Expand All | Collapse All

Family Health Magazine - growing older

Decision Making Capacity Assessment
When does someone need help to decide?

If you care for someone who is aging or ill, it can be challenging to know when you need to step in. Dementia and other chronic conditions can affect a person’s ability to make independent personal and financial decisions. Decision-making capacity assessment is the process that helps determine when someone needs help. As our population ages, the number of people requiring these assessments will increase.

What is decision-making capacity?

It is all about making decisions! Having capacity means that you are able to understand information important in making a decision. You are also able to grasp the reasonable consequences of making or not making that decision.

When making a decision, an adult:

• takes in key information
• thinks about the pros and cons, and
• makes a decision based on his or her values.  

Facts about capacity

• All adults have capacity to make their own decisions until it is shown they do not.
• Capacity assessment is the process used to decide whether someone is still able to make decisions.
• Making a risky decision, or a decision that others do not agree with, does not necessarily mean someone lacks capacity.
• A person may be able to make certain types of decisions but not others. For instance, someone might be capable of choosing where to live, but lack the capacity to manage money. A diagnosis of dementia does not automatically mean a lack of capacity. Someone with dementia may keep the ability to make personal decisions until well into the illness, but lose financial reasoning quite early. The opposite can also happen. A doctor, psychologist, or health care provider trained in this area can assess capacity.
• If an adult does not have capacity, steps can be taken to help them make decisions. (See Legal acts about capacity section on the next page.)

How is capacity assessed?

Capacity assessment usually includes the following:

• Information is gathered from the adult and caregivers on the risk caused by an adult’s decisions, and that person’s strengths and limitations are explored.
• The health care team will problem-solve to try to resolve the issue.
• If the issue is not resolved, the adult will be formally interviewed to determine whether capacity in a specific area exists.
• The formal interview looks at whether this person understands the facts about a decision, and what might happen if one choice is made over another.

When should capacity be assessed?

Consider this option in the following situation:

• An adult makes choices or behaves differently than usual, putting themselves or others at risk.
• You suspect that this change might be caused by impaired decision-making.

Often, this process begins when conflict about a decision exists, such as if someone refuses
surgery for a life-threatening illness.

Areas of decision-making

The decisions an adult has to make can be assessed in any of the following areas:

• health care
• accommodation
• finances
• education and training
• employment
• legal affairs
• social affairs
• choice of associates.

Capacity assessments are only done in the specific areas where the adult must make a decision. For example, an adult might refuse much-needed surgery while appearing to lack capacity. In this case, the capacity assessment will only be done for the area of health care.

Legal acts about capacity

The legal acts relating to capacity vary by province but are similar. They are the Personal Directive Act, the Powers of Attorney Act, and the Adult Guardianship and Trusteeship Act.

Personal Directive Act

• This Act allows an adult to name a trusted person (an agent) to make decisions on his or her behalf. The document is called a personal directive.
• The personal directive addresses personal decisions, including medical care. It does not include decisions concerning finances or property.
• A personal directive is set up by an adult when he or she has capacity, and then activated when that adult loses capacity.
• This procedure can help people feel confident that future medical decisions will be based on their values, wishes and beliefs.

Powers of Attorney Act

• This Act allows an adult to name a person to assist with finances and property.
• An enduring power of attorney agreement is set up when a person has capacity, and is activated once that adult loses capacity.

Adult Guardianship and Trusteeship Act

Sometimes it happens that a person is no longer able to make independent decisions, and no personal directive or enduring power of attorney is in place. In this situation, guardianship and trusteeship come into play. Guardianship relates to personal matters, and trusteeship for financial matters. Guardianship and trusteeship must be obtained through the courts.

Co-decision-making

• This procedure is also obtained through the courts. It can be used when capacity is significantly impaired, but the adult can still make personal (not financial) decisions with guidance and support.
• The co-decision-maker will help the adult to make decisions together.

Guardianship

• This legal process gives another adult (called a guardian) the legal right to make or help make decisions about non-financial matters on behalf of someone who lacks capacity.
• It deals with personal decisions, such as health care and accommodation, but not finances.

Trusteeship

• This legal process gives another adult (called a trustee) the legal right to make or help make decisions about financial matters on behalf of the person who lacks capacity.
• Financial matters include personal property, realty, money, investments, and income.

Decision-making capacity assessments can be a useful tool in keeping a loved one safe and secure. If you have questions, talk to your family doctor or access the resources in the sidebar.

More articles from this section

Article Listing

While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2019, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1    [GO_FHab19]