This blog post on the Elder Care Planning Framework for Decision Making, Part 2, is based on a panel presentation at Elder Law Day in Toronto in March 2023. Participants expressed an interest in using the elder care planning framework to provide context for decision-making and planning. Part 1 proposed the framework as a tool to aid in decision-making for elder care management; read it here.

The elder care planning framework is based on a continuum of care approach, a common health care process. The continuum of care reflects the involvement of integrated systems of care that track clients over time through various levels of intensity of care through various health services. It is important to note that advance care planning is becoming more recognized as a critical component of a comprehensive plan. Recently, Hickman et al. has suggested that advance care planning and preparing people and their decision-makers to communicate about end-of-life care should be fully integrated into the continuum of care approach and decision-making at all levels.[1] Integrating advance care planning into the tool makes it even more robust to aid in decision-making and planning.

The New Urgency to Understand Decision-Making Capacity and Plan Ahead

There is a new urgency to understand decision-making capacity and to plan for diminished capacity related to elder management. The fastest-growing age cohort in Canada is those 100 years and older. Based on the 2021 Census data, it is predicted that the number of people aged 85 years and older will triple to almost 2.5 million by 2023. The impact of this prediction means that more people will be living with diminishing decision-making capacity for longer periods than ever before.

The Complication: There Is No Single Definition of Capacity

There is no single definition of capacity. Each case is unique and accounts for the person, the specific task, the time, and the situation the person is in. What are some key considerations in considering decision-making capacity?

• People are presumed to have capacity unless reasonable grounds exist to the contrary
• Presumed capacity aims to balance promoting autonomy with protection against exploitation, coercion, and undue influence.
• People have the right to make unwise decisions, the right to learn from experience, and the right to change their minds.

Hospital-Based Considerations Involved in the Elder Care Planning Framework for Decision Making

Elder care decisions are not made in isolation as they are often intertwined with financial, legal, and clinical implications. The individual and/or their primary caregiver(s) will make a myriad of care decisions, such as hiring a home care service or moving to an assisted living facility for more care support. Interactions with a range of advisors, such as financial advisors, health care providers, lawyers, accountants, and real estate agents, will require that the advisors recognize signs of diminished capacity or undue influence.

Planning for a person’s transition from one setting to another often triggers concerns regarding decision-making capacity and even potential family disputes. During the Elder Law Day presentation, we discussed the all too frequent situation in acute care hospitals where an older person is designated as medically stable to be discharged and wishes to go home. However, the person is also assessed as unable to live alone. And if no one is at home to care for them, the discharge planning approach typically sends the person to a publicly funded long-term care home. Most hospital-based discharge planners are not skilled at recommending numerous alternatives in the community and do not believe it is their role, even if the older person has the resources to pay for private accommodation.

Plan Well for Your Future Care

The moral of the story is to plan well for your future care. How do you do that?

1. Thoughtful planning. Using the proposed elder care planning framework for decision-making enables you to think through the different levels of care and to make some thoughtful choices on what you want at different stages in the continuum of care.
2. Write out a roadmap. Set out your priorities and the decisions you need to make in advance.
3. Have conversations. Share your plan with your partner, family, attorneys, and advisors so they can clearly understand your wishes and preferences. And hopefully, once they understand, they will buy into your plan.

For more information, read Part 1 of this article, which proposes the framework as a tool to aid in decision-making for elder care management.

[1] Hickman, SE, Lum, HD, Walling, AM, Savoy, A, Sudore, RL. The care planning umbrella: The evolution of advance care planning. J Am Geriatr Soc. 2023; 1- 7. doi:10.1111/jgs.18287