With baby boomers retiring in large numbers, the question about who gets to make decisions becomes more important as the years pass.
At what point do we need to intervene because we’re concerned about a senior’s ability to make their own decisions?
“It is a serious step that should only be done as a last resort and only after exhausting other options,” says Dr. Jasneet Parmar, Medical Director of the Covenant Health Network of Excellence in Seniors’ Health and Wellness (NESHW).
“And the seniors involved have to go through a proper capacity assessment process before any move to declare them incapable is made.”
Thanks to the pioneering work of Jasneet and Dr. Lesley Charles, a geriatric physician at the Grey Nuns Community Hospital, and with support from an interdisciplinary team at Covenant and the University of Alberta, an innovative capacity assessment model was developed in 2006. It was implemented a year later and has since gone through refinements.
Earlier this year, a Decision-Making Capacity Assessment Model (DMCA) Toolkit, which details implementation procedures and best practices, was made available online. The toolkit distils more than 10 years of cumulative knowledge in capacity assessment and finding solutions to some of the unique challenges facing adults and seniors.
The assessment is premised on the idea of caring for seniors while respecting their freedom and their independence until they are no longer safely able to do so.
A situation might arise such as a senior often forgetting to turn off the stove at home. A scenario like this signals that it might be time to find out whether he or she is still capable of doing those tasks, says Jasneet.
“A family member might raise this issue with a doctor and then a capacity assessment—which includes cognitive and functional testscan be pursued as the next step.”
The DMCA toolkit provides a standardized way of testing someone’s capacity to make an informed decision, says Lesley.
A standardized screening tool
The move to do an assessment is usually triggered when a patient shows some cognitive or other impairments that affect decision-making, especially if it can potentially put them or someone else in harm’s way, says Lesley.
Nurses, doctors, social workers, occupational therapists and other healthcare professionals who have undergone training can administer the assessment toolkit. The information gleaned from it tends to generate a number of problem-solving approaches, significantly reducing the number of patients who go through actual declaration of incapacity.
“An overwhelming majority of those who go through the initial assessment and interventions that mitigate risk do not need a declaration of incapacity,” says Lesley. A much smaller proportion who were initially assessed continue to the final interview stage.
“Once referred for an interview, the chances that a physician and the team will make a determination to delegate decisions to a guardian or agent, especially for dementia patients, tend to be high,” says Lesley.
However, even at that stage, notes Jasneet, the path chosen should be the least intrusive to patient rights.
“It might not be necessary to take away all aspects of decision-making: financial, health, accommodation, social activities and others.”
For example, for someone who forgets to pay bills and is unable to manage financial affairs, perhaps this aspect of decision-making can be delegated to an attorney (in the enduring power of attorney) or trustee. But other quality of life decisions, such as whether to move forward with a surgery, may still rest with the patient, says Jasneet.
“This is a life-changing moment, and the families as well as medical practitioners and everyone involved really appreciate that there is a systematic process in place on how to go about doing it.”
Lesley notes that a decision to declare someone incapable can still be revisited or reversed at some point, especially if there’s an improvement in the patient’s health. “For example, if someone recovered from a stroke and no longer seems to have impaired cognition, a doctor can recommend a capacity reassessment.”
Family members could also decide to delay activation of personal directives.
“My dad is at an advanced age. He is blind and is dealing with a host of other health issues. Because he’s in long-term care, and well cared for, we don’t see the need at this point to enact his personal directive,” says Jasneet.
Jasneet notes she and her family also like to involve their dad as much as possible in making decisions about his life and health.
Before the implementation of this model, the practice on how to declare someone incapable was applied unevenly by practitioners and health organizations across the province.
Jasneet notes that back then, a patient could be declared incapable even if the impairment was only temporary—such as due to delirium.
Since launching the project 14 years ago, Jasneet and Lesley have conducted hundreds of workshops, courses and training sessions with more than 1,000 nurses, occupational therapists, physicians, social workers, lawyers, legislators and other members of health organizations in the province and elsewhere in Canada.
“Reaching out to colleagues and medical staff in the rural and small communities in Alberta will be the next priority focus in our efforts to provide training on the team-based approach to capacity assessment,” adds Lesley.
The development of the model toolkit has been made possible through funding and endorsement from Covenant Health and Alberta Health Services, and support from the Department of Family Medicine at the University of Alberta, where both Jasneet and Lesley also serve as faculty members.