Aid To Capacity Evaluation (ACE)

Capacity is the ability to understand information relevant to a decision and the ability

to appreciate the reasonably foreseeable consequences of a decision (or lack of a

decision). The purpose of the Aid to Capacity Evaluation (ACE) is to help clinicians

systematically evaluate capacity when a patient is facing a medical decision.

The developers of the ACE (i) assume no liability for any reliance by any person on

the information contained herein; (ii) make no representations regarding the quality,

accuracy or lawfulness related to the use of the ACE, and (iii) recommend that ACE

users attend a standardized ACE training session.

Sunnybrook & Women's College Health Sciences Centre

Sunnybrook Campus

Room C4-10, 2075 Bayview Avenue

Toronto, Ontario, M4N 3M5

Telephone: (416) 480-6100 x5996, Fax: (416) 480-5951

Email: edward.etch[email protected]

For an additional resource on capacity, please see Dr. Etchells’ paper, "Bioethics for

Clinicians: 3. Capacity" (Canadian Medical Association Journal 1996; 155: 657-61).

www.jcb.utoronto.ca/tools/ace.shtml

1. Medical Condition:

Aid To Capacity Evaluation (ACE) – Administration

*(This is the definition of capacity from 1996 legislation in Ontario, Canada. Although

similar definitions exist across North America, we suggest that users check existing

3.Before assessing capacity, identify and address any barriers to

communication (e.g. hearing impairment, visual impairment, language barrier,

translating). These other people should not attempt to answer questions for the

person being assessed.

4.While assessing capacity, the assessor must:

 Disclose information about the treatment, alternatives, the risks and side

effects of treatment, and the consequences of not having treatment, that a

reasonable person in the same circumstance would require in order to make

a decision.

 Respond to any questions or requests for other information.

7.Do not assess whether you agree or disagree with a person's decision. Assess the

person's ability to understand and appreciate their decision.

ACE SAMPLE QUESTIONS

 What problems are you having right now?

 What problem is bothering you most?

 Why are you in the hospital?

Joint Centre for Bioethics – Aid To Capacity Evaluation (ACE)

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3. Alternatives:

4. Option of Refusing Proposed Treatment (including withholding or withdrawing

proposed treatment):

7a. The Person's Decision is Affected by Depression:

7b. The Person's Decision is Affected by Psychosis:

 What else can we do to help you?

 Can you have [proposed treatment]?

 Are there any other [treatments]?

 What other options do you have?

 Can you have [alternative treatment]?

 Can you refuse [proposed treatment]?

 Can we stop [proposed treatment]?

 Could you get sicker/die if you don't have [proposed treatment]?

 What could happen if you have [alternative treatment]? (If alternatives

are available)

 Do you feel that you're being punished?

 Do you think you're a bad person?

 Do you have any hope for the future?

 Do you deserve to be treated?

 Can you help me understand why you've decided to accept/refuse treatment?

 Do you think anyone is trying to hurt/harm you?

 Do you trust your doctor/nurse?

withdrawing treatment). Domains 5-6 evaluate whether the person appreciates the

2.For domains 1-6, if the person responds appropriately to open-ended questions,

score YES. If they need repeated prompting by closed-ended questions, sore

UNSURE. If they cannot respond appropriately despite repeated prompting, score

NO.

3.For domain 7, if the person appears depressed or psychotic, then decide if

their decision is being affected by the depression or psychosis.

For domain 7a, if the person appears depressed, determine if the decision is affected

by depression. Look for the cognitive signs of depression such as hopelessness,

worthlessness, guilt, and punishment. (See sample questions above.)

For domain 7b, if the person may be psychotic, determine if the decision is

www.jcb.utoronto.ca/tools/ace.shtml

Aid To Capacity Evaluation (ACE) - Training

capacity assessment for our undergraduates and postgraduates.

The session consists of:

 An introduction, including the ethical and legal importance

 A definition of capacity

 A case scenario

 Distribution of the ACE

 An interview with a standardized patient

 Scoring of the interview using the ACE

 Discussion emphasizing the key process issues in capacity assessment

including: establishing effective communication, ensuring adequate

which became gangrenous. It was then that he discovered that he was diabetic. The

toe was amputated. Last year, he bruised his right leg while getting into a bus. The

portion of his foot was amputated. At that time an arterial bypass was done to

decrease the likelihood that gangrene would recur. He went from the hospital to a

rehabilitation centre, where he remained for five months. It was found that he had

gangrene in the remainder of the foot. He was started on intravenous antibiotics with

no response. A below knee operation was then suggested to him. On the morning of

the operation he withdrew his consent and went home to stay with his daughter for

three days. He has now been brought back to hospital by his daughter. Mr. C. has

been unhappy since the death of his wife. He does not wish to burden his children,

Instructions:

Mr. C. will be interviewed by one of the members of your group. Use the ACE

"Examples of Scoring" (see below) to help you assess Mr. C.'s capacity. Any

the "Comments Section".

EXAMPLES OF SCORING

Joint Centre for Bioethics – Aid To Capacity Evaluation (ACE)

www.jcb.utoronto.ca/tools/ace.shtml

Joint Centre for Bioethics – Aid To Capacity Evaluation (ACE)

Joint Centre for Bioethics – Aid To Capacity Evaluation (ACE)

www.jcb.utoronto.ca/tools/ace.shtml

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