Capacity, guardianship and goals of care in dementia (MEQ)

(i) Definition and four abilities. Decision-making capacity is a clinical judgment about whether a person can make a specific decision at a specific time. It is not a global status label from dementia diagnosis alone. Appelbaum–Grisso abilities: understand relevant information; appreciate the situation and consequences for oneself; reason (use or weigh options); communicate a choice.[1][2]

(ii) Assessment plan. Name the decisions separately (antibiotics, oxygen, ICU escalation/intubation, possible residential care). Disclose material information simply; use teach-back. Maximise supports (quiet room, hearing aids, short sentences, daughter as support not sole speaker). Because of drowsiness and possible evolving delirium, treat reversible factors (infection, hypoxia, medications) and reassess when more lucid if delay is safe for each decision. Document findings per ability, time, and supports. Cognitive screens are adjuncts only.[1]

(iii) Substitute decisions and family conflict. If currently lacking capacity for escalation decisions, identify the lawful decision-maker. A valid enduring power of attorney for health typically authorises the appointed attorney (daughter) to decide within the scope of the instrument — confirm under local law without inventing section numbers. Decision standard: substituted judgment (what mother would have wanted — daughter reports refusal of life-prolonging care if she would not return home) then best interests if values incomplete. Meet both children; explain legal hierarchy calmly; involve senior clinician, palliative care, and social work; ethics or guardianship/tribunal pathways if dispute remains unresolved under local process. Do not treat the louder relative as automatic authority.[3][7]

(iv) ACP principles and evidence. ACP is a process preparing patients and surrogates for future decisions, not only a one-time form.[4] Advance directives associate with care more aligned with preferences when older people lack capacity near death.[3] End-of-life discussions associate with less aggressive near-death care and better caregiver bereavement outcomes in observational data — use structured goals-of-care meetings now and document consensus and residual uncertainty.[5]

(v) Psychiatric issues and disposition. Screen for delirium, depression (distinguish from preparatory grief), anxiety, uncontrolled symptoms driving distress, and desire for hastened death.[6] Disposition: clear ceiling of treatment if agreed under lawful authority; treat pneumonia to comfort vs curative goals as decided; avoid MHA misuse for placement; name multi-agency follow-up; reassess capacity if mental state improves; support grieving family. Statutes for guardianship/VAD/consent are jurisdiction-specific — state principles only.[1][7]