1. No category

ZD G CP F N K DC O K K I F UG S C \ GK \B \ GP N K E G \ G R G ZY T
NGBK OKZVB
DGXZF FZ[ OKNGIF-\KC ,CMZGP EGTKSN \KZJBKZDF FYNIPF NFRP
OKN[GZK ,"FSEF"G \KZCTF FJKSZCKRGBF N[ FBGVZN ZVSF-\KCN URGSP
OGKM[ \GKF \BH .\GCGZP \GK\B \GKTC GRKRVC CKXP ZDGCPF OEBC NGVKJF
OKCZG ,\GKRGZMF OFK\GNIP OT \GCZ OKR[ OKKI ,OKPK OKMKZBP OKNGIF
.L[GPP HGV[B \GZDSPC \GRGZIBF OFK\GR[C OKFG[
HMZPC EPGT NVGJPF[ LMC BJC\PF ,KGRK[ NNGI\P \GRGZIBF OKR[C
FZCD NVGJPF N[ FKPGRGJGBF .FEKXF YIER NVJPF[ EGTC ,JKNIP[ FH BGFG
LMKVN .JBN NINIP FH KGRK[ ,\BH OT .NVJPF N[ OHKNRZJVF NT QM OB
,NVJPC K\GN\ OEBF GC[ ,ZDGCPF NKDC \PXT\P \K\B-\KBGVZF FPNKEF
OKZIB KEK-NT \GNCY\P \GJNIFF CGZG ,GKKI UGSC NGNX BN OK\KTNG [NI
.\GKEKKP \GJNIF OK[ZGE[ WIN KCXPC
FNGIC \GC[I\P QRKB ,ZDGCPF NKDC \GNCY\PF \GJNIFFP \GCZ
,N[PN LM .GK\GVETFG GK\GRGXZ \B \GECMP QRKBG \KMZTG \K[DZ FRKICP
NGVKJF \[DEF LG\ JYRKFN FMKZX KRVGSF FNGIC KR[NGV NGVKJP \GTRPKF
LKNF\C FIV[PFG FNGIF KGGKN .\GIGR-KBG NCS ,CBM TGRPN ETGR[ LPG\F
BGF \GGPF QM[ ,NVJPF N[ G\CGI OF G\GP KRVN FNGIF \[KJR-KBG FSKSDF
.KBGVZ QGN[KM IZMFC GRKBG KTCJ
OT EEGP\FN OKRMGP ORKB OFK\GIV[PG OKNGIF[ BKF \VSGR FKTC
\GZB[R \GPNKEFP \GCZ ,LMP FBXG\M .GCBJ OFC OKBGZG \GK\B \GPNKE
.OKKIF UGSC \GZG\V K\NC
\KBGVZF FYK\BC OKD[GPC ,\KZJBKZD JCP \EGYRP ,QE KIMGRF ZPBPF
\KBGVZ \GZK[M ,FKPGRGJGBF QGZYKT :QGDM ,GKPK UGSC FNGIN OKSIKK\P[
ZPBPF LMN USGRC .\GPEYGP \GKIRFG \TEP FPMSF ,(\GKJRJVPGY)
L[GPP HGV[BN \GZDSPC \G[IZ\PF \GKPGKPGK \GK\B \GPNKEC YSGT
EGYV\ KNTCG OKK\GN\ OCGZ[ OKNVGJPN \GZG[YG (LTC ± Long Term Care)
\GZK[Y TGXKC ,FCKYN \ZRX LZE FRHF Q\P :QF \GPNKEF .EGZK KCKJRDGYG KRVGD
OKKIF K[EGIC LPG\ NGVKJ ,OKNGI-\KCN FZCTF ,OKNVGJPF \NCDFG
.OKNGIF \GKGMH NT FZKP[G OKRGZIBF
FYK\BF \GRGZYT
BVGZG FNIP ,(NVGJP) FNGI { OKRPHF NM N[ KIXRF [NG[PC OKEGYEGYF \[GN[
F\JR OKR[ \GZ[T L[PC[ \NJGJPF .FHT FNJNJ \GRGZIBF OKR[C OKZCGT { (NVJP)
,NVGJPN CGJ FP TEGK[ FH BGFG KBGVZF TEKPF NM GKEKC[ (BVGZ) NVJPC EYP\FN
83
{
{
99 83 ,2008 J"S[\ ,(3)FN FKDGNGJRGZD
NGBK OKZVB
\GKIB ,OKBVGZ { OKNVJPN .FNGIC \EYP\P \TMG \GRGZIBF OKR[C QGGKM F\RK[
HMZPC BXPR FNGIF GC[ ,[EIF CXPF OT OKN[FN NY BN { OKZIB OKKTGXYP OKNVJPG
FMVFG NVJPF N[ OHKNRZJVF \B FIXKR NVGJPF N[ FKPGRGJGBF .ZCE Y[K GKV NTG
.FXYGPN LVF OHKNRZJVF[ EGTC ,OK[EGYF [EGYN
OT EIK .OHKNRZJVF \B YGIEN FKPGRGJGBF NTG GEGSKC QGMR BGF LKNF\F[ YVS QKB
QGHKB ,\GK\EKP NT ZGP[NG \GNNMFP ZFHKFN [K ,GRKRKT EDRN \EPGT FNGIF \CGJ OB ,\BH
.CFHF NKC[ \B BGXPN KEM QGMR QGRKPG
,CIZ BGF \GKTCF IGGJ .\GCZ \GK\B \GKTC GRKRVC CKXP ZDGCPF OEBC NGVKJF
\GKGMHN \GSIKK\FC FNMG GN[ QGPKPF \GZGYPG NGVKJF OGYKP NT \GJNIFP NIF
\GC[I\FN \GTDGR \GK\GFP \GK\B \GNB[ .\GJNIFC GVG\K[ \EKPNG FNGIF
NGVKJF N[ \GKCKSRJRKBF \EKPN ,OKRG[F NGVKJF KDGS NT FJNIFC FNGIF \GVETFC
NDGSP GRKB FNGIF OFC[ OKCXPC \GJNIF \NCYNG \GPEY\PG \GKRVGS \GNIPC
.JKNIFN
[NI ,K\GN\ G\GKF N[C \PXT\P ZDGCPF OEBC NGVKJC \K\BF-\KBGVZF FPNKEF
.WIN KCXPCG OKZIB KEK-NT \G[TR \GJNIFF CGZ ,LMN KB .GKKI UGSC NGNX BN OK\KTNG
OT EIK G\KCC FNGIF \JKP EKN ,BVGZF KEK-NT NGVKJF NT \GJNIFF G[TR ZCTC
,LVKFN BNB ,\GKRGZMF OFK\GNIPP OKZJVR ORKBG OKKI OKMKZBP OKNGIF OGKM .G\IV[P
FKDGNGRMJNG KEGTKSFG KBGVZF NGVKJN \GEGF ,O\GP OZJ \GCZ OKR[ LZGBN Q\KB OKKI
WZPR NGVKJ \YNIP QGDM \GKRMJG \GZMGRP \GZDSPC OKZJVR OCGZ .\PEY\PF \KBGVZF
.OKNGIF-K\CC \GKPKRVF \GYNIPFG
\GJNIFFP \GCZ ,\K[BZ .ZDGCPF FNGIC NGVKJC OKK\KKTC OKJCKF ZVSP \GRPN Q\KR
FNGIN \GSIKK\F FZSI .ORGXZCG OKNGIC \GC[I\P QRKB \GNCY\P[ \GKBGVZF
.GK\GVETF \B BNPKG GK\GRGXZ \B ECMK[ QVGBC KMZTFG K[DZF ZG[KPC G\IV[PNG
,K[GRBF ,LPG\F NGVKJF N[ FIRHFG KRMJFG KR[NGVF NGVKJF N[ F[DEF [K ,\KR[
KGGKN ZSIG KBGVZ QGN[KMM SV\KFN LK[PP \GGPF ,\K[KN[ .\GIGR-KBG NCS ,CBM \TKRPN
.(Lynn, 1996) FSKSDF LKNF\C FNGIF N[
OFK\GIV[P KRCG OKZDGCPF OKNGIF QM[ ,\GZG\V K\NC \GZB[R \GCZ \GK\B \GPNKE
.QFP OKT\ZR UBG GNB \GPNKE OT EEGP\FN OKRMGP ORKB
\XGCY OKRYHF OKNGIC \GBZN KGBZ OBF BKF FYK\BF OGI\C \K\GFP FNB[
KVM FC NVJR OBG "FKKI \B F\KI" \ZDGCPF FKSGNMGBF[ QGTJN Q\KR .\EZVR \GSIKK\F
\DGT \B [[GZKG OKCB[PF \GRKPH \B EKZGK ZCEF ,FKKI \B LKZBRG OKZKTXC OKNVJP[
QRKB[ \GKEGIK \GKTC QF ZDGCPF NKDC \GK\B \GKTC ,GH F[KD KV-NT .\NENEKPF CKXY\F
\GIKM[ \GK\BF \GKTCF ORPGB .FEGSKC \GTJ[ FC[IP KFGH .\KNNMF FYK\BN \GZG[Y
GKFK FKZJBKZDC WPBR[ \GRGZ\VF[ KGBZ LB ,OKZKTXF N[ GNBP \GRG[G OKRYH NXB Z\GK
.ZIB OGI\ NMC OKDGFRF OKK\BF \GRGZYTN OB\FC
OKBC OF GC[ QVGBC QGEN LM-ZIBG OKK\BF \GRGZYTF \B FNKI\ JZVN LMKVN KGBZ
:OF \KBGVZF FYK\BF \GRGZYT .ZDGCPF FNGIC NGVKJC KGJKC KEKN
84
ZDGCPF NKDC OKKIF UGSC \GK\B \GPNKEG \GRGZYT
KBGVZ NGVKJ FHKBG GVGDN F[TKK FP JKNIFN G\GMHG FNGIF QGXZ EGCKM .FKPGRGJGB
.NCYK BN ZYKTCG NCYK
.G\CGJN NGTVNG FNGIF OT CKJKFN FCGIF .CGJ \KK[T
.FGG[ FZGXC OKCB[PF \B YNING Z[GKC NVJN FCGIF .YEX
.FNGIN YKHFN BN FCGIF .YHR \TKRP
Kane, R. L., Ouslander, J. G., &) FNGIN \GRPBR NT ZGP[N FCGIF .\GRPBR
.(Abrass, I. B., 2004
.1
.2
.3
.4
.5
.FPDGEN OKZYP \BCF LG\ ,\KBGVZF FYK\BC OKKSKSC OKD[GP FPMC \TM QGER
\GKIRFG \TEP FPMSF ,(\GKJRJVPGY) \KBGVZ \GZK[M ,FKPGRGJGBF QGZYKT :OF OKD[GPF
.\GPEYGP
.GK\GRGXZN OB\FC GVGD NT FNGIF \GMH [GPKP BGF \KBGVZF FKPGRGJGBF QGZYKT .B
.\GJNIFF \B NCYP NVJPF FC[ \KJSKNRZJVF F[KDN EGDKRC ,JKNIK[ FH BGF NVGJPF
.\GRGMR \GJNIF NCYNG CXPF \B LKZTFN NDGSP NVGJPF OBF BKF \ZZGT\PF FNB[F
ZETKF[ FZYPC .YHR \TKRPG CGJ \KK[T N[ \GRGZYTC [DR\FN NGNT FKPGRGJGBF QGZYKT
YKEXFN LMKVN Q\KR ,K\GTP[P QVGBC GCXP \B ZV[K NGVKJ Q\P GNKBG FNGIC TDVK NGVKJ
G\NIPP [\GP FNGIF Z[BM BGF FKPGRGJGBF NT ZGP[N F[Y GC[ USGR CXP .OHKNRZJV
.JKNIFN F[Y\PG
FZVGFG KBGVZ OHKNRZJV NTVGF ,FNGIF \GP \B TGRPN KEM GC[ DKZI ZGVKS QNFN
OT \ZMGS \NIPP NCS[ 60 QC ZCDN SIKK\P QGERF FZYPF .FNGIF N[ FKPGRGJGBF
FR[ .GKKI \B QMKSG OFEHF[ GNDZ-UMC K\ZMGS CKM FKF FNGIN .FZJPF KZCB NMC FTKDV
.OKNDND BSKMN Y\GZP FKF HBPG ,I\GR BNG LZKF ZBGGX [BZ \B ZC[ BGF QMN OEGY
BN \BH[ ZKFCFG UYG\ NMC FTKJYN EDR\F BGF LB ,GNDZ \B TGJYN [K[ ZPBR FNGIN
(SKSVS) OEC J[V\F OGFKHF .GNDZ \B TGJYN OKCKKI[ GN ZPBR FC[ FRG[BZF OTVF
.NDZF \TKJY BNN KRNJYF OKPSYF NDTPP \BXN FKF Q\KR BN .ZEZEKF \GKNMF EGYV\G
OFKCB N[ KBGVZF GCXP KM OFN ZFCGFG GKENK GBZYR ,OGKZKNEC TY[ FNGIF[ ZIBN
NCYNG OFKCB NT OKSGVGZJGVBM \GRP\FN G[YC\F OF .\GPK ,I\GRK BN OBG F[Y
CBFG OKSGVGZJGVB O\GB FRKP JV[PF-\KC OGK G\GBC .GRGXZ \B \EDGRF FJNIF
-\KCP GZGZI[ OGKCG ,FTKJYF ZIBN FYNIPN ZHI FNGIF .GNDZ \TKJYN IG\KRN IN[R
NKXFN FMH[ KP FGGI[ ZKER Z[GB N[ TDZ F\KF KZGCTC[ ,FKEGF \CKSP LZT OKNGIF
.\IB [VR
\GZK[M NTC \GKFN NVGJPF NT ,FKPGRGJGBF \B [PPN KEM .\KBGVZ \GZK[M .C
\B TKCFN G\NGMKC ,BXPR BGF FC[ FKXBGJKSF \RCFC \BJC\P \GZK[MF .(\GKJRJVPGY)
\TEP FPMSFC ZCGEP OB QKC ,FJNIF NM N[ \GMN[FF \B QKCFNG GK\GVETFG GK\GRGXZ
.\TEP CGZKSC GB
.\KBGVZ \GZK[M QKCN (legal competence) \KJV[P \GZK[M QKC QKICFN GRKNT
85
NGBK OKZVB
CGJ QKC QKICFN TEGKF FNTPG 18 NKDP OEB NMN SIKK\PF KJV[P IRGP BKF FRG[BZF
.JV[PF-\KC FRPP G\GB[ SGVGZJGVBN YGYH ,LMN NDGSP BN[ KP .TZN
NVGJPF N[ G\GZK[MN \TDGRG BVGZF \GMPSN FRG\R \KBGVZ \GZK[M ,\BH \PGTN
N[ \GMN[FF \B NGY[NG GCXP \B QKCFN GKNT .KBGVZF GCXPN SIKC FJNIF NCYN
NT SSC\FN FMKZX \KBGVZ \GZK[M NT FJNIFF .G\JNIFP \GTCGRF NGVKJ-KB GB NGVKJ
OKRICP :GNB \GNGMK N[ Q\EKEPN \GRG[ \GJK[ \GPKKY .(\GKCKJKRDGY) \GKNM[ \GNGMK
\KBGVZ \GZK[M NT FJNIFF .OKKDGNGMKSVGZKR OKRICPG OKKEGYV\ OKRICP ,OKKNJRP
\B OKYEGC OKKEGYV\F OKRICPF .OKKEGYV\ OKRICP NT ZYKTC SSC\FN FMKZX
Z[B (Activity of Daily Living ± ADL) \GKPGKPGK \GKGNKTV N[ \GNJPC FNGIF KTGXKC
\KEGYV\ FMZTFN OKREPGB N[ \GPZ FPM \GPKKY .\KBGVZF G\GZK[M \EKP \B \GVY[P
(Basic Activity of Daily Living ± BADL) KSKSCF KPGKPGKF EGYV\C \GNJP TGXKC :QFG
;OKZDGSF NT FJKN[G FRKKDKF NT FZKP[ ,\GZCTF TGXKC ,\G[CN\F ,FNKMB ,FXIZ QGDM
\KCF Y[P NGFKRN NNM LZEC \GZG[Y[ (\GKNJRPGZJSRKB) \GCMZGP \GNJP TGXKC
\RGMP \NTVF ,\GIGZB \RMF N[PN ,(Instrumental Activity of Daily Living ± IADL)
NGFKRG \GVGZ\ \NKJR ,QGVNJC [GPK[ ,FZGCI\C [GPK[ ,\GKRY \MKZT ,\KCF KGYKR ,FSKCM
GPM (Advanced Activity of Daily Living ± AADL) \GPEY\P \GNJP TGXKC ;OKVSM
JPGVSMP USM \MK[P ,[KCM \KKXI ,FVY-\KCC FIK[G KGNKC ,CMZC FDKFR \TC \GDFR\F
.\GRIC OKMZXP \[KMZG
,QGRM\ ,JGVK[ N[ \GKCKJRDGY \GNGMK \RDVF [ZGE \GPEY\PG \GCMZGP \GNJP TGXKC
,NBKZB) \KBGVZF \GZK[MF \MZTFN \GCG[I[ \K[KB-QKC \ZG[Y\G \GJNIF \NCY
.(2002 QKXZGYG KRPKSGB
,OKTDVR BN (BADL) OKKSKSCF OGKPGKF KEGYV\ ,QG\PFG KRG[BZF CN[C FKXRPEC
QICP GPM OKKNJRP OKREPGB .OKTDVR (IADL, AADL) \GCMZGPF \GNJPF KEGYV\ GNKBG
N[ FMZTFN CGJ EEP ORKB (Mini Mental State Examination ± MMSE) KCKJKRDGY
OKKGRK[G \GJNIF \NCY ,JGVK[F \NGMK NT FMZTF OKNNGM OF[ OG[P \KBGVZ \GZK[M
,OKVKZI OKTGZKB CYT \KRPH \KBGVZ \GZK[M-KB \PKKY[ OD QM\K .(1998 ,YRKKF) \GK[KBC
EGCKB GB QGZMH \KTC NM BN .\GKNGCJPG \GKPGFKH \GNIPG OKNGI-K\CC OKHGV[B GPM
FNB OKCXPC OK\KTN .\KBGVZ \GZK[M-KBN EEP OF OGYPCG QPHC (FKXJRKKZGB) \GBXP\F
NM BN ,LMN USGRC .\GVETF TKCFNG \GJNIF NCYN \NGMKG FKXBGJKSF N[ FRCF [K QKKET
OF FKBZFG ,FEGZK \KBGVZ \GZK[M NT FTKCXP FFGCD \GN\C FGGNPF FEGZK EGYV\ \PZ
EGPT KTGDVG (Anyotrophic Lateral Sclerosis ± ALS) \KEX \KVGZJGKPB \[ZJ KNGI
.\KBGVZ \GZK[M KNTCM OKZEDGP LMKVNG FKXBGJKSF \B OKRKCP QKKET[ ,FZE[
[K ,\BH OT .\KBGVZ FNGTV NM KRVN FNGIF \GKGMH YGI KVN \CKKI\P \TEP FPMSF .D
FRKB \KBGVZF FV[F .\GCK[I FN [K K\PG TXC\FN FPMSFF NT EXKM ZKFCFN OGYP
\B ZKFCFN [K .OKKBGVZ OKIRGP BNN FZGZC FV[C ZCEN [K QM NTG OKNGIN \RCGP EKP\
\GBZNG \GKGZ[VB CIZP \\N [K .\[YC\PF \KBGVZF FNGTVC[ \NTG\F NGP OKRGMKSF
86
ZDGCPF NKDC OKKIF UGSC \GK\B \GPNKEG \GRGZYT
OKZIB EDRPG ,OKJZV KJZVC NGMF TGP[N OKXGZ[ OK[RB [K .GRNGP EPGT[ OEBF GFKP
F\B" :FJNIFF \B BVGZF NT NKJP NVGJPF OK\KTN .O\GB EKIVP JZGVP ZGBK\[
\EYGPP \GKFN FMKZX FJNIFF ,LMN USGRC "?K\GB NBG[ F\B FPN .JKNI\ HB ,BVGZF
FJNIF LGZMN QKB ,N[PN LM .\GKTC ZVSP KCDN \VZGD FJNIF BNG \IB \PKGSP FKTCC
G\RCFN ZSPRF TEKPF \PZ \B OKB\FN [K .\GCB-\KCN ZCTP NT FJNIF OT IG\KR NT
TEKPF \B Q\GR[ BVGZF .FCGI KEK \BXN KEM SVGJF \BKZYC YV\SFN BNG ,FNGIF N[
.G\TE \B UGMN BN LB ,GTRM[N \GSRNG ECNC NVGJPF \CGJ \B GKRKT EDRN \GBZN LKZX
TDZC[ FEKPC OKKIF UGSN TDGRC \GJNIFN SKSC G[P[K[ \GKIRF QF \GPKEYP \GKIRF .E
NCYRG B[GRF NT NVGJPF OT IIG[R OB .GK\GVETF \B BJCN NMGK BN FNGIF \PBF
.JV[P-\KCP ZG[KB \NCYN FKKRV LSIK\ LMG GK\GVETF QFP TER ,\PEYGP FJNIF
OKSRMRF \B OKEEGTP WZBC \GBKZCF EZ[P UBG \KZCF-\GXZBC OKKNZEV OKYGI
KBGVZF \GGXF QFKV NT[ \GPKEYP \GKIRF \\N \GM[GPP HGV[B \GZDSPNG \GCB-K\CN
.FJNIFF \B NCYN FIV[P-QCN IGM KGVK GB OKKI \BGGX Q\K NVGJPF .NGTVN NMGK
?\PBF TDZC NCY\FN \GEK\T[ GNBN \GFH GKFK GNNF \GJNIFF OBF FNB[F \NB[R
FPNKE ."OKKRZGVKXCG OKKRK[C" OKKIC OKHIBR GRBG \GR\[P \GJNIFF \PBF TDZC TGEKM
QMB FKPGRGJGB BJCN \GBC[ \GPKEYP \GBZGF OBF \TEN F[Y .FZG\V FRKB QKKET GH
FRB\ FNT \G[P[P QF BP[ GB ,FNGIF N[ \GK\KPBF GK\GJNIFG GK\GVETF \B \GVY[P
OB FNB[C \GYVSF CYT .OKKNMNM OKNGYK[P OKKI KMKZBP OKNGVKJP TRPKFN KEM
FJGRF FNGIF YGI ,\PBF TDZC NCY\FN \GEK\T[ GNB \B \GPBG\ \GPKEYPF \GKIRFF
.(G"S[\ ,DZCRKJ[) OKR[ [PI KEP \GKIRFF \B [EIN [K[ TCGY \GPN
:QF \GPKEYP \GKIRF KCDN NVGJP OT FIK[C CKXFN [K[ \GZJPF
.\GKZ[VBF \GMN[FFG \GCZT\FF DGS NT NVGJPN TEKP Q\P .1
.FNGIF N[ OKMZTF \ZFCF .2
.LZGXF \T[N OKKI \BGGX \CK\M GB IGM FVGKP KGRKP NT FJNIF .3
N[ CXPC GB \GKRVGS \GNIPC JKNIFN \NGMK-KB N[ OKZYPC \GKNGVKJ \GZJP \CXF .4
.FKXRPE
:QF EZGK ZESC \GCZT\FF \GPZ
.(Cardio Pulmunary Resuscitation ± CPR) FP[RFG FBKKIF .1
.\KDZGZKM FNGTV TGXKC GB WZPR NGVKJN FEKIKC HGV[B .2
.FHKNBKE TGXKC .3
.FYKJGKCKJRBG OE Q\P .4
.OKNHGRG \KNZJRB FRHF .5
.ECNC KEGTKS NGVKJ .6
Do Not) FP[RF GB FBKKIF TGXKC-KB NT FNGI N[ FJNIF[ ZKFCFN [K
OE KZXGP ,FYKJGKCKJRB ,FRHF Q\P QGDM OKZIB OKNGVKJ \NNGM FRKB (Resuscitate ± DNR
87
NGBK OKZVB
OKNGIF ,FMGPR BKF FC OKNGIF \GEZ[KF[ ,CMZGP EGTKSN \KZJBKZDF FYNIPC .QXPIG
FEKPC .OKKIC FNGIF \ZB[FN GNKTGK BNG \GZYT QF \GNGTVF Z[BM DNR-M OKZEDGP
TXCN \[YCP FIV[PF[ FZYPC GB ,FZYT FRKB FBKKIFFG FP[RFFP NGPDN Q\KR[
Q\KR ,GNB \GNGTV TGXKC-KB N[ FZYPC OD ,\BH OT .DNR-M FNGIF \B ZKEDR BN ,FBKKIF
,\GZKXT ,\GNKIC ,\GIGR-KB ,CBM GPM FNGIN \GYKXPF \GKTCC NVJN KEM FCZF \G[TN
.FPK[R ZXGYG EZD
L[GPP HGV[BN \GZDSPC OKKIF UGS N[ \GK\B \GPNKE
OKBZR OFKKI .EGZK KCKJKRDGYG KRVGD EGYV\ KNTCG OKK\GN\ OF OKNGIF CGZ GNB \GZDSPC
OFK\GKGMH \B IGM[N GRN NB LB .NGVKJ \YSVF YKEXFN NYG ,FGGY\G LZT KZSI FZGBMN
\GSIKK\PF \GPNKE QR[K .OFKKIN \GTDGRF \GJNIFC OV\[N FCGIF \BG OKNGIF N[
LPG\ NGVKJN ,OKNGI-K\CN \GZCTFN ,\GNCDFG \GZK[Y TGXKCN ,\ZRX LZE FRHF Q\PN
.OKNGIF \GKGMH NT FZKP[NG OKRGZIBF OKKIF K[EGIC
HGV[BF \GZDSPC QYHN \GTDGRF \GKPGKPGK \GK\B \GKTC ZVSPC FCIZFC \TM QGER
:QFG ,L[GPPF
.OKKZSGPG OKK\B ,OKKRKNY OKJCKF { \ZRX LZE FRHF .1
.O\NCDFG OKNVGJPF FZK[Y .2
.HGV[B \GZDSPC FNGIF \GKGMH .3
.OKNGI-K\CN \GZCTF .4
.LPG\ NGVKJN KGVKZP OKRGZIBF OKKIF K[EGIC NGVKJF \ZJP KGRK[ .5
OKKZSGPG OKK\B ,OKKRKNY OKJCKF { \ZRX LZE FRHF .B
\GNIPG \ZMGSF \NIP ,OEF-KNMG CNF \GNIP \GIKM[ \B F\NTF OKKIF \NIG\ \MZBF
\GPZGD QFN[ OEY\P CN[C GNB \GNIP .QGSRKYZVG ZPKKFXNB QGDM IGPF N[ \GKRGGKR
,FSKTNC K[GY ,FTKNCC \GTZVF GPM \GRG[ \GCKSP FVF LZE NGMBN \NGMKC FTKDVN
FKDGNGRMJC \GPEY\F FNI NKCYPC ,\BH OT .\G[K[\G QGXZ-KB ,FRCF ZSGI ,CGZKS
Percutaneous Endoscopic) \KZGTNP \ZRX \ZEIF LZE FRHFC NGVKJC \KBGVZF
FEEI\FG \ZRX LZE OKRHGPF OKNGIF ZVSP FNT ,LMP FBXG\M .(Gastrostomy ± PEG
.FKXRPE KNGIN \ZRX LZE FRHF Q\P-KB GB Q\P N[ FPNKEF
FKPGJSGZJSDG (FERGH) K\CKY-KVB ZEIP :\GKZYKT OKMZE K\[C \TXC\P FRHFF
.FCKYN \GZK[K PEG \JK[C
N[ KBGVZF OCXP \B ZV[N FZJPC KBGVZ NGVKJM \R\KR FRHFF[ FPMSF \PKKY
(Finucane, Christmas, & Travis, 1999) KBGVZ ZYIP .ZIB KBGVZ NGVKJ NM GPM ,OKNGIF
LZE FRHF Q\PC \GMPG\F \GBXG\ BGXPN FZJPC 1999 1966 OKR[F QKC \GZVSF \B ZYS
,FRGH\-\\ KCXP ZGVK[N ,\GKXZKVSB \TKRPN \TKKSPF LZEM OKKJRPE OKNGIN \ZRX
\GIGRFG KEGYV\F CXPF ZGVK[N ,OKPGFKHC FEKZKN ,WIN KTXV N[ OCXPC FCJFN
{
88
ZDGCPF NKDC OKKIF UGSC \GK\B \GPNKEG \GRGZYT
FRHFC FMKP\ FBXPR BNG \CHMBP F\KF FBXG\F .OKNGIF N[ OKKIF \NIG\ \MZBFNG
.GYECR[ OKZGJYVFP EIB UBC FKXRPE KNGIC \ZRX LZE
F[KDF \B WPBN \GCBF-K\CCG OKNGIF-K\CC OKBVGZN FXKNPP (Gillick, 2000) YKNKD
FRHF Q\PC[ \NTG\F F\RTJN .\PEY\P FKXRPE KNGIC \ZRX LZE FRHF TXCN QKB FKVN[
CKGIP GRKB GHM FRHFC K\ZDK[F [GP[FG ,NNMC OB ,FJTP BKF OKKJRPE OKNGIN \KNZJRB
OKPEY\PF OKCN[C FVF LZE FRHFF \B \\N BKF \GIV[PN \KZYKTF F\XNPF .\GBKXPF
BKF YKNKD N[ FH DGSP OKZYIP NT FRHFC OKMPG\F N[ \KZYKTF \ZGYKCF .FKXRPEF N[
\NIG\[ OKVKZI OKKBGVZ OKCXPC OKBXPR OYNI[ OKNGI NT OKSSGCP FNB OKZYIP[
Q\P N[ \GBXG\F ,CKXK OCXP[ OKKJRPE OKNGI NXB[ EGTC ,BNKPP FZXY OFC OKKIF
.(Van Dijk, Y., & Sonnenblick, M., 2006) \GCGJ \ZRX LZE FRHF
.OKNGIF KKI \B FMKZBP \ZRX LZE FRHFF OBF FNB[C OKKCJGY \GTE KYGNKI OKPKKY
CYT O\GB \ZXYP UB BKF BNB ,OKKIF \B FMKZBP FRKB BKF[ ECNC GH BN[ OKRTGJF [K
F\GP\ NT OKTKCXP (Grant, Rudberg, & Brody, 1998) GK\KPTG JRZD .FRHFF KMGCKS
OKVSGR OKZYIP .FVKZIF O\NIP LNFPC OKHV[GBP OKNGIC PEG TGXKC ZIBN FFGCD
TGXKCP \GTRPKFC OKMPG\ (Niv & Abuksis, 2002; Rimon, Kagansky, & Levy, 2000)
ZIBN ET FTGXKC \B \GIEN OKXKNPPG FVKZIF O\NIP LNFPC OKHV[GBP OKNGIC PEG
FMGZB OKKI \NIG\ NT OKTKCXPF OKZYIP OR[K ,\BH \PGTN .KBGVZF CXPF \GCXKK\F
Dwolatzky, Berezovski, &) L[GPP HGV[BN \GZDSPC OKNGI N[ \ZRX OT FRHFC
N[ \KRGKXI \GEZ[KF { (Friedmann, 2001; Jaul, Singer, & Calderon-Margalit, 2006
.PEG-C OGK 350-G FERGHC OGK 256
[K ?FRHFF CYT OKNCGS OKNGIF OBF BKF \GTEF \GYGNI FC OD[ \VSGR FNB[
Finucane, Christmas, & Travis,) O\ZK[YC LZGXF CYT OKNCGS OKNGIF KM OKRTGJF
Jaul, Singer, & Calderon-Margalit,) OKZIB OKZGCS O\PGTN .(1999; Gillik, 2000)
,IPX KCXPC UB OYNIG \PEY\P FKXRPE N[ CXPC OKBXPR OKNGIF[ ZIBP KM (2006
OKRHGPF OKNGIF ,FERGHC OKRHGP[ FNBN EGDKRC .OFN[ NCSF \EKP \B TGCYN F[Y
\NJGP OFN \PZDR[ \GIGRF-KB \EKP LMKVNG ,FZK[YN OKYGYH ORKB PEG \GTXPBC
.YVSC
GB ,FRHFF KMGCKSP \GZK[K ZJVR FNGIF OBF FNB[F FNGT FRHFF KMGCKS QKKRTC OD
OKPGFKH) UKZIF KBGVZF CXPF[ BKF FCG[\F ?F[YF KBGVZF GCXPC OKMGCKSP BP[
QMSP CXPN \C[IR FRKB FKXRPE[ BXPR .F\GP\F \B CK\MP[ BGF (OE-KNM \GNIPG
QGMKSC GKF ,OE-KNMG \ZMGS \NIPP GNCS[ OKNGI[ EGTC ,OKEZG[ FC OKNGIFG OKKI
\GEDR\FF \GZPN .(Jaul, E., Singer, P., & Calderon-Margalit, R., 2006) F\GP\N FFGCD
N[ FFGCD \GIKM[ OKBXGP GRB ,FKXRPE OT OKNGI N[ \ZRX LZE FRHFN \KZCF-\GXZBC
.(Teno, Desilva, & Kabumato, 2002) GHM FRHF OKNCYP[ OKNGI
OGKYN WGIR[ "KSKSC" NGVKJ BKF \ZRX LZE FRHF OBF NGB[N GRKNT K\BF ZG[KPC
ZJJY \SRMF QGDM OKNGVKJ ,OGKPGKC OKTXCP GRB[ OKZIB OKKBGVZ OKNGVKJ GPM ,OKKIF
QKC \GYGNI FH QKKRTC \GTEF ?"DKZI" NGVKJC ZCGEP[ GB ,EKZGGN Z\RX GB Q\[F SKMN
89
NGBK OKZVB
DKZI NGVKJC ZCGEP[ OKZGCS OYNI .\KBGVZ FYK\B K[RBG OKRCZ ,OKBVGZ ,OKRJV[P
ZCGEP[ OKRTGJ OKZIB GNKBG ,\GCZT\FC LZGXFG NGVKJF \GKBEM ZCEC \GKF\ OKNTPG
ZVSP OKZMHGP \GZVSC .OKKIF OGKY LZGXN OKETGKPF OKKSKSC OKK\ZD[ OKNGVKJC
QGZIBF FZYPF QMG ,(1988) QHGZY JV[PG (1986) KGZRGY JV[P QGDM OKPSZGVP OKJV[P
FNGIF FRHGF FC[ FERGHF \B BKXGFN [K[ JV[P-\KC YSV GC[ ,(2005) GCKK[ KZJ N[
JVG[F GC[ (1998) KYXCGN JV[P TGEK WZBC .FKZGF \GEDR\F \GZPN ,NTCF \[YC KVN
LB ,SGVGZJGVB FKF[ QCF \[YCN FNGIF N[ FERGHF \B BKXGFN GRKE YSVC ZK\F ODNJ
ZKKR FPSZV \KBGVZF \GZE\SFF N[ \K\BF FETGGF .GETC ZXT FN[PPN KJV[PF WTGKF
NXB FRHFF \ZRX \B BKXGFN Q\KR GKVN[ (2005 ,Israel Medical Association) FEPT
FETGGF \JNIFN UGVMC ,(Persistent Vegetative State ± PVS) IPX N[ CXPC OKNGI
LMKVNG ,"DKZI" NGVKJN \C[IR FRKB FRHF[ \SZGD \KEGFKF FMNFF .\KESGPF \K\BF
BKF OKKIF \[GEY QM[ ,KI FNGIF EGT NM FRHFG OKNHGR Q\PC LK[PFN \GGXF NT FCGI
.ZIB FNGI N[ GHN KJRPE FNGI N[ OKKIF \GMKBC KRG[ QKB ,FMNFF \RKICP .\TCGYF
FEKPC \ZRX LZE FRHF TGXKC-KB ZK\P ,FRGZIBN NCY\F[ \GPN FJGRF FNGIF YGI
QKKRGTP GRKB[ GKCDN TCYR[G ,OKCGZYF OKKTGC[F LNFPC \GBEGGC \GPN EK\T FNGIF[
.(G"S[\ ,DZCRKJ[) GKKI \MZBFC
CGZKS"C ZCGEP OB YGECN [K ,NGMBN CZSP JGVK[ Z[GM NTC FNGI GC[ FZYP NMC
QMB[ ,QKY\ JGVK[ Z[GM LG\PG FNGNX FTEC FJNIFF \B NCKY[ FNGIC ZPGNM ,"\TEP
.ZIB GB K\IV[P ,K\ZCI WIN KZV ORKB G\PMSF GB GCGZKS[G ,TXGPF NGVKJF \B QKCF
KEK-NT \[ZV\P \ZG[Y\CG ZGCKEC K[GYC FGGNPF FNKMB \YSVF[ LMN OKET GRB OK\KTN
OK[N FNGIF N[ \KRGXZ FJNIFM (FIV[P-KRC GB OKKEGTKSG OKKBGVZ OK\GGX) OKCCGSF
CYT \GPZDR FNKMB \GYSVF OKZYPF CGZC[ LMN OKKRZT \GKFNG [KDEFN CG[I .GKKIN WY
.KBGVZ CXP
\B YEC[ ZYIPC .FRHF KCDN OF\GIV[P-KRCG OKNGIF \EPT \B QGICN QKKRTP
Sonnenblick, Friedlander, & Steinberg,) OKKRVGS OKNGI N[ OFKENK GNCKY[ \GJNIFF
LK[PFN G[ZE OKKRVGS OKCXPC OKRYH OKNGI N[ FIV[PF-KRCP 66% KM BXPR ,(1993
Ouslander, Tymchuk, &) GK\KPTG ZERNSGB GTXKC[ ZYSC ,\BH \PGTN .FRHFC
OT FRHF TGXKCN GPKMSF O\KXIP ,OKEYV\PG OKNGNX OKRYH CZYC (Kaynski, 1993
\XGCY CZYC FBXPR FRHFP TRPKFN FKKJR .EK\TC LMN OKYGYH GKFK[ FEKPC \ZRX
,\BH \PGTN .OKKRGBMKEF OKNGIF \XGCYG \GESGPC OKZZGD\PF \XGCY ,Z\GK OKZDGCPF
GPKMSF ,QGBMKEP OKNCGS ORKB[ FNBG FNKFYC OKZZGD\PF ,(FJPG 75 KRC) \KSIK OKZKTXF
\GCKSF .\GKIN LK[PFN QGXZF BKF O\PMSFN \KZYKTF FCKSF[ GRKKX 58% .FRHFN
.(21%) FEGZK OKKI \GMKBP EIVFG (53%) ZKFP \GGPC QGXZF GKF \GTRPKFN \GIKM[F
(OK[R ZYKTC) OKRYH 61 N[ OFK\GVETF GYECR (2004 ,CKRG ,KGN ,CKR ,CKR) USGR ZYIPC
GEDR\F (GRT BN OKNB[RFP \KXIP) OKCK[PFP 75% .WZBF HMZPC QDGP ZGKEC OKZZGD\PF
KTXPBM FSV\R FRHFF .OKKJRPE O\GKFC FN GYYEHK[ FEKPC \ZRX LZE FRHF TGXKCN
.FKXRPE N[ CXPC KGXZ GRKB[ OKKI LKZBP
90
ZDGCPF NKDC OKKIF UGSC \GK\B \GPNKEG \GRGZYT
FMKZX[ FIV[PN FNY FRKB \GEEGP\FG ,OKCZ \G[DZ CZTPG ZZGTP FRHFF B[GR
SIKK\FN ,\GEEGP\FC \GIV[PF \B U\[N [K .FNGIC NVJPF \GGXNG FJNIFF NCYN
FRKB \ZRX LZE FRHF[ QFKRVC [KDEFN [K .OKRG[F FJNIFF KCN[C QFC LGP\NG QFKNB
.G\KB CKJKFN FNGMK UBG OEBF EGCMC \TDGV
OKZ[TP Z\GK KRVN HV[GB FNGIF .\ZRX LZE \M[GPP FRHF OT FNGI N[ FZYP BKCB
FYNIPN ZCTGF LM-ZIBG ,\KZJBKZDGMKSVF FYNIPC FF[ \GRG[BZF OKR[F Z[TC .FR[
LZE QHGF ,OKNDND BSKMNG FJKPN Y\GZP FKF \GRGZIBF OKR[F Z[TC .\CMZGPF \KEGTKSF
.\G[Y \GZGJYZJRGYP NCSG (FKPGJSGZJSD TGXKCN FEDR\F G\[B) FERGH
\KCC GC FNVKJ G\[B .OK[KPI QCM ZKTX OEB FKF BGF \KCKJKRDGYF FEKZKF FNIF[M
NKDC .GKNT ZGP[K[ KP FKF BN[M F\EGCT OGYPN G\GB \IYN FDFR UBG OKR[ Z[T L[PC
F\KF G\[B .ZJVR OKRGP[ NKDCG ,OKNGIF-\KCC HV[GB BGF ,\KSIK ZKTX GEGTC ,OK[K[
FP K\NB[[M .GKKI \B LKZBB BN[ KRPP F[YKC ZJVR[ OEGY OKR[ Z[TG GRPP FZKTX
.OGFKH LNFPC FYKJGKCKJRB FNGIN \\N BNG FERGHF \B BKXGFN KNT[ F\RT ,\G[TN KNT
,YGIFG KBGVZ NGVKJ \\N K\CGIP BVGZM[ FN K\ZFCF ,\KSGVGZJGVB F\KF BKF[ ZIBP
\GRVN FKRVC K\XNPF .FERGHF LZE FRHF Q\P YKSVFN KN OKZ[VBP ORKB ,KRGVXP OD GPM
\B OD FN K\TXF .O\JNIF KV-NT NTVR HBG ,\KESGPF \K\BF FETGGN GB JV[PF-\KCN
FERGHF \B BKXGFN) FRGVXPG F\RCF KVN GC DGFRNG F\KCF FNGIF \B \IYN \GZ[VBF
FJYR BN LB ,FCK[YF BKF .F\[YC KVN GZYCN LK[PB[ K\IJCF .(FVF LZE GNKMBFNG
.FN K\TXF[ GNBP FNGTV OG[C
BGCB[ F[YKCG LGZBFG ZGSPF NGVKJF NT KN F\EGF G\[B ,ZJVR FNGIF[ ZIBN
BKF ,EIB EXP .FRHFF \NB[C FKKI NM FKGXI F\KF[ K\RCF .NDTP \ZKDS O[N FTC[N
.FRGXZ \B [PPN \GSRN KEM FNGTV NM FJYR BN ,KR[ EXPG ,FRPP TRPB[ KRPP F[YKC
OKNVGJP \NCDFG FZK[Y .C
UBG GPXTN FNGIF N[ YHR TGRPN FRG[BZCG [BZC \ETGKP G\TGR\ \NCDFG FNGIF \ZK[Y
JNGC JY[-KB OKKY OKCZ OKCXPC .(OKRM[F OKNGIF GB NVJPF \GGXF) G\GB OKCCGSN
.(Q\[F SKMP ZJJYG UBFP FERGH ,EKZGGFP OKJIP) \ZRXF \B [GN\N GN OZGD[ (OGKZKNE)
BSKMP F[KNDN GB \GNKVRN [[I LG\P FNGIF \B NKCDFN OKMKZXP[ OKCXP GRM\K
\ZZGT\P OKZIBG FNB OKZYPC .EGCKBN LNK[ [[I GB ,WIN KTXV \GI\V\FG OKNDNDF
?LMP TRPKFN [K[ GB ,FNGIF N[ FKPGRGJGBF \B NKCDFN KGBZ OBF FNB[F
\KPKM FNCDFG (FZK[Y) \KHKV FNCDF :FNCDF N[ \GKZYKT \GZGX K\[ \GPKKY
BKF .QYHF N[ FTGR\F CIZP OGXPXN \PZGD ,QKTN \KBZRF ,\KHKVF FNCDFF .(\GVGZ\)
OKNDNDF BSKMN QING[ ZGCKI ,FJKPF \GRVE \PZF ,EKF \ZK[Y QGDM OKTXPB \NNGM
LZE FRK[ \BZ[FNG QYHF \TDZFN \PZGD ,FKGPSF ,\KPKMF FNCDFF .\G\NE \ZKDSG
\[KZE KVN \GNJGP BNG \GYEXGP \GKFN \GCKKI \GKPKMG \GKHKV \GNCDF .\GTKDZP \GVGZ\
FNGIF[ OG[P FTDZF \GVGZ\ Q\PN \GIB N[ F[KZE N[PN NCYN QKB .KEGTKSF \GGXF
-\GXZBC \GCBF-K\C NT FPZGVZF \NIF HBP .GKRM[NG GN TKZVP GRKB ZCEF OB [KTZP
91
NGBK OKZVB
\GKVGZJGMKSV \GVGZ\ Q\PCG \GKHKV \GNCDF \NJFC \K\GTP[P FEKZK FNI ,(\KZCF
.(Kane, Williams, & Williams, 1993)
LM .\GNCDF \NJF NT FJNIFC GV\[N [K ,\KBGVZ \GZK[M NTC BGF FNGIF[ FEKPC
\B GB G\PMSF \B OKNCYPG FNGIF \B OKV\[P GRB ,FJKPF \GRVE \PZF \NB[C ,N[PN
TRPKFN F[YKC[ \NVGJP KN FZGMH .FNGTVC[ QGMKSFG \NTG\F \B QKCF[ ZIBN ,GCGZKS
.FEP[FF \GRIP \B FN ZKMHP[ ZCE ,FBGNM [KDZFN FN OZGD FH[ OG[P \GRVEF \PZFP
\B ONGMN K\ZFCF[ ZIBN F\EPT \B K\NCKY .F\IV[P-KRC KEK-NT FMP\R UB F\[YC
K\ETK\[ QKKXN Z\GPN .FID[F BNN FNKNC FPKYC GB FJKPFP \GNKVRC OKRGPJF OKRGMKSF
NT NVGJPF N[ FKPGRGJGBF FH FZYPC .FNGIF \B K\P\IFG KBGVZF YK\C FIK[F \B
.BVGZF N[ OHKNRZJVF QP FYHI F\KF GVGD
UGN[N GN Z[VBN [K OBF ?JGVK[ Z[GM ZSIG NGNX BN NVGJPC \G[TN GRKNT FP LB
GB GK\GVETF \GTGEK OB .QKTEGKC G\GB QMSN OGYP QKB[ KBEG ?EGCKBN \MNN GB \ZRXF \B
.(1997 ,QKHGZG KYSCHGZC) QFKV-NT NGTVN [K ,GN[ SGVGZJGVBF \EPT
HGV[B \GZDSPC FNGIF \GKGMH .D
.FRK[NG \GIGZBN ,FPKYN \GTGCY \GT[G KREVY OGK ZES N[ ZJ[P OKKY GNB \GZDSPC
G\GMH .FYNIPFG \GGXF \G[KZE QKCN GK\GRGXZ \B BNPN FCGIF QKC LGG\C CXKR NVGJPF
,\BH G[T ONGM[ \GZPN OEYGP QG[KN \MNN BN G\GMH .NJR BGF[ [KDZFN KNCP QRGN\FN
FJNIF NMC GV\[N [K .QRGN\K OB GN TNGCK QV [G[IN GN NB .ZIGBP OGYN GNKVBG
,OKPGNKX ,OKPE \IKYN GPM ,\ZIBG \KBGVZ FNGTV NM KRVN ZCSF GN \\NG \KNGVKJ
\GCZT\F NMC JGYRNG FKHGVRKB ZCIN ,Q\[F \KIGVN[N ZJJY SKRMFN QKB .FXIZG \GEZGF
.SGVGZJGVB \PMSFC GB G\PK\IC LZGX QKB[ \GZPN ,NVGJPF N[ G\PMSF BNN
NCYN OKNGIF \GMH \B IKJCFN ETGR[ ,FNGIF \GKGMH YGI YYIR (G"R[\) 1996 \R[C
G\GR[ZVNG YGIF QG[NN SIKK\R[ KRVN .O\GKJZVG OEGCM NT QDFNG ONGF KBGVZ NGVKJ
N[ GK\GKGMH OBF .YGIC LZGX NNMC [K OB NGB[N [K ,ZDGCPF NVGJPF N[ GJCP \EGYRP
-KRCG OKZDGCPF OKNVGJPF .\KNKN[ BKF FCG[\F KM ZC\SP ?\GZGZC QRKB NVGJPF
Q\PC \GPKPTG NGVZT [K .QFKNT OKEPGT ORKBG OFK\GKGMHN OKTEGP ORKB OFK\GIV[P
.(2004 ,NGBK) TEKPF
NGVKJ NCYN O\GMH NT EGPTN [K ,HGV[BF \GZDSPC JZVC ,OKK\GN\ OKRYH KCDN
\EGYRP YGIC OKK\KKTC OKJCKF ZVSP \GR[ZV NT CMT\R QNFN .YGIN OB\FC OK\GZK[G
:L[GPP HGV[B \GZDSPC K\GN\F NVGJPF N[ GJCP
.OGBNG QKP ,THD ,\E NT ZCEP YGIC TKVGPF FKNVBF ZGSKB { 4 FYSV ,'D YZV (1)
NVGJPN GZPBK FNKNI[ ZGSB ?\K[VR GB \KRVGD \GNCDGP ?\GN\ GB EGYV\ ?NKD KCDN FP
.GC GNVJK BN ,\KCKJKRDGYF G\GZEZEKF GB GNKD CYT KM
OKKZJBKZDF \GESGPN \GBKZCF EZ[P N[ ZHGIC ,2000 \R[C YZ QYG\ NKDF B[GR
.F\KF[M FZB[R YGIF QG[N ,\BH OT .FKNVBF ZGSKBC NKDF \B NKNMF[
\KTGXYP FRKICP QF \GBR KBGVZ NGVKJ Q\P CKKIP FH UKTS { 5 FYSV ,'D YZV (2)
92
ZDGCPF NKDC OKKIF UGSC \GK\B \GPNKEG \GRGZYT
?KFP \GK[GRB OKEPGN QMKFG ?\KTGXYP FPZ OKEEGP LKB ONGB .[GRBF-KSIK \RKICP QFG
BGF .NVJPF \GFH ZCEC TEKP \ZKSP CKKIP YGIC FH UKTS { 6 FYSV ,'D YZV (3)
OK[DKR OK\KTN .OKKEGTKS OKNGIC NGVKJC EIGKPC ,QKKET IGGZF OHKNRZJVF QKKRTN Z[Y\P
.Z[Y\P GRKBG QKCP GRKB FNGIF[ FIRFC \PEYGP \GFEHF BNN FNGIN
FTE \TKP[ .\VSGR \TE \GGI NCYN \GMHC YSGT FH UKTS { 7 FYSV ,'D YZV (4)
.F[PPN OFN Z[VBN [KG OKNVGJPF N[ O\GMH BKF \VSGR
\NB[R ONGB .\GBR NGVKJ L[PF \IJCF TCG\ FH UKTS { 8 FYSV ,'D YZV (5)
\GZDSPCG \GCGZY OK\KTN HV[B\P[ NVGJPC ZCGEP[M TGXKCN Q\KR ZCEF EXKM ,FNB[F
.OFKRKC Z[Y QKB[ OKRG[ OKNVJP OT ,\GRG[
.NVGJPF N[ G\GKJZVG GEGCM NT FZKP[ [ZGE FH UKTS { 10 FYSV ,'D YZV (6)
YZ BN GK\G[ZVF \B \GYRN KNGB ?GEGCMN OGYN KGBZ OBF ?GN \\N [K[ EGCMF GFP ONGB
KFP FNB[F \NB[R ,EGTG \BH ?[YCP BGF Z[BM EKKP GN \GRTKFN KNGB ?CGCKSF QPHC
GB ,NGVKJ LNFPC EGDZV OKP[ BN GB \NEF \B OKZDGS BN[ FT[C ,\GKJZV NT FZKP[
.NGM KRKTN NMGBF-ZEIC G\GB OKYEGC UB OK\KTNG OKZH \GIMGRC NVGJPF NT OKZCEP[
FBGVZ K\GZK[ YZ BN NCYN KBMH NVGJPF[ ZGMHN [K FNGIF \GKGMH \ZDSPC ,OGMKSN
KIGGJ NT ZGP[N KEM { YGSKTC KGVKZG FKVZ\GKHKV { KPGYK[ NGVKJ OD BNB ,EGTKSG
\GNKVR \TKRPG \GZCTF KCDN FMZEF FIV[PN YVSN [K .GCXPC \GZEZEKF TGRPNG FTGR\F
BGF OB GNKVB ,OKKVDC OK\GGKTG \GZGJYZJRGY \TKRPN NGVKJ FNGIN YKRTFN [K .\GNCIG
UB ,NGVKJ NCYN GB HV[B\FN QKKRGTP GRKB OB G\TE \B NCYN [K .KEGTKS NVGJPM ZEDGP
QGDM ,OKK[KBFG OKK\ZCIF GKMZX \B YVSN [K .NVJPF \XNPFN EGDKRC \EPGT G\TE OB
.(1999 ,WKCGYK) \GKPKJRKBCG \GKJZVC LZGXF
OKNGI-K\CN \GZCTF .E
FNI OB OKKNNM OKNGI-K\CN OKZCTGP ,L[GPP HGV[BN \GZDSPC OKZZGD\PF OKCZ OKRYH
OB \KPGKPGK \GJCN\F \PKKY OKBVGZF NXB .OCXPC \GZEZEKF GB O\NIPC FVZIF
FYNIPC GZKB[FN GB ,KNNM OKNGI-\KCC HGV[BN \KEGTKSF \ZDSPC KIF QYHF \B \GRVFN
\GVKZIF \EKPC GB NVGJPF N[ KBGVZF GCXPC FKGN\ FJNIFF .(Buchanan, 2006)
OKRPKS OKPKKYG KPGB\V QVGBC TZGF GB UKZIF CXPF OB[ ZGZC .G\NIP N[ FZPGIFG
OGI ,QGNIKM ,LGPR OE WIN ,\GZKFP \GPK[R ,ZKFP YVGE) CXPF \ZPGI NT OKTKCXP[
LKZX[ LM NT YNGI QKB .HGV[BN GZKCTFN [K ,(\NVZGTP FZMFG FMGPR Q\[ \YGV\ ,FGCD
.OEGYF GCXPN GZKHIFN Q\KR OKNGI-\KCC NGVKJ \GTXPBC[G ZEZEKF[ NVGJP HV[BN
BN CXPFG FKTC F\GB N[C ZCTC HV[GB OB GB ,FDZEFC ZEZEKP GCXP OB F[TR FP NCB
CYT[ OKNVGJP N[ HGV[B Z\KC OKYGN GRRKB OBF ?GHV[BRG ZGHIR OBF ?ZV\[F
\GKZIBF \B GRKNTP ZKSFN OKJGR GRB ,\GYST\FG QPH \G[ZGEF OFK\GKTC \GCMZGP
\KM[PF ,Z\GK FCGJ FZGXC NVJN Q\KR \ZMGPF HGV[BF \ZDSPC BYGGE KNGB ?OHV[BNG
.FNGIF \B ZKMP[ \GGX \ZHTC ,FNKTKG
\GBKZ \YNE \TVGF BKF OKNGI-K\CN \GZCTFF \KKDGS \B F[KIPP[ FPDGE
93
NGBK OKZVB
\YNE OT OKNVGJP QIC[ K\BGG[F ZYIPC .\KEGTKSF FYNIPC OKHV[GBPF OKNVGJPC
QGZ\K BXPR BN ,OKNGI-\KCN GZCTGF[ OKNVGJP \PGTN \KEGTKSF \ZDSPC GNVGJ[ \GBKZ
.(Loeb, Causone, Goeree, & Walter, 2006 ;1998 ,KYXZK) HGV[BN
.GC[ QGMKSF \PGTN HGV[BC[ \NTG\F KFP ZZCN GRKNT ,FNGI \KKRVF NM KRVN
OKTXPBF NM OT FEGPX \KBGVZ FID[F [K :FZGZC OKNGI-\KCC HGV[B N[ \NTG\F
KBGGNF \GTVG\ ,OKRGMKSF ,\BH \PGTN .GCXP ZGVK[NG FNGIF KGVKZN OKNNMG[PF OKKRMJF
NC .Z\GKC OKCZ OF ,OKZDGCP OKNVGJPN SIKC EIGKPC ,OKNGIF-K\CC OKPKKYF OKTDVPFG
\GGX ,F[EI FVGZ\ ,\KR[NGV \GCZT\F ,KBGVZ LKNF NMN TKDV KEGTKSF NVGJPF[ IM[R
.OGKF-ZESCG FCKCSC OKKGRK[G [EI NVJP
.(OK[MZR OKPGFKH) FNGIN FNGIP OKZCTGPF OKPGFKHC YCEKFN Z[VB OKNGIF-K\CC
GB FNKFYC [DGV NVGJPF[ FNBP Z\GK OKPKNB NNM LZEC OF OKNGIF-K\CC OKYEKKIF
TDGV HGV[BF ,LMN USGRC .(FEKPTF FNBKSCNYF \NFC N[PN GBZ) \KEGTKSF FYNIPC
QGDM \GKSKSC \GKGNKTV [GCK[N OZGDG NVGJPF N[ NKDZF OGKF-ZESCG OKKIF \ZD[C
\GTXC\P QRKB OK\KTN[ \GKGNKTV { BSKMN FEZGFG FKK\[G FNKMB ,OKKTP \NGTV
OKZGVS OKPK L[PC FJKPC FCKM[ GNKVB .OKNGIF-\KC N[ OGKF-ZES \GJN\[F CYT
FNB OKMGCKS NT .YG\KZ N[ OKMGCKSN G\GB \V[GIG ZDGCPF NVGJPF \B \RMSP
(Deep Venous Thrombosis ± DVT) OKKNDZC OE K[KZY \GZXGGKF QGDM \GKTC \GRPR
;Q\[F ZDGS NT FJKN[ ZSGI ;(Pulmonary Embolism ± PE) \GBKZC OKVKIS\G
QGHKBFP FBKXKG ;OKPFG QEKSF N[ OHKNGCJPC FTZVF ;FBGX KRCBG \KRGZM \GZKXT
.(SKHJSGPGF)
EZI BGF .NCNGCP F[TR NVGJPF ,ZMGP BN \GGX OT ,OKNGIF-\KC N[ FZHF FCKCSC
.QGBMKEN [NGDG FKXCKJGPF \B ECBP ,G\GB G[JRK QV
NVPN OKSRMR GRB ,KBGGN \GTVG\ \GPKKY \KNGVKJ GB \K\RICB \GCZT\F NMC[ ZIBP
BN[ KEM FJKPN G\GB OKZ[GY GB ,FTDZF \GVGZ\ OKR\GR NCNGCPF NVGJPN .OKMGCKS N[
\SRMF ZGZD\ FNKMB \YSVF .WIN KTXV \TVGFN GPZDK \GKPKMFG \GKHKVF \GNCDFF .NGVK
NVGJPF[ BGVB BXGK .Q\[F SKMN ZJJY \SRMFN NKCGK OKZDGSC FJKN[ ZSGI .FERGH
,EKZGGN FYKJGKCKJRB Q\P ZIBN HGV[BF LNFPC FZV\[F[ ,\GBKZ \YNE CYT TKDF[
.\ZCGD \NGHC GN[ \GN\FG ,KNNMF KEGYV\F GCXPC ZEZEKP
\B [KIPP ,O[ FZKB[FN FXNBRG QGKP ZEIN FPKB \B FBKCF[ \C N[ FZGVKS
\B K\BXP" :F\BZ[ FP \B FZBK\ ,\KZJBKZDF FYNIPN \CF FZHI[M .NVGJPN QGMKSF
F\RV[M ."Q\[F ZDGS NT \JNG[ BPB KZFG ,NG\KI OT FPGZKT KXI FJKPC \CMG[ BPB
."!TDZ NM OK\GZK[N F\GB EKZGFN OKNGMK BN GRIRB" :FCG[\C F\RTR ,\GGXN
\GKGCZT\F TGXKCCG OKNGI-K\CC OKPKKY[ OKRGMKS ,NKTN GJZGV[ OKRGMKSF IMGRN
QFP NGB[N [K .QGMKSFP FNGED \NTG\F OBF CJKF NGY[N [K ,\GKNGVKJG \GK\RICB
OGZDN GRN NB .BXPR BGF FC[ \ZDSPC FNGIC NVJN Q\KR BN OBFG HGV[BF \GZJP
\NB[C G\IV[P-KRCG NVGJPF OT WTKK\FN [K .FJTP BKF \NTG\F OB NVGJPF QGMKSN
OKNVGJPF \KKRVFN OKEDR\P OFK\GIV[P-KRCG OKNVGJPFP OKCZ .OKNGI-\KCN FKKRVFF
94
ZDGCPF NKDC OKKIF UGSC \GK\B \GPNKEG \GRGZYT
\GBEG ZSGI \TZGHG \GIGR-KB \PZGD FPXT FZCTFF .\GKGCZT\F TGXKCN GB OKNGI-K\CN
\GEYP\FF ,\ZIB GB LM .HGV[BP TRPKFN CJGP QMB ,FCZ FRKB \NTG\F OB .OKEIVG
\EZGF BNG ,NVGJPF \ZCTF ZCEC FJNIFF \B \GIRFN FMKZX FNGIN CGJ[ FPC
.NVJPFP \GKZIBF
LPG\ NGVKJN KGVKZP OKRGZIBF OKKIF K[EGIC NGVKJF \ZJP KGRK[ .F
OKNCGS OFP OKCZ[ BGF ,KRVGSF CN[C OKKGXPF OKZDGCPF OKNGIF \B EIKKPF ZCEF
BN \GNIPP OKZJVR OCGZ .FFGCD OKZIBC O\GN\G \GKNM[G \GKRVGD \GKGNCDGPP
OKTGZKB N[ \GKGIYN\F CYT \XBGP[ \KJKB \GZEZEKFC QKKVB\P LNFPF .\GKDGNGYRGB
QPHC .\R\P\P \GZEZEKFFG (remission) FDKSR FNI OK\KTN NGVKJN \GEGF .OKVKZI
OKRG[ OK\GGXC OK[KGBPF QGKP-KZEING OKNGI-K\CN OKRVGP OKNGIF OKVKZIF OKTGZKBF
"\GBSKMF QKC NVGR" FNGIF \GCZ OKPTV ,LMP FBXG\M .KBGVZF OCXP \B OKZKMP ORKB[
ORKB[ OKBVGZ KEK-NT \GNCY\P OKKIF UGSN Z[YC \GK\BFG \GKBGVZF \GJNIFFG
DZCRKJ[ ,FGGZ ,WZD ,YKNCRRGH) OFK\GVETF \BG G\IV[P-KRCG FNGIF KMZT \B OKZKMP
TGEK[M NGVKJN ZGZC ETK ZSI .GCXP \B OBG\[ NGVKJ NCYP GRKB NVGJPF .(2003 ,QGRKG
KNGVKJ TGXKCG WZPR NGVKJN FEKIKN FKRVF) NGVKJ UEGT [K OK\KTN .CZYG LNGF \GGPF[
\ZCTFG QGN[KMC FBEGF ,OKKEK \PZF) NGVKJ-\\ OK\KTNG (OKZYT FP[RFG FBKKIF
K\MKP\ NGVKJ \NCY BNN ZJVR FNGIF ,ZCE N[ GVGSC .(FYNIPC QGZIBF ZEIN FNGIF
O\GB TGRPN QGKSKR BNNG [I BGF[ \GIGRF-KBNG NCSN ,CBMN \GSIKK\F BNN ,KRIGZG K[DZ
.(Lynn, 1996)
GY OKKY BN .OCXPC FZPIF QPHC OKNGIF-K\CN OKIN[R \GKEGTKS \GYNIPC OKNGI OD
KZEI QKC CG[G LGNF OKIN[R OKNGIFG ,OFKKIN OKRGZIBF OK[EGIF LNFPC ZGZC KNGVKJ
NGBK) OK[\GPG OKVKKT \GIV[PF QFG OKNGIF QF .OKNGI-K\CC HGV[B \GYNIPG QGKP
.(1998 ,QKHGZG
UKYFN NGVKJF NT .OKKIF UGSC NGVKJ \\N FNGMK[ \NNGM \KHMZP \KRMG\ FZSI OGKM
UKXZ NGVKJC LZGX [K .KRIGZFG K\ZCIF ,K[VRF ,KRVGDF :GKJCKF NM NT FNGIF CXP \B
-\KCCG \GCBF-\KCC ,FNKFYC \KCC G\GF[ \B UKYPG FNGIF N[ \GZDSPF NM \B NNGM[
OKGGNPG FNGIF \B OKZKMP[ OKNVJP OK\GGX KEK-NT O[GK\[ \KRMG\C LZGX [K .OKNGIF
.GKPK UGS ET ,QPH LZGBN G\GB
KRVC FDXGF GKPK \KZIBC QYHF KMZGXN SIKC \NNGM \KZGCKX \GKRKEP FGG\P[ \KRMG\
-\GVGY KDKXR ,\GBKZCF EZ[PP FKZJBKZDF KDKXR \GIMGRC ,FKZJBKZDN \KPGBNF FXTGPF
FNGTV-UG\K[ FDKXP \KRMG\F .(Jaul & Rosin, 2005) WZBC FKZJBKZDF KZKMCG OKNGIF
FEKIKF \GGX QKCN (KNBKXGS ECGT ,\GIB ,FIV[P KBVGZ) FNKFYC KRG[BZF \GGXF QKC
LPG\G KNBKXGS ECGT ,\GKIB ,OKBVGZ) CMZGP EGTKSN \KZJBKZDF FYNIPC LPG\ NGVKJN
GRKBG ZEZEKP GCXP[ FNGIF \B ZKCTFN \GZ[VBC QE FNKFYC KRG[BZF \GGXF .(KRIGZ
FNGIF NT TEKP NCYP FEKIKC \GGXF .LPG\ NGVKJN FEKIKN ,G\KCC \GF[N EGT NGMK
.FNGIF \GVETF QFP ZZCP Z[B ,FNKFYC KRG[BZF \GGXFP
95
NGBK OKZVB
OKNVGJPC OKKIF UGSC NGVKJ N[ \KRMG\F \NCY KRVC OKEPGT OKNG[MP ZVSP
:(Feinberg, 1997) OKBCF OKPZGDFP OKTCGR FNB OKNG[MP .OKKRVGS
FNGIF QKCN { K\ZCIFG KEGTKSF ,KBGVZF { NVJPF \GGXF QKC \ZG[Y\C K[GY .1
.GK\GMN[FG F[YF CXPF \ZCSFC OKKGYKNG G\IV[PG
.(WZPR NGVKJ) KR[NGV NGVKJ Q\P LMKVNG ,OKBVGZF EXP KNGVKJ QGN[KMM \GGPF \KKBZ .2
LNFP \GR[N FNGIF EXP UB OK\KTNG FIV[PF EXP BVGZFP \GK\GBKXP BN \GKVKX .3
.\GNIP N[
FH OGYPCG OKKIFP YNIM \GN\F \BG \GGPF \B NCYN BN FZCIC \PKKYF FKKJR .4
.O\GB YKIEFN
FC[ ,"ZGHI-NB"F \EGYR \BXPR QMKF FNB[C \K\BF-\KBGVZF FJNIFC K[GY .5
.(KCKJBKNV) LPG\ NGVKJN KGVKZP FR\[P \KNGVKJF FZJPF
ZVSPC ZHTKR F\ZEDF O[N .FR\[P KNGVKJF QGGKMF FC[ "ZGHI-NB"F \EGYRC EYP\R
:OKKRKNY OKRGKZJKZY
,OKKNNM OKNGI-K\CC OKHGV[BF ZVSP :FRGZIBF FR[C FNGIF N[ KBGVZ LNFPF .1
\KRVGDF ,\KEGYV\F \GN\CG \GNCDGPC \GZEZEKFF \PGYT ,QGKP-ZEIN \GKRVF ZVSP
.\KCKJKRDGYFG
,NGVKJN FCGD\ ZSGIC OKRKICP FIV[PFG NVJPF \GGXF F\ZDSPC[ \KPGKPGK \KVX\ .2
.G\GB F[K\P FNIPF FPM ET OKBGZG FNGIF N[ GNCS \B OK[I
:OKK[VRFG OKKRVGDF ,OKKRGKIF OKRPKSC \GZEZEKF NT OKTKCXPF OKKRKNY OKEEP .3
FEKZK ,NGZJSNGMFG QKPGCNBF \PZC FEKZK ,NY[PC FEKZK : O K K R V G D O K E E P (B)
QGXPIG Q\[ \YGV\ ,CBM ,\GPK[RF ,YVGEF ,OEF WIN QGDM OKKRGKI OKRPKSC
.\GPYZF
;JCPF ,LGKIF ,\GKRGKIF ,\GRZKTF ,FZMFF \PZC FEKZK : O K K [ V R O K E E P (C)
.OKRV \GTCFG UGD \V[ \GTXPBC \GTCGP[ \GCGD\ \GJTP\F
:GRKNT ,LPG\ NGVKJ Q\P BKF NGVKJF \ZJP KM FJNIFF \NCY\P[ ZIBN
.TJGYP BNG KM[PF ,UKXZ ,KBGVZ NGVKJ \\N
GB \NTG\F NT FNGT NCSF OB FKDGNGRMJCG WZPR NGVKJ K\GZK[C [GPK[C JTPN
.ZYT NGVKJF[
.\GIGR-KBG JY[-KB ,\GEZI ,OKCBM NT NYFN
.\GIMGRG FC[YF \GTXPBC FIV[PNG FNGIN BVGZF QKC \ZG[Y\F \B ZV[N
.\GZIB \GZDSPN \GZCTFG \GIGR-KB TGRPN ,\GKJZV Z[VBN ,EGCM \\N
.1
.2
.3
.4
.5
NT OKJKNIP K\P ZKFCFN ETGR[ WIN TXV OT KRVGS FNGI N[ FZYP ZGBK\ QNFN
:(KCKJBKNV) LPG\ NGVKJN KGVKZ NGVKJP G\MKVFG NGVKJF \GZJPC KGRK[
,ZEIF LG\P GNT[ CBF N[ CBMF \GIKRD .KMCC FZZKP ,ZEIN WGIP FC[K[ \CF
96
ZDGCPF NKDC OKKIF UGSC \GK\B \GPNKEG \GRGZYT
\GKIB K\[ KGGKNC \KCF KBVGZ KR[ \B K\BXPG ZEIN K\SRMR .QGZESPC CJKF GTP[R
.WIN TXV N[ FKZJF OKTXCP
OKSKMG \G[ZVF BNP ,OKZJPKJRS 20620 GNEGD[ ,YRT ,YGPT WIN TXV FKF FH
.QG\I\F CDF NM NT \TCJF KVN \GNGJSKV OT ,OKK\NDGP
.LZKF ZBGGX \B ZC[G NVR HB ,QM-KRVN [EGI ET KBPXT FKF BGF .90 QC FKF FNGIF
,(FHKNBKEGPFG OE-KNM \NIP ,\ZMS) GK\GNIP N[ KBGVZF TYZF CYT LB ,I\GR BGF
CGZG CGBMG NCGS FBZR ,FVF LZE JTP NMB FNGIF .WIN TXV I\KV BGFG GCXP LC\SF
.OGKZKNECG KRGR[K FKF QPHF
NGVKJF \GZJP QFP FNB[F FZZGT\F ,FKZJFF ZIBN K\MZT[ OKBVGZF ZGYKCC
KGMKS QKB[ ZIBP ,KCKJBKNV NGVKJC GB ,TXVF KGVKZ O[N NGVKJC ZCGEP OBF .FNGIC
FNGT GRKB FNGIF N[ NCSF OBF ?FNGIF N[ KBGVZF GCXPC C[I\FC TXVF \B BVZN
FNGIF ,BVZ\K BN TXVF[ F\KF K\NCKY[ FCG[\F ?TXVF KGYKRP YKVR[ \NTG\F NT
,OB\FC NGVKJ \\N GRKNTG KCKJBKNV NGVKJC ZCGEP ,K\ZPB ,LM OB .KRVGSM ZEDGPG NCGS
K\IIG[ .FNGIF N[ FIGR\ KGRK[P Q\KRF NMM TRPKFNG \GIGR-KBG CBM ,NCS TGRPN GRKKFE
\B K\NCKY .FRGXZ FP K\NB[G CXPF \B FN K\ZFCF .\KSGVGZJGVB F\KF[ \CF OT
.OKCBM EDR ZCDGP NGVKJ Q\PNG FHKNBKE L[PF TGXKC-KBN ,FERGH \SRMF-KBN F\PMSF
.CBM BNNG TGDZ ,\ZIPN ZJVR FNGIF
-KRCNG NVGJPN F[Y BKF (FERGH) NGVKJ \\N BNG (FHKNBKE) NGVKJ [EIN BN FJNIFF
\K[DZ FMKP\ LG\ ,KJSGRDGZVFG KRKNYF TEKPF Q\PC KRGKI EKYV\ [K BVGZN .G\IV[P
-KB \GZPN[ GTEK OB \GJNIF NCYN Z\GK NY FKFK FIV[PN .G\IV[PCG FNGIC \K\ZCIG
,\GIGR-KBG CBM GPM ,FNGIN OKYKXPF OKRKPS\C NVJN OKMK[PP ,OKGSP NGVKJ [GEKI
.FPK[R ZXGY NT OKNYPG FIGR\ KGRK[ KEK-NT G\GB NJNJNP OKTRPR
\GZGYP
.FKXRPE KNGIC \KEGYV\ \GNDGSP N[ FMZTFC KGXZFG KGXPF .(2002) .T ,QKXZGYG .B ,KRPKSGB ,.B ,NBKZB
.798 795 ,141 ,FBGVZF
,133 ,FBGVZF .F\GRDN [K GB \YEXGP OKHV[GBP OKRYH OKNGI \ZK[Y .(1997) .B ,QKHGZG .S ,KYSCHGZC
.183 180
.\KBGVZF \TEF \GGI :FBGGX QKY\FN KRGKJ[F FNGIF N[ \KJV[P \KBGVZF \GZ[MF .(1998) .K ,YRKKF
.481 476 ,134 ,FBGVZF
OKKI KMPG\ OKNGVKJ N[ FKDGNGKPEKVB .(2003) .T ,QGRKG .B ,DZCRKJ[ ,.E ,FGGZ ,.N ,WZD ,.P ,YKNCRRGH
.654 650 ,142 ,FBGVZF .\GKPKRV \GYNIPC
.\TEGP FPMSF \NCY .13 FYSV ,'E YZV ,(1996 G"R[\F) FNGIF \GKGMH YGI
.KRVGSF CN[C \GKDGNGYRGB BN \GNIPC OKNGIF OK[K[YC NGVKJF NT \GC[IP .(1998) .B ,QKHGZG .B ,NGBK
.147 141 ,F"M ,FKDGNGJRGZD
{ N[B :OKN[GZK .NGVKJFG \GEEGP\FF ,\KEGYV\F FEKZKF KCN[ { KEGTKSF QYHF .(2004) .B ,NGBK
.QYHF QTPN OK\GZK[ IG\KVNG QGRM\N FEGDBF
{
{
97
{
{
{
{
NGBK OKZVB
B[GRC IK[-CZ LG\P ,\KNBKXGS FEGCTFG YGIF { \GKESGP \GZDSPC FNGIF \GKGMH YGI .(1999) .B ,WKCGYK
.67 63 ,G"M ,FKDGNGJRGZD .NGVKJFG FYK\BF ,YGIF :QYHF FNGIF \GKGMH
.518 516 ,134 ,FBGVZF .HGV[BN FKRVFN \GKIRF { \KEGTKS FYNIPC \GBKZ \GYNE .(1998) .B ,KYXZK
.QGKJK[ KCXPC FRHF KVNM OK[K[Y N[ \GEPT ZYS :GVGD NT OEBF \GMH .(2004) K ,CKRG .H ,KGN ,.D ,CKR ,.K ,CKR
.655 652 ,43 ,FBGVZF
.NBZ[K \RKEP .\GPN FJGRF FNGIF YGI .(G"S[\F) .B ,DZCRKJ[
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{
{
{
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home residents with severe cognitive impairment. Journal of the American Medical
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without a consensual solution. Israel Medical Association Journal, 8, 503±504.
99