Elder Abuse pp 229-246 | Cite as

Medical Decision-Making Capacity and Ethical Considerations

  • Elizabeth J. SantosEmail author
  • Corey Nichols-Hadeed


Assessment of medical decision-making capacity is challenging and especially complicated for victims of elder abuse. Given the complex nature of this work, this chapter aims to introduce concepts and ethical considerations related to decision-making for vulnerable older adults, to present the current practice for assessing capacity to make medical decisions and to consider research and future directions. Despite the goal to achieve shared decision-making with older adults and provide patient center care, capacity assessment is still needed when one suspects that an older adult cannot understand the situation and the consequences of the medical decisions which the older adult is making when the decisions may cause irreparable harm. Physicians may turn to established guidelines, standardized forms, and ethics committees to effectively utilize medical decision-making capacity assessments. Depression and dementia are common among abused older adults and can impair their abilities to appreciate decisions they are making about their medical care. These capacity assessments may influence legal guardianship or conservatorship proceedings, but are different from legal determinations to appoint a guardian or conservator due to incapacity or incompetence. Once a physician deems an older adult to lack capacity, the physician consults surrogate decision makers in order to provide the appropriate care. If there are no health care proxies assigned, surrogate decision makers are prioritized under state law, which varies from state to state. Despite ethical challenges and other barriers to understanding decision-making capacity in older adults, future developments in technology and patient-centered research may provide the tools needed to improve current practices.


Capacity Incapacity Incompetence Guardianship Conservatorship Shared decision-making 


  1. 1.
    Agency for Healthcare Research and Quality. Making Health Care Safer II; Rockville, MD; 2013. Retrieved from March 7, 2016.
  2. 2.
    American Bar Association. Guardianship Law and Practice. Retrieved from March 7, 2016.
  3. 3.
    American Bar Association. Health Care Decision Making. Retrieved from March 7, 2016.
  4. 4.
    American Medical Association. Ethics Opinion 8.08, Informed Consent; 2006. March 7, 2016.
  5. 5.
    American Psychological Association. ABA/APA assessment of capacity in older adults. Retrieved from March 7, 2016.
  6. 6.
    Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834–40.CrossRefGoogle Scholar
  7. 7.
    Appelbaum PS, Grisso T. MacCAT-CR:MacArthur competence assessment tool for clinical research. Sarasota, FL: Professional Resource Press; 2001.Google Scholar
  8. 8.
    Aulisio MP, Arnold RM, Younger SJ. Health care ethics consultation: nature, goals, and competencies. Ann Intern Med. 2000;133:59–69.CrossRefGoogle Scholar
  9. 9.
    Baker RR, Lichtenberg PA, Moye J. A practice guideline for assessment of competency and capacity of the older adult. Prof Psychol Res Pract. 1998;29(2):149.CrossRefGoogle Scholar
  10. 10.
    Barry MJ, Edgman-Levitan S. Shared decision-making—the pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780–1.CrossRefGoogle Scholar
  11. 11.
    Brandl B, Dyer CB, Heisler CJ, Otto JM, Stiegel LA, Thomas RW. Elder abuse detection and intervention: a collaborative approach. New York, NY: Springer; 2007.Google Scholar
  12. 12.
    Caulfield SE. Health care facility ethics committees: new issues in the age of transparency. Am Bar Assoc Sect Civ Rights Soc Just. 2007;34(4). March 7, 2016.
  13. 13.
    Centers for Elders and the Court. Guardianship Basics. Retrieved from March 7, 2016.
  14. 14.
    Chin JJ. Doctor–patient relationship: from medical paternalism to enhanced autonomy. Singp Med J. 2002;43(3):152–5.Google Scholar
  15. 15.
    Daveson BA, Bausewein C, Murtagh FE, et al. To be involved or not to be involved: a survey of public preferences for self-involvement in decision-making involving mental capacity (competency) within Europe. Palliat Med. 2013;27(5):418–27.CrossRefGoogle Scholar
  16. 16.
    Demakis GJ. State statutory definitions of civil incompetency/incapacity: issues for psychologists. Psychol Public Policy Law. 2013;19:331.CrossRefGoogle Scholar
  17. 17.
    Edersheim JG, Brendel RW, Price BH. Neuroimaging, diminished capacity and mitigation. In: Simpson JR, editor. Neuroimaging in forensic psychiatry: from the clinic to the courtroom. Wiley; 2012. Google Scholar
  18. 18.
    Grady C. Enduring and emerging challenges of informed consent. N Engl J Med. 2015;372:855–62.CrossRefGoogle Scholar
  19. 19.
    Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatr Serv. 1997;48(11):1415–9.CrossRefGoogle Scholar
  20. 20.
    Jeste DV, Palmer BW, Appelbaum PS, Golshan S, Glorioso D, Dunn LB, et al. A new brief instrument for assessing decisional capacity for clinical research. Arch Gen Psychiatry. 2007;64(8):966–74.CrossRefGoogle Scholar
  21. 21.
    Lai JM, Karlawish J. Assessing the capacity to make everyday decisions: a guide for clinicians and an agenda for future research. Am J Geriatr Psychiatry. 2007;15(2):101–11.CrossRefGoogle Scholar
  22. 22.
    Leo RJ. Competency and the capacity to make treatment decisions: a primer for primary care physicians. Prim Care Companion J Clin Psychiatry. 1999;1(5):131–41.CrossRefGoogle Scholar
  23. 23.
    Levin A. Coercion and autonomy sometimes collide in patient-care decisions. Psychiatric News; 2014;49(12). Google Scholar
  24. 24.
    Lichtenberg PA, Stickney L, Paulson D. Is psychological vulnerability related to the experience of fraud in older adults? Clin Gerontol. 2013;36(2):132–46.CrossRefGoogle Scholar
  25. 25.
    Lichtenberg PA, Stoltman J, Ficker LJ, Iris M, Mast B. A person-centered approach to financial capacity assessment: preliminary development of a new rating scale. Clin Gerontol. 2015;38(1):49–67.CrossRefGoogle Scholar
  26. 26.
    Liu YL. Autonomy, filial piety, and parental authority: a two-year longitudinal investigation. J Genet Psychol. 2013;174(5–6):557–81.CrossRefGoogle Scholar
  27. 27.
    Lui VWC, Lam LCW, Chau RCM, Fung AWT, Wong BML, Leung GTY, et al. Structured assessment of mental capacity to make financial decisions in Chinese older persons with mild cognitive impairment and mild alzheimer disease. J Geriatr Psychiatry Neurol. 2013;26(2):69–77.CrossRefGoogle Scholar
  28. 28.
    Mental Disability Advocacy Center. Legal capacity in Europe: a call to action to governments and to the EU. October 2013. Retrieved from March 17, 2016.
  29. 29.
    Mills WL, Regev T, Kunik ME, Wilson NL, Moye J, McCullough LB, et al. Making and executing decisions for safe and independent living (MED-SAIL): development and validation of a brief screening tool. Am J Geriatr Psychiatry. 2014;22(3):285–93.CrossRefGoogle Scholar
  30. 30.
    Mills WL, Snow AL, Wilson NL, Naik AD, Kunik ME. Conceptualization of a toolkit to evaluate everyday competence in planning transitions from nursing homes to the community. J Am Med Dir Assoc. 2013;14(8):626-e1.CrossRefGoogle Scholar
  31. 31.
    Mortimer AM, Likeman M, Lewis TT. Neuroimaging in dementia: a practical guide. Pract Neurol. 2013;13:92–103.CrossRefGoogle Scholar
  32. 32.
    Moye J, Marson D, Edelstein B. Assessment of capacity in an aging society. Am Psychol. 2013;68(3):158–71.CrossRefGoogle Scholar
  33. 33.
    Munthe C, Sandman L, Cutas D. Person centered care and shared decision making: implications for ethics, public health and research. Health Care Anal. 2012;20(3):231–49. doi: 10.1007/s10728-011-0183-y.CrossRefPubMedGoogle Scholar
  34. 34.
    Nilsson A. Who gets to decide? Right to legal capacity for persons with intellectual and psychosocial disabilities. Council of Europe, Commissioner for Human Rights Issue Paper. February 20, 2012.Google Scholar
  35. 35.
    Pape T. Legal and ethical considerations of informed consent. AORN J. 1997;65(6):1122–7.CrossRefGoogle Scholar
  36. 36.
    Pope TM. Legal briefing: healthcare ethics committees. J Clin Ethics. 2011;22(1):74–93.PubMedGoogle Scholar
  37. 37.
    Rudrauf D. Structure-function relationships behind the phenomenon of cognitive resilience in neurology: insights for neuroscience and medicine. Adv Neurosci. 2014;1–28.Google Scholar
  38. 38.
    Schillerstrom JE, Horton MS, Royall DR. The impact of medical illness on executive function. Psychosomatics. 2005;46(6):508–16.CrossRefGoogle Scholar
  39. 39.
    Schillerstrom JE, Horton MS, Schillerstrom TL, Joshi KG, Earthman BS, Velez AM, et al. Prevalence, course, and risk factors for executive impairment in patients hospitalized on a general medicine service. Psychosomatics. 2005;46(5):411–7.CrossRefGoogle Scholar
  40. 40.
    Schillerstrom JE, Salazar R, Regwan H, Bonugli RJ, Royall DR. Executive function in self-neglecting adult protective services referrals compared with elder psychiatric outpatients. Am J Geriatr Psychiatry. 2009;17(10):907–10.CrossRefGoogle Scholar
  41. 41.
    Stiegel LA, Wood EF. Nine ways to reduce elder abuse through enactment of the uniform adult guardianship and protective proceedings jurisdiction act. Bifocal, e-journal of the ABA Commission on Law and Aging 2009;30(3):1–6.Google Scholar
  42. 42.
    Tai MC, Tsai T. Who makes the decision? Patient’s autonomy vs paternalism in a confucian society. Croat Med J. 2003;44(5):558–61.PubMedGoogle Scholar
  43. 43.
    United Nations Convention on the Rights of Persons with Disabilities. Accessed online March 7, 2016.
  44. 44.
    United States. The Belmont Report: ethical principals and guidelines for the protection of human subjects research. Bethesda, MD: The Commission; 1978.Google Scholar
  45. 45.
    Wigglesworth A, Austin R, Corona M, Schneider D, Liao S, Gibbs L, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;S57:1191–6.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of Rochester Medical CenterRochesterUSA

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