Case 1: Mr. Allen. Mr. Allen is an 80-year-old widower living alone in an unheated rural shack. His family says he is an alcoholic of 20 years and a loner. He is successfully treated for pneumonia in the hospital, but the antibiotic leaves him with a life-threatening coagulopathy. He insists on going home but does not seem to appreciate the seriousness of his condition, and there is concern he will not take the pills he needs to remain alive. The social worker wonders if this would be a safe discharge or whether he should be discharged to a nursing home.

Case 2: Mrs. Benson. Mrs. Benson is a 75-year-old widow with advanced vascular dementia and end-stage congestive heart failure. She listens to a description of the benefits and burdens of having a do-not-resuscitation (DNR) directive, and when her physician recommends it, she agrees. The next day she has no memory of the discussion, so her physician repeats the consent process, and she again agrees. Her physician wonders if she could have capacity when her memory is so compromised.

CAPACITY AND COMPETENCE

Capacity and competence are among the most important ethical and legal issues in geriatrics. Although the terms are often used interchangeably in conversation, it is advisable to keep capacity and competence as two distinct concepts, with capacity as a clinical concept and competence as a legal concept. It is not that the two words have different meanings in our everyday discourse, but that it is best to remind ourselves that sometimes we are talking about legal conflicts that can only be resolved in court whereas other times we are talking about clinical decisions that are best made without any legal complications (or costs).