Training › For Family Advocates › Advocacy and ethics

Karim's son is in the kitchen telling you his father should not be living alone anymore. Karim is in the living room. He has not been asked. After this module, you can hold the line that Karim is the one with the right to decide, even when his son disagrees with the decision. You can read capacity correctly: not as a label, but as a question that applies to one decision at a time and can shift. You can identify who the substitute decision-maker is when capacity for a specific decision is absent, and what they can and cannot decide.

The default rule

The older adult is the person whose life this is. They are the default decision-maker about their body, their home, their money, their care, and their day. This is the starting point for every conversation in their household.

Family members do not get to decide for them. Doctors do not. You do not. The older adult decides. Even when the decision is one you would not make. Even when the decision is risky. Even when family members are upset by the decision. Autonomy is the right to make a decision other people disagree with.

What capacity is

Capacity is the ability to understand a specific decision, weigh its consequences, and communicate a choice. It is not a label that gets applied to a person. It is a question that gets asked about a specific decision at a specific moment.

• Capacity is decision-specific. Mrs Diallo may have the capacity to decide what to eat for lunch and not have the capacity to decide whether to enter a long-term care facility. Both can be true on the same day.
• Capacity is time-specific. Capacity in the morning may not be capacity at sundown. Some conditions (delirium, medication changes, infection, dehydration) shift capacity hour by hour.
• Capacity is not "competence." "Competent" is a legal status decided by a court. Capacity is the practical, decision-by-decision question you and the care team work with day to day.
• A poor decision is not a lack of capacity. An older adult with capacity can decide things you would not decide for your own parent. That is autonomy, not a capacity problem.

Substitute decision-making

When an older adult lacks capacity for a specific decision, someone else has to decide it on their behalf. That person is the substitute decision-maker. The framework matters because the wrong person deciding can do real harm.

• The hierarchy is usually set by law in advance. A power of attorney for personal care, a power of attorney for property, a court-appointed guardian, or, in many jurisdictions, a defined family hierarchy if no documents exist. The order is jurisdiction-specific.
• The substitute decides only the decisions the older adult lacks capacity for, not every decision. Mrs Diallo's power of attorney for personal care can decide her medical treatment when she cannot, but cannot decide what she eats for lunch when she can decide that herself.
• The substitute decides as the older adult would have decided, not as the substitute would decide for themselves. "What would Karim have wanted?" is the question, not "what do I think is best?"
• If you are not sure who the substitute is, the care plan or the family record drawer is the place to look. If it is not documented there, message your advocate channel.

Documenting the conversation

Every meaningful conversation about a decision goes into the family record. The next advocate covering for you needs to be able to read the situation cold.

• Who was in the room or on the call.
• What decision was being discussed.
• What the older adult said, in their words if possible.
• Whether capacity for this specific decision was clear, in question, or absent, and why.
• If a substitute decision-maker was involved, who it was and what their authority is.
• The outcome and the next step.

The line with safeguarding

Respecting autonomy is the default. Safeguarding is the exception. The line between them is harm.

• If Karim decides to continue living alone in his apartment and you disagree with that decision but he has the capacity to make it and is not in danger, that is autonomy. You document the conversation and you do not act on his behalf.
• If Karim decides to continue living alone and you see signs of harm or neglect that he is unable or unwilling to address, that is a safeguarding concern. You follow the safeguarding path, same day, per the Safeguarding module.
• If Karim's son starts speaking for Karim in front of Karim about a decision Karim has capacity to make, your job is to direct the conversation back to Karim with the warmth that lets the son feel heard.
• If a substitute decision-maker is making a decision that is plainly against what Karim would have wanted (and you have evidence of that from prior conversations or the care plan), that is also a safeguarding-adjacent concern. Escalate to iCaria Support.

Finding this again Open Training from your portal any time to come back to this module. A knowledge quiz follows, and you re-take it each year when you renew your certification.