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Loss of Autonomy

Shawn Hersevoort, MD, MPH and Rob Orman, MD
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Psychiatrist Shawn Hersevoort touches on some of the legal, medical, financial and emotional concerns that arise as someone loses the ability to care for themselves.


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Chris -

I was glad to hear this topic reviewed, but I was struck by Dr. Hersevoort's suggest at around 3 minutes 41 seconds that "they have to convince you" of their capacity. Though I realize that this is something that will vary across the various practice locations of the listeners, I would suggest that this is inaccurate in Ontario where a presumption of capacity exists. As described by the College of Physicians and Surgeons of Ontario (, "A person is presumed to be capable with respect to treatment unless reasonable grounds to suspect incapacity exist." So I would suggest that in general there is not an obligation for patients to convince of their capacity - instead we should be making an assessment of a patient's capacity from a starting point of the presumption of them having capacity (rather than seeming to suggest we're assuming they do not and that they must "convince" us that we're incorrect in that assumption).

Maybe Dr. Hersevoort meant more that when there are reasonable grounds to suspect incapacity that then you need to be convinced of their capacity, but the reason I am commenting anyway is that it seems all too often that when there is an inpatient over the age of 80 that immediately when a decision needs to be made the question of "has anyone talked to the family" comes up before the patient has been spoken to. Essentially, there often seems to be a presumption of incapacity for our older patients, which always seems to irk me.

Heidi J., MD -

Agreed. As primary care providers, this is especially important as we are usually the ones making the initial ass't of capacity. I suspect the playing field is a little bit different for specialists who are asked, usually by us after considered evaluation, to see a patient in consultation regarding capacity.

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Bones Lose Their Autonomy Full episode audio for MD edition 193:25 min - 91 MB - M4AHippo Primary Care RAP January 2017 Summary 329 KB - PDF