Dignity, Risk and Choice

Education, resources and practice considerations in older adult care

What is Best-Interest Care?

Decision making on behalf of another individual must be done with consideration and knowledge of the individual's values and beliefs. The Personal Directives Act of Nova Scotia section 15(2b) states that in the absence of instructions, a delegate or substitute decision maker (SDM) must act according to what they believe to be the wishes of the individual in their care. 

Best-interest care process IS NOT

  • Arriving at a decision that health care professionals or others believe will lead to their own preferred outcomes. 

Best-interest care process IS

  • Arriving at a decision that health care professionals or the decision maker reasonably believe best reflects the person as a unique individual and human being.

What is a Substitute Decision Maker (SDM)?

When an older adult is deemed incapable of making a particular decision, a delegate or substitute decision maker (SDM) can be involved to make the decision(s) for them. 

An SDM may be beneficial to the person experiencing impairment. The role of SDM is challenging because they are now responsible for making decisions on another person's behalf. An SDM may enhance or limit another person's dignity, meaningful risk-taking, and everyday choices.

The following principles, informed by The Mental Capacity Act 2005 (UK), should be considered in best-interest care decision-making:

  • Do not discriminate
    Avoid assumptions based on the person’s age, condition, appearance, or feature of behaviour.
  • Consider all relevant circumstances
    What factors or potential outcomes related to the decision would the person consider most important if making this decision themselves?
  • Evaluate status of capacity
    Is it possible the person could regain capacity? Can the decision wait until then?
  • Reflect on a least restrictive approach
    Have all reasonable ways been tried to optimize the person’s abilities to participate in their own decision-making, or to consider a supportive decision-making model?
  • Review evidence of personal wishes/beliefs
    What evidence is there identifying the person’s wishes, values, and beliefs? How would the individual have made decisions at full capacity?
  • Gather input
    Consider consulting the views of other people who have known the person and could contribute information on their values and ways of making decisions in the past. Balance this with respecting right to confidentiality.


  • How do we approach ethical issues when we believe an SDM is making decisions that are in line with the SDM's beliefs/interests/values rather than in the best interest of the individual in care?
  • What if we identified a strategy to mitigate risk that costs money, which the person has, but the SDM doesn't agree to release the funds?
  • How could we improve our skills in communicating best-interest care to SDMs and other health care professionals?
  • How may convenience or risk aversion lead us to decisions that fail to reflect the individual’s wishes and values?