Capacity Assessment: Making Sense of the Confusion Clarissa Bush, Ph.D., C. Psych. Designated Capacity Assessor (SDA) Presentation at The Geriatric Patient: Behaviour Management and Safety Ottawa, 2013

The Standard of Capacity- Uniform Across Legislation Understand the information necessary to make a particular decision Understand the information necessary to make a particular decision Appreciate the consequences of a particular decision or lack of decision Appreciate the consequences of a particular decision or lack of decision

What is Understand having the factual knowledge base and skills needed to manage the decision-making demands of his or her circumstances (or can be educated in that regard) and having the capacity to intellectually understand the options for meeting his or her needs and the ability to communicate his or her choices or decisions

What is Appreciate? the ability to realistically appraise the risk and likely outcome of a decision or lack of a decision and the ability to plan and take action to implement a plan and the ability to rationally manipulate information to reach a reasoned decision consistent with personal values and free from delusional beliefs.

Current Legislation Relevant to Capacity in the Context of Health Care Mental Health Act Health Care Consent Act (HCCA) Substitute Decisions Act (SDA) Personal Health Information Protection Act (PHIPA)

Substitute Decisions Act Overall Purpose to give people more control over what happens to them if they cannot make their own decisions about property or personal care to protect mentally incapable people from harm

Substitute Decisions Act When is it used? longer term or recurring incapacity person failing to manage property or personal care decisions or likely to giving or terminating POA with special provisions (Ulysses contract)

Formal capacity assessment needed for:- Statutory Guardianship (property only; Form 4 required) Court Appointed Guardian – Summary Disposition (1 assessment for property, 2 assessments and one needs statement needed for personal care) Power of Attorney coming into effect upon incapacity where assessment is specified or no method of determining capacity specified

Opinions about capacity are often requested regarding:- Capacity to give and revoke POA (criteria in s.8 and s.47 of SDA) Testamentary capacity Capacity to instruct counsel (less common)

What is a Capacity Assessment an interview with a capacity assessor questions will be about: - the facts of the persons current financial or personal situation - the facts of the persons current financial or personal situation - their understanding of the decisions they face - what would the consequences of particular decisions be (appreciation)

Who Can Perform a Capacity Assessment? only people authorized by the Ministry of the Attorney General a list of capacity assessors can be obtained from the Public Guardian & Trustee in Ottawa ( ) the list specifies languages spoken by assessors

Who Pays for a Capacity Assessment? the person requesting it pays unless they are in financial need people in financial need can apply for funding from the Capacity Assessment Office in Toronto ( ) usually, people on welfare or ODSP will qualify for funding

What Happens after the Assessment? the capacity assessor completes the required forms they are sent to the person who was assessed and either the Public Guardian and Trustee or the person who requested the assessment, depending on the circumstances

If a person is incapable, does the PGT always take over their finances? Not necessarily, it depends on: –whether they had given power of attorney –whether the person requesting the assessment intends to apply for guardianship

Vignette I 80 year old woman, several medical problems and poor memory living alone in a house, failing to care for herself, not paying bills, phone has been cut off several times refuses capacity assessment what are the options?

Vignette II 89 year old man, living alone indwelling catheter he continually removes lets strangers in and they rob him grandson, major caregiver, has POA for property & personal care but isnt willing to confront his grandfather family all agree client needs to move to residence

Vignette III elderly couple living together she has dementia, he is irascible and wont care for himself or her she mixes up his medication, he becomes ill, is hospitalized and she cannot manage alone only relative lives in the US and is unable to help at all