Governance









White Paper on Surrogate Decision-Making and Advance Care Planning in Long-Term Care

Table of Contents
  1. Introduction
  2. Competence
  3. Decision-Making Capacity
  4. A framework for assessing decision-making capacity
  5. Surrogate Decision-Making
  6. Advance Directives
  7. Guardianship
  8. An Ethical Framework for Surrogate Decision-Making
  9. Decision-making by mentally incapacitated long-term care facility residents
  10. The hierarchy of medical decision-making for incapacitated nursing home residents
  11. Guidance for guardians and other surrogates about medical decision-making
  12. What surrogates and health care provider should expect from each other
  13. Some Important Clinical Issues
  14. Summary and Conclusions
  15. References

Decision-making by mentally incapacitated long-term care facility residents

Long-term care facility residents judged to be incompetent may still possess the capacity for making some decisions, particularly about such personally meaningful things as what to wear and what to eat. Thus, an incompetent person may possess the capacity to make meaningful personal decisions and yet lack the legal authority to do so.

Among the major losses experienced by people admitted to nursing facilities are loss of independence, loss of control over daily schedules, and often loss of the ability to perform basic activities of daily living. Consequently, the decisions that nursing home residents remain able to make loom large, representing the last vestiges of personal control. Thus it may be advantageous, for the sake of their quality of life, to ensure that even those residents who are incompetent, and those mentally incapacitated residents who simply lack the ability to make complex reasoned decisions, are encouraged to make those decisions they are able to make for themselves. The idea of providing choices to incapacitated people in the spirit of preserving and respecting their dignity has been described as part of 'everyday ethics.'17 The choices offered to mentally incapacitated people should not involve risks to their health if they make unwise choices. The goal is to balance the risks inherent in poor decisions against the loss of autonomy.1
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