Welcome Wisdom

Competency, Capacity, and Decision-making

by Felicia Juntunen, MA, CMC, Director of Care Management

Among the complex aging issues Aging Life Care professionals encounter is the question of competency and capacity and the impact on decision-making for older adults and their families. For decisions to have personal or legal significance, a person must have decision-making capacity and with advancing age decision-making capacity can be influenced by cognitive, physical, or emotional issues. 

Legal competency refers to an individual’s status of being under court-appointed guardianship. Competency determination is all-encompassing. It is issued by the court (a judge), which means an individual loses all rights to make autonomous decisions, and leads to an appointment of a legal guardian assigned by the court to make decisions on behalf of the individual. Capacity refers to a person’s functional ability to understand the significance of making a particular decision. Unlike competency, capacity is not “all or nothing.” Decision-making capacity is more limited, is determined through assessment by a medical doctor, psychiatrist, or neurologist, pertains to a specific time and situation, and can be optimized to provide the best possible supportive decision-making for the individual. People may have the capacity to make some decisions but not others, they may be able to make decisions sometimes but not other times, and they may be able to make decisions if they have assistance understanding the decision needing to be made. A person’s lack of capacity does not necessarily mean the court must make a competency determination or appoint a legal guardian, a costly process that can almost always be avoided with proper planning. 

Aging Life Care professionals encounter individuals across the spectrum of capacity. Care managers regularly serve individuals living with dementia and are very familiar with the impact cognitive decline can have on a person’s decision-making ability. In our role as advocates, guides, and facilitators of services, Aging Life Care professionals work to help families understand the ability of their loved ones to participate in decision-making. While our efforts do not replace that of a formal clinical assessment, a care manager’s regular interaction with a client often provides further clarity regarding the extent to which the older adult may interact with the decision-making process. The holistic approach of an Aging Life Care professional provides a whole-person picture of the individual. The care manager also seeks to determine if the person’s decision-making capacity results from a temporary or reversible condition including illness or infection, medication side effects, delirium, pain, emotional stress, sensory deprivation (hearing, vision), or cultural barriers- all areas of context a care manager aims to understand about their client.

An Aging Life Care Professional can help mitigate confusion or provide confirmation and support to a family as they work through decision-making consequences when the capacity of their loved one is in question – always referring them to either the legal plans previously put in place or to those who can answer their legal questions and concerns. Most families recognize the profound impact of making decisions for their aging loved one whose decision-making capacity may be in question or who has already been deemed not to have decision-making capacity. Families often feel conflicted about making decisions for their loved one– especially in the parent-child relationship where the roles have reversed, and the adult child is now tasked with making decisions on behalf of their parent. Care managers regularly guide client’s families through what can be a tender time of transition as they grapple with their loved one’s changing abilities and strive to ensure they are safe and well cared for. 

Decision-making ability and functionality are profoundly influenced by planning. Anyone can encounter a time when their decision-making capacity is diminished. Aging Life Care professionals encourage all adults (young and old!) to engage in the legal planning process for their future while they can understand their choices and make decisions. While it’s impossible to predict all scenarios, thoughtful planning can cover the main areas of decision-making, including where one lives, what kind of medical care one receives, and how one’s financial resources are used. Preparing documents like a power of attorney and advance healthcare directive ahead of time can better protect the decision-making rights of an older adult and provide important insight for those appointed to speak for them.  

“Supported Decision Making for Elder with Dementia: A Deep Dive” – J. Pilcher, P. Greenfield, M. Huber, Journal of Aging Life Care, Summer 2019

 

“On Competency and Capacity of Older Adults to Make Decisions” – Donald Freedman, JD, Journal of Geriatric Care Management, Spring 2013