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Understanding Dementia

Competence and Capacity

This is an excerpt from the book Understanding Dementia, which is meant to be a practical manual for primary care physicians and other health care professionals. Dementia exists when impairment with cognition (e.g. memory , language, calculation) is severe enough to interfere with function. Decision making is discussed in Chapter 7, as an aspect of the assessment of a patient's competence .



Several domains of competence must be considered, including financial competence, testamentary capacity, competence for living arrangements, for health care, and for driving. Planning future arrangements when patients are in the early stages of dementia and can still make their own choices greatly simplifies management. Competence is situation specific, and patients who cannot make decisions on some issues may be able to make decisions on other issues. The patient's lawyer is a valuable resource when discussing the various options and issues.

If the patient is able to describe their income and payments, have maintained calculation abilities , and no history of errors in banking or bill paying, then there is no question about financial competence, providing judgement is maintained. Commonly, however, by the time the diagnosis of dementia has been made, some errors and impaired performance will have occurred. The question then becomes whether the patient is able to give power of attorney for financial decisions. The standard varies among jurisdictions, and the physician should be familiar with local legislation. In general, the patient should know the extent of his or her estate and financial obligations, and demonstrate a broad understanding of their monthly income and expenditures. They should also be able to explain to whom power of attorney is being granted and why. Clearly, the earlier in the dementing illness this takes place the better and, optimally, all older patients should appoint an enduring power of attorney if there is a suitable person to whom such responsibility can be granted. Indeed, it is a useful practice to recommend power of attorney for all patients. If the patient is unable to assign power of attorney a guardian will need to be appointed through the courts. This can be a long and costly affair. Being aware of the difficulties and costs involved in appointing a guardian is often a powerful incentive for patients and families to make arrangements early.

The process of assigning enduring power of attorney is usually conducted through a lawyer (although some jurisdictions accept a simple notarized statement) and is relatively simple. The person with power of attorney can then assume greater degrees of responsibility as the patient deteriorates. If this is not done, the assets of an incompetent patient may become unavailable until a guardian can be appointed. Determination of testamentary competence follows a similar course, and the patient should be able to demonstrate a knowledge of the extent of their estate and those named in the will. Although it is not always required, it is helpful if patients can explain why the assets will be dispersed in the way which they propose. Where the rationale for proposed distribution is not obvious, it helps if the patient can demonstrate that their judgement is in keeping with what might reasonably be inferred as their system of values. The presence of unusual bequests is often a signal for referral , as the resulting legal entanglements can be complex, and most dementia specialists have a reasonable working knowledge of the local practice and arrangements.

Enduring power of attorney for health care needs to be specifically included with the financial power of attorney. Again, discussion of future wishes when the patient is still competent leads to simpler decision-making in later stages.

Taken from Understanding Dementia: A Primer of Diagnosis and Management
Kenneth Rockwood & Chris MacKnight, 2001
Chapter 7, pp 118-119


 

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Last updated August 13, 2014
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