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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #55, #56, #58


Learning Objectives

  • To review the elements of decisional capacity

  • To describe ways to determine capacity

  • To understand special instances where knowledge of decisional capacity should be applied

Key Clinical Points

  1. There are four necessary elements to making a capable decision: understanding, appreciation, reasoning, and expressing a choice.

  2. Critical cortical functions involved in decision making include immediate memory, language, and executive function.

  3. Decisional incapacity is task-specific and may be time-limited. Therefore, decision-making capacity may fall along a spectrum and the ability of an individual to make decisions often needs to be thought of in flexible terms.

  4. An assent-consent model of surrogate decision making is key to decision making in patients who retain the ability to participate in decisions but do not have full decision-making capacity.


Assessing a patient’s capacity to make decisions is a role with which all clinicians should be familiar. Although certain situations may call for specialized assessment, generalists, family physicians, internists, subspecialists, geriatricians, and advanced practice nurses, among other health professionals, should be sufficiently familiar with the principles and process to manage most situations. The purpose of this chapter is to explain some of the ethical underpinnings to this responsibility, to highlight the strengths and weaknesses of approaches to assessing decisional capacity, and to describe the role of the clinician in decision making.

Autonomy is defined as self-determination (see also Chapter 61). Respect for individual autonomy is understood to be an elemental principle of our society. Nonetheless, all of us face limitations on how much we can truly determine our fates. Limitations of resources and opportunity, societal and legal prohibitions, and the limits imposed by the rights of others not to have their autonomy infringed upon all limit one’s self-determination. There are also limitations on who qualifies as an autonomous “self.” The full right to self-determination is generally recognized to apply only to adults who are “of sound mind.”

Paternalism is defined as limiting an individual’s autonomy in order either to prevent that individual from doing harm to themselves or to prevent the person from missing a substantial benefit. The circumstances under which paternalism is acceptable are not defined by the action the individual may wish to undertake, or by the probable untoward consequences of an action, but rather by the individual’s ability to make decisions. In other words, our wish to protect an individual from doing themselves harm does not justify paternalism; we cannot prevent an individual from doing things that may cause them harm (drinking, sky diving, etc). We can only justify intervention if we judge that an individual lacks the capacity to make decisions. In such a case, we are responsible for protecting the person from the possible harm of an incapable decision.

The interplay between ...

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