Medical Decision-Making Capacity and Ethical Considerations

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.