Introduction: When a patient is incapable of making medical decisions for themselves, choices are made according to the patient's previously expressed, wishes, values, and beliefs by a substitute decision maker (SDM). While interventions to engage patients in their own advance care planning exist, little is known about public readiness to act as a SDM on behalf of a loved one. This mixed-methods survey aimed to describe attitudes, enablers and barriers to preparedness to act as a SDM, and support for a population-level curriculum on the role of an SDM in end-of-life and resuscitative care. Methods: From November 2017 to June 2018, a mixed-methods street intercept survey was conducted in Ottawa, Canada. Descriptive statistics and logistic regression analysis were used to assess predictors of preparedness to be a SDM and understand support for a high school curriculum. Responses to open-ended questions were analyzed using inductive thematic analysis. Results: The 430 respondents were mostly female (56.5%) with an average age of 33.9. Although 73.0% of respondents felt prepared to be a SDM, 41.0% of those who reported preparedness never had a meaningful conversation with loved ones about their wishes in critical illness. The only predictors of SDM preparedness were the belief that one would be a future SDM (OR 2.36 95% CI 1.34-4.17), and age 50-64 compared to age 16-17 (OR 7.46 95% CI 1.25-44.51). Thematic enablers of preparedness included an understanding of a patient's wishes, the role of the SDM and strong familial relationships. Barriers included cultural norms, family conflict, and a need for time for high stakes decisions. Most respondents (71.9%) believed that 16 year olds should learn about SDMs. They noted age appropriateness, potential developmental and societal benefit, and improved decision making, while cautioning the need for a nuanced approach respectful of different maturity levels, cultures and individual experiences. Conclusion: This study reveals a concerning gap between perceived preparedness and actions taken in preparation to be an SDM for loved ones suffering critical illness. The results also highlight the potential role for high school education to address this gap. Future studies should further explore the themes identified to inform development of resources and curricula for improved health literacy in resuscitation and end-of-life care.

Current approaches to the assessment of cognitive capacity in many jurisdictions seek to balance older people's empowerment with their protection. These approaches incorporate a presumption of capacity, a decision-specific rather than global assessment of that capacity, and an obligation to provide the support needed for adults to make or communicate their own decisions. The implication is that older people are assisted to make decisions where possible, rather than using substitute decision makers. For older people, decision making about financial matters is a contentious domain because of competing interests in their assets and concerns about risk, misuse and abuse. In residential-care settings, older people risk being characterised as dependent and vulnerable, especially in relation to decisions about financial assets. This paper reports an Australian study of the factors that facilitate and constrain residents' involvement in financial decision making in residential settings. Case studies of four aged-care facilities explored how staff interpreted the legislative and policy requirements for assisted and substitute decision making, and the factors that facilitated and constrained residents' inclusion in decisions about their finances. The observed practices reveal considerable variation in the ways that current legislation is understood and implemented, that there are limited resources for this area of practice, and that policies and practices prioritise managing risk and protecting assets rather than promoting assisted decision making.

Managing the assets of older people is a common and potentially complex task of informal care with legal, financial, cultural, political and family dimensions. Older people are increasingly recognised as having significant assets, but the family, the state, service providers and the market have competing interests in their use. Increased policy interest in self-provision and user-charges for services underline the importance of asset management in protecting the current and future health, care and accommodation choices of older people. Although ‘minding the money’ has generally been included as an informal care-giving task, there is limited recognition of either its growing importance and complexity or of care-givers' involvement. The focus of both policy and practice have been primarily on substitute decision-making and abuse. This paper reports an Australian national survey and semi-structured interviews that have explored the prevalence of non-professional involvement in asset management. The findings reveal the nature and extent of involvement, the tasks that informal carers take on, the management processes that they use, and that ‘minding the money’ is a common informal care task and mostly undertaken in the private sphere using some risky practices. Assisting informal care-givers with asset management and protecting older people from financial risks and abuse require various strategic policy and practice responses that extend beyond substitute decision-making legislation. Policies and programmes are required: to increase the awareness of the tasks, tensions and practices surrounding asset management; to improve the financial literacy of older people, their informal care-givers and service providers; to ensure access to information, advice and support services; and to develop better accountability practices.