Aid to Capacity Evaluation (ACE): Capacity Note

What it assesses

The Aid to Capacity Evaluation (ACE), developed by Etchells and colleagues at the Joint Centre for Bioethics, University of Toronto, is a structured interview for decision-specific capacity to consent to a medical decision. The tool starts with the decision context: the medical condition, the proposed treatment, and the alternatives discussed, including refusal or withdrawal. It asks you to use the patient's own words where possible.

The seven domains

• 1. Able to understand the medical problem
• 2. Able to understand the proposed treatment
• 3. Able to understand alternatives to the proposed treatment (if any)
• 4. Able to understand the option of refusing, withholding, or withdrawing treatment
• 5. Able to appreciate reasonably foreseeable consequences of accepting
• 6. Able to appreciate reasonably foreseeable consequences of refusing
• 7a. Decision affected by depression; 7b. Decision affected by delusions or psychosis

Each domain comes with sample interview prompts. For domains 1–6, YES means an appropriate response to open-ended questions, UNSURE means the patient needs closed-ended prompting, and NO means the patient cannot respond appropriately despite repeated prompting. For domain 7, YES means the decision is affected by depression or psychosis. Observations can be recorded for each domain.

Overall impression

The ACE does not produce a numeric score. You select an overall impression: definitely capable, probably capable, probably incapable, or definitely incapable. The tool reminds you that people are presumed capable and that, if uncertain, you should err on the side of calling the person capable. A finding of incapacity should never rest on domain 7 alone; when depression or psychosis appears to drive the decision, the tool suggests an independent assessment.

What the report includes

The EMR-ready note lists the date, time taken, the decision context, each domain score with observations, the overall impression, comments, and notes. The notes state that capacity is decision-specific and that, if incapacity is suspected, treatable causes such as delirium, drug toxicity, pain, and communication barriers should be addressed before reassessing. A blank form can be printed. Before scoring, address hearing, vision, language, or speech barriers and give adequate disclosure of the treatment, alternatives, risks, and consequences.