Decisional Capacity

What is decisional capacity?

Decisional capacity is the ability to make choices. Sometimes, when you are very sick or very old, you may become unable to make decisions. However, problems making decisions are not a normal part of getting older.

If for some reason you lose your decisional capacity, you will need to have others help you make some decisions. Some 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.

What affects the ability to make a decision?

Things that may for a time affect your ability to make decisions include:

• grief, pain, or anxiety about things happening in your life such as a recent move
• side effects of medicines
• various illnesses.

When you recover from illness, or you have less pain, or life problems not so stressful, your decisional capacity may get better.

Some health problems severely affect decisional capacity, such as

• worsening dementia
• delirium or confusion from serious illness
• brain injury, for example, from a stroke or accident
• severe anxiety, depression, or other mental illness

When is it a problem?

Questions about your ability to make decisions may come up when:

• A family member 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 certain way to check decisional capacity. 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. Your healthcare provider will usually ask questions to see if:

• You understand your situation.
• You can explain the reasons for your choices.
• You can describe the risks and benefits of your choices.

Your healthcare provider will also see if:

• You know your name.
• You know the year, month, date, day of the week, and season.
• You know where you are.
• You can pay attention.
• You can do simple math or spell a short word backward.
• You can remember things that have happened recently.

Your healthcare provider will compare your present and past behavior and choices. The focus is on how you make decisions and not how correct others think your decisions or actions are. Your healthcare provider will also consider information provided by relatives and other providers.

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

• You make choices other people do not like.
• You need extra time to make decisions.
• You 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 determine your decisional capacity—that is, your ability to make decisions about your life, including your health. There may be some decisions you cannot make and others you can.

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. 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 as a guardian. There are degrees of guardianship. The court can limit the guardian’s authority to (for example) just healthcare decisions.

Courts review competency cases only if someone asks for the review. Usually it’s a family member or caregiver who makes the request for a hearing.

What can I do to help myself?

The more you can plan ahead as you get older or frailer, the less you leave your life to chance and the courts. There are legal documents that you can create and sign 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 that you cannot make decisions for yourself.

You can keep your affairs, including your health, more under your control by planning ahead with advance directives for medical care and appointing durable powers of attorney.