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. As you age, you may slow down in the speed of your decision-making, but 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 hard 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 decisions yourself.

When is it a problem?

Worries about your decisional capacity may come up when someone gets concerned that you are not making "good" decisions for yourself. Usually, this will be a family member, caregiver, or healthcare provider.

Your ability to make decisions may come up when:

• a family member becomes concerned and asks your healthcare provider if you are still able to make certain decisions
• you need to give consent for surgery while in the hospital
• your release from the hospital is being planned.

Here are examples of problems that may cause concern:

• You refuse to get the medical treatment you need.
• You are not paying your bills.
• You agree to surgery without understanding anything about the medical condition or the surgery.
• You do not bathe or wear clean clothes.
• You give large amounts of money to strangers.
• You refuse to make decisions.

How is it evaluated?

When decisional capacity is being evaluated, 4 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)
• understand what is happening around them
• make a decision based on their own values
• have an idea of what the possible results of their decisions might be.

There is no one way to check decisional capacity for certain. The best practical test is for your healthcare provider or a family member to ask you to talk about a decision you have made. They may check to see how much you understand about what might happen with your choice and alternatives.

If you are a hospital patient, an ethics committee may help. For healthcare decisions, a medical doctor will always be involved, whether you are in the hospital or not. The doctor will usually ask questions to see if you:

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

The doctor will also want to know if you:

• know your name
• know the year, month, date, day of the week, and season
• know where you are
• can pay attention
• can do simple math or spell a short word backward
• have problems with short-term memory.

The doctor will compare your present and past behavior and decisions. The focus is on the how you make decisions and not how "correct" your decisions or actions are.

The doctor will also consider information provided by relatives and other healthcare providers.

You may still be able to make decisions, even if you:

• make choices other people do not like
• need extra time to make decisions, or
• need to have information repeated before you make a decision.

Is decisional capacity the same as competence?

Decisional capacity is a "common sense" concept. You, your family, and your healthcare provider(s) determine if you are able to make a decision about treatments affecting your life, your activities, or your health. You may be very capable, or your health may make some decision-making hard for you to manage. 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. In some cases, these decisions may be limited to what clothes to wear or what foods to eat.

The terms competence and its opposite, incompetence, are legal concepts. A court of law judges competence. All adults are assumed to be "of sound mind" unless the court declares them incompetent. Courts will review competence cases only if someone asks for the review. It's usually a family member or a caregiver who asks the court for a competency hearing. 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. There are degrees of guardianship, and the court can limit the guardian's authority to (for example) just healthcare decisions.

The more you can plan ahead as you get older or frailer, the less you leave your life to chance and the courts. Planning ahead with a living will and appointing a durable power of attorney for healthcare keeps your health affairs more under your control.

What affects the ability to make a decision?

Things that may affect decisional capacity include:

• depression
• medicines
• grief
• pain
• life events that make you anxious or distracted, such as a recent move
• various illnesses.

When problems related to these things are solved, decisional capacity may get better.

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 (DPOA-HC).

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 DPOA-HC. These documents apply only during the time you cannot make decisions for yourself.