Decisional Capacity

What is decisional capacity?

Decisional capacity is the ability to make the right choices for yourself. The ability to make decisions does not depend on age or medical condition, but 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.

How does the issue arise?

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.

Examples of problems that may cause concern include:

• refusing needed medical treatment
• failing to pay bills
• agreeing to surgery without being able to describe anything about the medical condition or the surgery
• failing to bathe or wear clean clothes, especially if this is new behavior
• giving money to strangers
• refusing to make decisions.

How is decisional capacity 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 standard 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 consider if the person's present behavior and decisions seem to be in line with his or her past values. The focus is on the how the person goes about making decisions and not how "correct" decisions or actions are.

The doctor will also consider information provided by relatives and other health care 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.

What is the difference between decisional capacity and competence?

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

A judge determines competence. All adults are presumed competent unless a judge has declared them incompetent. Unlike decisional capacity, competence is usually an "all or nothing" arrangement. If the court finds someone incompetent, the court will appoint a guardian to act on that person's behalf. For most people, it is best to avoid being declared incompetent in order to preserve the ability to make some choices.

What conditions or situations can affect 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 health care 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.