Supported decision making: Facilitating the self-determination of persons living with Alzheimer's and related diseases.

Decision-making capacity describes the ability to make a particular decision at a given time. People with Mild Cognitive Impairment (MCI) and mild stage dementia typically experience an associated erosion of their decisional abilities. Many could be said to have marginal capacity. These individuals are in a liminal space between adequate and inadequate capacity. Too often, marginal capacity is overlooked as a category: individuals are classified either as having capacity and being able to make decisions independently or as lacking capacity and needing a surrogate to make decisions for them. These approaches can, respectively, result in under- or overprotection of individuals with marginal capacity. A promising alternative approach is supported decision making. In supported decision making, a person with marginal capacity identifies a trusted person or network of persons to aid them in making their own decisions. Supported decision making is recognized by law in a growing number of states; it is important for geriatricians to be familiar with the concept, as they are increasingly likely to encounter it in their practice. Even in states where supported decision making is not formally recognized, it can be practiced informally, helping patients, care partners, and clinicians strike an appropriate balance between respecting autonomy and recognizing vulnerability. In this article, we describe supported decision making, discuss its ethical and legal foundations, and identify steps by which geriatricians can incorporate it into their practice.