Capacity Assessment:Capacity Assessment:Making Sense of the Making Sense of the

ConfusionConfusion

Clarissa Bush, Ph.D., C. Psych.Clarissa Bush, Ph.D., C. Psych.Designated Capacity Assessor (SDA)Designated Capacity Assessor (SDA)

Presentation at Presentation at The Geriatric Patient: Behaviour Management The Geriatric Patient: Behaviour Management

and Safetyand SafetyOttawa, 2013Ottawa, 2013

The Standard of Capacity- The Standard of Capacity- Uniform Across LegislationUniform Across Legislation

• UnderstandUnderstand the information the information necessary to necessary to make a particular make a particular decisiondecision

• AppreciateAppreciate the consequences of a the consequences of a particular decision or lack of particular decision or lack of

decisiondecision

What is “Understand”What is “Understand”

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

What is Appreciate?What is Appreciate?

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

Current Legislation Relevant Current Legislation Relevant to Capacity in the Context to Capacity in the Context

of Health Careof Health Care

Mental Health ActMental Health Act

Health Care Consent Act (HCCA)Health Care Consent Act (HCCA)

Substitute Decisions Act (SDA)Substitute Decisions Act (SDA)

Personal Health Information Personal Health Information Protection Act (PHIPA)Protection Act (PHIPA)

Substitute Decisions ActSubstitute Decisions ActOverall PurposeOverall Purpose

to give people more control over what to give people more control over what happens to them if they cannot make their happens to them if they cannot make their own decisions about property or personal own decisions about property or personal carecare

to protect mentally incapable people from to protect mentally incapable people from harmharm

Substitute Decisions ActSubstitute Decisions Act

When is it used?When is it used?

longer term or recurring incapacitylonger term or recurring incapacity

person failing to manage property or person failing to manage property or personal care decisions or likely topersonal care decisions or likely to

giving or terminating POA with special giving or terminating POA with special provisions (Ulysses contract)provisions (Ulysses contract)

FormalFormal capacity assessment capacity assessment needed for:-needed for:-

Statutory Guardianship (property only; Form 4 Statutory Guardianship (property only; Form 4 required)required)

Court Appointed Guardian – Summary Court Appointed Guardian – Summary DispositionDisposition (1 assessment for property, 2 (1 assessment for property, 2 assessments and one needs statement needed for assessments and one needs statement needed for personal care)personal care)

Power of Attorney coming into effect upon Power of Attorney coming into effect upon incapacity where assessment is specified or no incapacity where assessment is specified or no method of determining capacity specifiedmethod of determining capacity specified

What is a Capacity AssessmentWhat is a Capacity Assessment

an interview with a capacity assessoran interview with a capacity assessor

questions will be about:questions will be about:

- the facts of the person’s current financial - the facts of the person’s current financial or personal situationor personal situation

- their understanding of the decisions they - their understanding of the decisions they faceface

- what would the consequences of - what would the consequences of particular decisions be (appreciation)particular decisions be (appreciation)

Who Can Perform a Capacity Who Can Perform a Capacity Assessment?Assessment?

only people authorized by the Ministry of only people authorized by the Ministry of the Attorney Generalthe Attorney General

a list of capacity assessors can be a list of capacity assessors can be obtained from the Public Guardian & obtained from the Public Guardian & Trustee in Ottawa (613-241-1202)Trustee in Ottawa (613-241-1202)

the list specifies languages spoken by the list specifies languages spoken by assessorsassessors

Who Pays for a Capacity Who Pays for a Capacity Assessment?Assessment?

the person requesting it pays unless they the person requesting it pays unless they are in financial needare in financial need

people in financial need can apply for people in financial need can apply for funding from the Capacity Assessment funding from the Capacity Assessment Office in Toronto (866-521-1033)Office in Toronto (866-521-1033)

usually, people on welfare or ODSP will usually, people on welfare or ODSP will qualify for fundingqualify for funding

What Happens after the What Happens after the Assessment?Assessment?

the capacity assessor completes the the capacity assessor completes the required formsrequired forms

they are sent to the person who was they are sent to the person who was assessed and either the Public Guardian assessed and either the Public Guardian and Trustee or the person who requested and Trustee or the person who requested the assessment, depending on the the assessment, depending on the circumstancescircumstances

If a person is incapable, does the If a person is incapable, does the PGT always take over their PGT always take over their

finances?finances?

Not necessarily, it depends on:Not necessarily, it depends on:

– whether they had given power of attorneywhether they had given power of attorney– whether the person requesting the whether the person requesting the

assessment intends to apply for guardianshipassessment intends to apply for guardianship

Vignette IVignette I

80 year old woman, several medical 80 year old woman, several medical problems and poor memoryproblems and poor memory

living alone in a house, failing to care for living alone in a house, failing to care for herself, not paying bills, phone has been herself, not paying bills, phone has been cut off several timescut off several times

refuses capacity assessmentrefuses capacity assessment

what are the options?what are the options?

Vignette IIVignette II

89 year old man, living alone89 year old man, living alone

indwelling catheter he continually indwelling catheter he continually removesremoves

lets strangers in and they rob himlets strangers in and they rob him

grandson, major caregiver, has POA for grandson, major caregiver, has POA for property & personal care but isn’t willing property & personal care but isn’t willing to confront his grandfatherto confront his grandfather

family all agree client needs to move to family all agree client needs to move to residenceresidence

Vignette IIIVignette III

elderly couple living togetherelderly couple living together

she has dementia, he is irascible and won’t she has dementia, he is irascible and won’t care for himself or hercare for himself or her

she mixes up his medication, he becomes ill, she mixes up his medication, he becomes ill, is hospitalized and she cannot manage aloneis hospitalized and she cannot manage alone

only relative lives in the US and is unable to only relative lives in the US and is unable to help at allhelp at all