As a first step in helping a person engaged in advance care planning, physicians and other health care providers must determine if the person is capable of making health care decisions
Legally, people are presumed capable unless proven otherwise. To be deemed capable of making health care decisions, a person must:
- UNDERSTAND: a person must be able to grasp and retain the relevant information to the decision at hand. If doubts about the person’s ability to understand arise, the following questions must be explored:
- Has the person been given the relevant information in language appropriate to their level of understanding and in their language of fluency?
- Has the person been educated about his/her illness and the treatment alternatives AND been given opportunities to ask any questions he/she may have?
- Does the person understand that he/she has a choice and what each alternative involves and its risks and benefits?
- Can the person remember the information long enough to reach a decision?
- Can he/she remember the choices he/she has previously made and be consistent in his/her decision-making over time?
- APPRECIATE: a person must be able to grasp how a given treatment will affect him/her personally. Moreover, he/she must be able to show that his/her reasoning is based in reality. If doubts as to the abilities of a person to appreciate the information he/she has been given arise, the following questions should be explored:
- Does the person understand how the risks and benefits of a given treatment and the available alternatives will affect him/her personally in his/her current situation?
- How did he/she arrive at his/her decision? Was the decision reasoned, based in reality and consistent with the person’s previously expressed values and beliefs? If a person’s reasoning seems strange, physicians/clinicians may seek to explore it in the context of appropriate religious and cultural background.
- Capacity may be transient and change over time. Reversible causes must be ruled out/treated and capacity must reassessed.
- If a person seems to be incapable because he/she either doesn’t understand or doesn’t appreciate the treatment options and their risks and benefits, he/she will need a formal capacity assessment.
- One such tool to help health care providers perform a specific capacity is the Aid to Capacity Evaluation (ACE) developed by Dr. E. Etchells and available through the University of Toronto Joint Centre for Bioethics website.
- In cases where you, as the person’s physician, are uncertain of his/her capacity, these specific capacity assessments can be done by psychiatrists, psychologists, nurses, social workers, bioethics committees or by Consent and Capacity Review Boards.