmarch et al., 2013).

Fifth, the participants seemed to have a rather fixed conception of cognition according to which decision-making—whether intact or impaired—is independent, at least to some degree, of social influences, including social support. If true—and supported by further studies—this conception may lead people, including health professionals and family members, to neglect the explanation of tasks and social support that, many psychologists contend (Dunèr & Nordstrom, 2007), are needed for sound decision-making, especially among people who are or may be cognitively impaired.

There are also implications for research. Prusaczyk, Cherney, Carpenter, and DuBois (2017) have recently suggested that owing to concerns related to the ethical imperative of informed consent, elderly people are too often excluded from high-quality studies even when these studies are not directly related to cognitive functioning. If researchers and members of ethics committee could be better informed that, with adequate assistance, elderly participants can knowingly consent, more research on the effect of aging could be conducted.

Limitations

Our study has limitations. First, our samples, especially of health professionals, were of modest size, were convenience samples, and were composed only of people living in the south of France. Generalizations of our findings to other groups must be made with caution, and further studies of health professionals, in particular, need to be done.

Second, we presented the participants with scenarios, not with real patients. While scenarios are less realistic than patients, their use is more feasible, allows more precise statistical analyses of the variables, and has been repeatedly defended (Froberg & Kane, 1989; Ulrich & Ratcliffe, 2008).

Third, the experimenters did not ask further questions to elucidate the reasons, no doubt both personal and cultural, for the participants’ responses. These questions might have taxed the patience of the participants and their willingness to disclose personal information but would have been of great interest and allowed us, in particular, to understand better the relation between declared beliefs and actual judgments.

Fourth, although participants did not complain, the time and effort needed to respond to multiple scenarios may have resulted in some fatigue and loss of concentration. The random order of scenarios reduced the impact of fatigue on the mean responses of clusters of participants.

Characteristic	Level	Cluster
Gender	Female	18 (13)^a	55 (41)	30 (22)	32 (24)	135
Male	10 (29)^a	10 (29)	6 (17)	9 (26)	35
Age	18–26 Years	12 (19)	14 (23)^a,b	17 (27)	19 (31)	62
27–39 Years	5 (10)	25 (51)^a	8 (16)	11 (22)	49
40+ Years	11 (19)	26 (44)^b	11 (19)	11 (19)	59
Experience	No	13 (23)	16 (29)	16 (29)	11 (20)	56
Yes	15 (13)	49 (43)	20 (18)	30 (26)	114
Status	Laypeople	15 (15)	34 (35)	23 (23)	26 (27)	98
Health professionals	13 (18)	31 (43)	13 (18)	15 (21)	72
Nurses	6 (22)	13 (48)	3 (11)	5 (19)	27
Occupational therapists	0 (0)	6 (60)	3 (30)	1 (10)	10
Psychologists	3 (14)	7 (33)	3 (14)	8 (38)	21
Physicians	4 (29)	5 (36)	4 (29)	1 (7)	14
Total		28 (17)	65 (38)	36 (21)	41 (24)	170

Cluster and factor	df	MS	F	p	$η_{p}^{2}$
Often impaired
Social support (S)	1	260.58	34.0983	.001	.56
Type of decision (D)	4	17.71	3.8274	.01	.12
Trouble (T)	4	766.71	50.6882	.001	.65
Depends on trouble
Social support (S)	1	295.51	26.428	.001	.29
Type of decision (D)	4	6.00	1.384	.24	.02
Trouble (T)	4	6,748.16	623.845	.001	.91
Depends on degree
Social support (S)	1	894.65	27.129	.001	.44
Type of decision (D)	4	15.63	2.293	.07	.06
Trouble (T)	4	1,109.88	65.756	.001	.65
D × T	16	6.33	3.455	.001	.09
Often impaired
Social support (S)	1	166.4	19.190	.001	.32
Type of decision (D)	4	14.9	3.604	.01	.08
Trouble (T)	4	1,204.6	106.052	.001	.73
Whole sample
Group	2	97.08	0.67	.41	.00
Social support (S)	1	1,363.03	86.41	.001	.34
Type of decision (D)	4	24.15	4.87	.001	.03
Trouble (T)	4	8,412.07	409.65	.001	.71

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Astrid Lhermite is a clinical psychologists who is currently in private practice.

Maria Teresa Munoz Sastre is professor of health psychology at the university of Toulouse.

Paul C. Sorum is professor of internal medicine at Albany Medical College.

Etienne Mullet is director of research at the Institute of Advanced Studies (EPHE), Paris.

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