Introduction to Adult Guardianship and Substitute Decision-Making (15:I)

The purpose of the legislation in British Columbia pertaining to adult guardianship and substitute-decision making is to create a scheme by which adults (people over the age of 19) can plan for their future in the event that they may need assistance with decision making, and to provide a means to assist adults who may be vulnerable to abuse and neglect.

The legislation is informed by the guiding principle that all adults have a right to self-determination and autonomy and that any incursion into this right must be governed by the presumption that they are capable of making their own decisions and that any support provided to them is the least intrusive available.

There are six statutes governing adult guardianship and substitute decision-making:

Power of Attorney Act Representation Agreement Act Health Care (Consent) and Care Facility (Admission) Act Public Guardian and Trustee Act Adult Guardianship Act Patients Property Act

This chapter will begin with a discussion of the concept of ‘capacity’ or ‘capability’ (which will be used interchangeably), following by a discussion of the planning mechanisms available to appoint a substitute decision maker and finally to the concept of adult guardianship and how assistance can be provided to vulnerable adults

B. Mental Capacity

NOTE: For the purposes of this manual, there is no distinction between “mental capacity”, “capacity” and “capability”. The terms are used interchangeably.

In BC the law presumes that an adult is capable to make personal and legal decisions (e.g. decisions regarding health, life, property, assets, financial arrangements, etc.), unless there is evidence to the contrary (PAA s 11). A person may become incapable at a point in their life due to illness, disability or accident. If an adult is, or becomes incapable, another person (or persons) can become the substitute decision-maker(s), who acts on the wishes and values of the incapable adult. A substitute decision-maker can be appointed in either of the following ways:

An adult who meets the appropriate test for mental capacity can name the substitute decision-maker(s) in an Advance Planning Document (e.g. an Enduring Power of Attorney or a Representation Agreement,).
- Note: an adult may also make an Advance Directive that consents to or refuses specified health care.
An adult who is no longer capable of making financial or health care decisions may have a guardian (called a committee of estate or committee of the person) appointed by the courts to make decisions. The Public Guardian and Trustee may also become a Statutory Property Guardian if a certificate of incapability is issued by a “health authority designate” stating the adult is incapable of managing their financial affairs.
- Note that pursuant to s 9 of the PPA an adult may nominate a committee and the nomination document may be one of an adult’s Advance Planning Documents.

An adult who has made a Power of Attorney, Representation Agreement or Advance Directive, maintains the right to make decisions about legal, financial and health care matters, even after these legal documents are made. Once the adult is incapable, the substitute decision-maker has a legal duty to act in accordance with the adult’s instructions, values, wishes and beliefs, regardless of capacity (s 19(2), Power of Attorney Act, RSBC 1996, c 370 [PAA]; s 16, Representation Agreement Act, RSBC 1996, c 405 [RAA]; s 19, Health Care (Consent) and Care Facility (Admission) Act, RSBC 1996, c 181 [HCCFA]). The substitute decision maker also has a duty, to the extent reasonable, to foster the independence of the adult and encourage the adult's involvement in any decision-making that affects the adult.

The statutory tests for incapability are summarized below. In many cases, Advance Planning Documents will specify what is required to determine incapability to bypass a court process.

1. Power of Attorney (POA)

As mentioned above, an adult is presumed to have capacity, unless proven otherwise. According to s 11 of the PAA, an adult is presumed capable of making decisions about financial affairs and understanding the nature and consequences of making, changing, or revoking an Enduring Power of Attorney (EPOA).

Difficulties or barriers in communicating are not adequate grounds for determining that an adult is incapable. Instead, incapacity is determined by a more thorough assessment, often as specified in Advance Planning Documents (i.e. a Springing POA will normally specify under what conditions a person is considered incapable, such as on the basis of medical opinions from two doctors or by an assessment of the court).

The PAA sets out a specific statutory test of incapability in s 12, which reaffirms that an adult is presumed capable to make an EPOA, unless there is evidence that the adult is unable to understand the nature and consequences of the EPOA. According to s 12(2) of the PAA, an adult is considered incapable of understanding the nature and consequences of an EPOA if the adult cannot understand all of the following:

The property the adult has and its approximate value
The obligations the adult owes to their dependants
That the adult’s attorney will be able to do on the adult’s behalf anything in respect of the adult’s financial affairs that the adult could do if capable, except make a will, subject to the conditions and restrictions set out in the power of attorney
That, unless the attorney manages the adult’s business and property prudently, their value may decline
That the attorney might misuse the attorney’s authority
That the adult may, if capable, revoke the enduring power of attorney
Any other prescribed matter

Note: This is a complex and rapidly changing area of the law. The above statutory test in s 12(2) of the PAA came into effect on September 1, 2011. This test is significantly broad in scope and appears to only apply to an EPOA. However, it remains to be seen how this test will be interpreted by the courts. As of June 21, 2019, there has been no judicial interpretation of this test. The case of Serban v Serban 2016 BCSC 2419, demonstrates how incapacity is approached in court proceedings.

2. Health Care Consent

The Health Care (Consent) and Care Facility (Admission) Act states that every adult who is capable of giving or refusing consent to health care has the right to (s 4):

Give consent or to refuse consent on any grounds, including moral or religious, even if the refusal will result in death
Select a particular form of available health care on any grounds, including moral or religious
Revoke consent
Expect that a decision to give, refuse or revoke consent will be respected
Be involved to the greatest degree possible in all case planning and decision making

According to s 3 of the HCCFA, an adult is presumed capable, unless proven otherwise, when:

Giving, refusing or revoking consent to health care
Deciding to apply for admission to a care facility, accepting a facility care proposal, or moving out of a care facility

Difficulties or barriers in communicating are not adequate grounds for deciding that an adult is incapable. For example, in Bentley (Litigation guardian of) v. Maplewood Seniors Care Society, 2014 BCSC 165 at paragraph 55 Justice Greyell stated that the legislature “precluded the possibility that a challenge to an adult's capability could be premised on her method of communicating”. Instead, incapacity is determined in accordance with s 7 of the HCCFA, which requires a health care provider to decide whether or not the adult understands the information given by the health care provider and that the information applies to the situation of the adult in need of health care.

3. Temporary Substitute Decision Makers

If a health care provider determines that an adult is not capable of consenting to health care that is being proposed, they will need to obtain consent from another adult, who is able to give or refuse consent on behalf of the incapable adult. The health care provider can get consent from a substitute decision-maker named in a Representation Agreement. An individual may also document consent or refuse consent in advance through an Advance Directive. With the exception of the provision of emergency health care (HCCFA s 12(1)), the health care provider will need to get consent from a Temporary Substitute Decision-maker (TSDM) if neither a Representation Agreement nor an Advance Directive are in place (or the AD does not address the medical issue for which consent is needed), and there is no appointed guardian (committee of person).

The HCCFA provides a hierarchical, default list of TSDMs, as follows (s 16):

spouse/partner
adult child (over 19 years old)
parent
sibling
grandparent
grandchild
other relatives by birth or adoption (not in-laws or step-children)
close friend
person immediately related by marriage (includes in-laws or step-children)

A TSDM has authority to decide whether to give or refuse consent, in accordance with the adult patient’s wishes, values and beliefs. The authority of a TSDM to give or refuse consent is generally valid for 21 days, but this time period may be extended upon written confirmation by the health care provider (HCCFA s 17 and 19). If the health care provider has reasonable grounds to believe that the adult patient may be capable during this time period, the health care provider must again determine the adult’s capability in accordance with s 7 of the HCCFA. If an adult patient is deemed to be capable again, consent must be given or refused by the adult patient. For more information, refer to section V. H. 1: Temporary Substitute Decision-makers (TSDM) in this chapter below.

4. Representation Agreement (RA)

An adult who meets the requisite mental capacity test may create a Representation Agreement (RA). An RA is a legally-binding document that appoints a substitute or supportive decision-maker and provides instructions with respect to health care decisions, personal care, and/or routine financial decisions. See s 7 and 9 of the RAA. Section 7 and 9 RAs deal with different types of decisions (see section V. A: Types of Representation Agreements) and are subject to different mental capacity standards.

In British Columbia, an adult is presumed to have capacity, unless proven otherwise. According to s 3(1) of the RAA, an adult is presumed to be capable of:

Making, changing or revoking a s 7 or s 9 RA
Making decisions about personal care, health care and legal matters
Conducting the routine management of their own financial affairs

An adult who has diminished capacity may still be allowed to make, change or revoke a s 7 RA, even when the adult is incapable of: (RAA s 8(1))

Making a contract
Managing their health care, personal care or legal matters
The routine management of their financial affairs

The statutory test to determine incapacity for a standard s 7 RA is set out in s 8(2) of the RAA. In determining whether an adult is incapable of making a s 7 RA, all relevant factors are considered. Examples of relevant factors mentioned in the statute include:

Whether the adult communicates a desire to have a representative make, help make, or stop making decisions
Whether the adult demonstrates choices and preferences and can express feelings of approval or disapproval of others
Whether the adult is aware that making the RA or changing or revoking any of the provisions means that the representative may make, or stop making, decisions or choices that affect the adult
Whether the adult has a relationship with the representative that is characterized by trust

The statutory test to determine incapability for non-standard, s 9 RAs, is set out in s 10 of the RAA. An adult is incapable of making a s 9 RA if the adult is “incapable of understanding the nature and consequences of the proposed agreement”.

For more information and an explanation of the differences between a s 7 RA and a s 9 RA, refer to section V. A: Types of Representation Agreements in this chapter.

5. Advance Directive (AD)

A capable adult may also choose to make an Advance Directive (AD), which is a legally-binding document that provides instructions with respect to giving or refusing consent to health care treatment or procedures. According to s 19.1 of the HCCFA, an adult is presumed to have capacity to make an AD, unless there is evidence that they are incapable of understanding the nature and consequences of the AD.

An adult is incapable of understanding the nature and consequences of an AD, if the adult cannot understand:

The scope and effect of the health care instructions set out in the AD
That a TSDM will not be chosen by the health care provider to make decisions on behalf of the adult about the health care described in the AD except in circumstances set out in s 19.8 of the HCCFA

For more information about the requirements and scope of ADs, refer to section VI: Advance Directives in this chapter.

NOTE: Health care consent is a complex and rapidly changing area of the law. Care should be taken in assessing capacity to make an RA or AD and assessing the legal validity of these documents.

6. Designated Agencies – Support and Assistance

Another area where the issue of capacity may be raised is when an adult is experiencing abuse, neglect or self-neglect. Under Part 3 of the AGA anyone can make a report to a Designated Agency who will meet with the adult, investigate whether or not the adult is experiencing abuse, neglect or self-neglect, and, if necessary, establish a support and assistance plan to protect the adult.

An adult in need of support and assistance does not necessarily lack mental capacity. In fact, according to s 3(1) of the AGA, an adult is presumed to be capable of making decisions about personal care, health care and financial affairs, regardless of whether the adult is vulnerable to abuse, neglect or self-neglect.

An adult’s way of communicating with others is not grounds for determining that an adult is incapable. Instead, the statutory tests of incapacity apply. For applications concerning guardianship, a formal assessment of capacity must be done in accordance with the Adult Guardianship (Abuse and Neglect) Regulation, BC Reg 13/2011 [AGR]. According to s 3(4) of the AGR, a capacity assessor must base the decision of incapability on whether the adult understands:

The services described in the support and assistance plan
Why the services are being offered to the adult
The consequences to the adult of not accepting the services

The AGA states that the adult in need of support and assistance must be involved in decisions about how to prevent abuse or neglect. It is also important to remember that an adult with capacity has the legal right to refuse support or assistance. For more information about responding to abuse and neglect, refer to section VIII: Abuse and Neglect in this chapter.

C. Advance Planning Documents

An adult who has mental capacity can execute various documents to appoint another person to make financial and health care decisions on their behalf. These documents may come into effect immediately, or only when certain events come to pass (e.g. upon loss of capacity), as follows:

Power of Attorney (POA): an adult (the ‘adult’ in legislation) with capacity may choose to appoint another person (called the ’attorney’) to act on their behalf, only in matters concerning financial affairs (e.g. property, finance, banking, business, etc).

Representation Agreement (RA): an adult with the requisite mental capacity may choose to appoint another person (called a ‘representative’) to act as a substitute decision-maker to act on their behalf for both s 7 and s 9 RAs (For differences between s 7 and s 9 RAs see Section V. A: Types of Representation Agreements).

Advance Directive (AD): an adult with capacity may choose to give or refuse consent to health care or give health care instructions in an AD, which will only come into effect when the adult is incapable and in need of health care.

In BC, various laws define what is required to validly execute each of these documents, the duties and powers held by the appropriate substitute decision-maker(s), and the legal authority or scope of decisions made.

For more information on preparing documents, consult the Appendix or organisations such as Nidus Personal Planning Resource Centre and Registry. Contact information may be found in section II. D: Resource Organizations of this chapter.

This information applies to British Columbia, Canada. Last reviewed for legal accuracy by the Law Students' Legal Advice Program on June 21, 2019.