Decisional Capacity

What is decisional capacity?

Decisional capacity is the ability to make choices for yourself. Some people are not able to make decisions when they are very sick or as they grow older. Problems making decisions are not a normal part of getting older.

People who lack decisional capacity need to have others help them make choices. Some of these decisions can be very difficult for someone else to make. While you are still able, you may want to talk to your family about your wishes and values. This will help you and your family if you are ever unable to make those decisions yourself.

When is it a problem?

A person's ability to make decisions in one or more areas of life may come up when:

• a family member becomes concerned about an older relative and asks the relative's doctor whether the person is still able to make certain decisions
• an older adult needs to give consent for surgery while in the hospital
• planning for release from the hospital.

Here are examples of problems that may cause concern:

• Some people refuse to get the medical treatment needed.
• They do not pay bills.
• They agree to surgery without understanding anything about the medical condition or the surgery
• They do not bathe or wear clean clothes.
• They give large amounts of money to strangers.
• They refuse to make decisions.

How is it evaluated?

Four important factors are considered. People who are able to make their own decisions can:

• communicate in some way (by speaking, writing, blinking their eyes, or using Braille, gestures, picture boards, or computers)
• grasp what is happening around them
• make a decision based on their own values
• foresee the possible results of their decisions.

There is no single way to check decisional capacity. If the person is a hospital patient, an ethics committee may help. A medical doctor will always be involved, whether the person is in the hospital or not. The doctor will usually ask questions to see if the person can:

• understand the situation
• explain the reasons for decisions or actions
• describe the risks and benefits of a decision or action.

The doctor will also want to know if the person:

• knows his or her own name
• is aware of the year, month, date, day of the week, and season
• knows where he or she is
• can pay attention
• can do simple math or spell a short word backward
• has problems with short-term memory.

The doctor will compare the person's present and past behavior and decisions. The focus is on the how the person makes decisions and not how "correct" decisions or actions are.

The doctor will also consider information provided by relatives and other healthcare providers in reaching a conclusion.

A person may still be able to make decisions, even when he or she:

• makes choices other people do not like
• needs extra time to make decisions
• needs information repeated to make a decision.

Is decisional capacity the same as competence?

A doctor determines decisional capacity. A person may have problems in one area, but not in others. For example, you may be able to pay bills but not manage investments. Even people who cannot make decisions about money, medical care, or safety can usually make some types of decisions. However, these decisions may be limited to what clothes to wear or what foods to eat.

A court of law judges competence. All adults are assumed to be "of sound mind" unless the court declares them incompetent. Unlike decisional capacity, competence is usually "all or nothing." If the court declares someone incompetent, the court appoints a guardian to act on that person's behalf.

What affects the ability to make a decision?

Things that may affect decisional capacity include:

• depression
• medicines
• grief
• pain
• a recent move
• various illnesses.

When these are resolved, decisional capacity may improve.

What can I do to help myself?

There are legal documents you can have created while you are of sound mind and able to make decisions for yourself. These include:

• a durable power of attorney (DPOA) for business, property, and financial affairs
• a durable power of attorney for healthcare decisions (HCDPOA).

In these documents, you appoint a person to make decisions on your behalf if you are ever unable to do so. The person named in the DPOA does not have to be the same person named in the HCDPOA. These documents only apply during the time you cannot make decisions for yourself.