Being able to make one’s own decisions is an example of personal autonomy. Personal autonomy is considered a basic human right. Some decisions may lead to risks that others may be uncomfortable with.
Participants from the Is the Patient Safe to Go Home? workshops identified the need to better understand autonomy, risk taking, and capacity within the complex scenarios health care professionals often find themselves in. Issues around capacity or decision-making ability occur frequently when working with older adults who have dementia or other conditions that impact judgment and cognition.
This section provides considerations, information, and guidance on how to preserve a person’s decision-making autonomy as much as possible.
Capacity is typically described as a person being able to:
Currently, Canadian capacity laws are mandated by provincial legislation. Canadian, U.S., UK and Australian mental capacity acts and laws all have four principles in common. These principles demonstrate a similar understanding of the issue of decision making for older adults and capture the concept of the Dignity of Risk:
It is important to understand the different elements when considering a person’s capacity for any given decision, in order to avoid making generalizations, assumptions, or removing decision making rights too soon or unnecessarily. The four tabs are adapted (with permission) from the Guidelines for Conducting Assessments of Capacity from the Ontario Ministry of the Attorney (2005).
Capacity for any decision may fluctuate.
This can be dependent on a delirium, pain, fatigue, medications, stress, environment, times of day, etc.
Decisions vary in complexity with line of reasoning, relevant information, people affected and potential outcomes.
Not all decisions are based on rationale and logical reasoning.
Some decisions may be made with a values or preference-based reasoning process. A person’s ability to state values and preferences is independent and separate from state/level of cognition. They could be experiencing significant cognitive impairment but still be included in decision making and choices related to their quality of life, or may still have cognitive abilities that reflect how they derive meaning in their lives.