Dear Editor,

We read with great interest the recent article by Doherty and Matthews, “Challenges in decision-making capacity in the acute hospital setting: two years on from the implementation of the Assisted Decision-Making (Capacity) Act 2015,” published in the Irish Journal of Psychological Medicine (Reference Doherty and Matthews2025). As physicians working in an Old Age Liaison Psychiatry service, we share the authors’ concerns regarding the continuing legal uncertainty arising from the Assisted Decision-Making (Capacity) Act (ADMCA) 2015 in acute hospitals, and we wish to highlight how these gaps disproportionately affect older adults, particularly those living with dementia, delirium, frailty, or without family supports.

The scenarios described, such as unsafe discharges and reliance on the High Court’s inherent jurisdiction, are central to our daily practice. In our experience, two interconnected issues warrant further emphasis.

Firstly, the vulnerabilities of older inpatients are not only clinical but profoundly ethical and social. We frequently care for very elderly individuals with moderate to severe dementia who attempt to leave hospital against medical advice, unaware of the risks of falls, nutritional decline, or medication error. As the ADMCA provides no statutory mechanism to prevent an unsafe discharge, clinicians must rely on the High Court’s residual inherent jurisdiction, as affirmed in A.C. v Hickey (2019) IESC 73. This reliance introduces delay, procedural complexity, and emotional distress; for patients who lack capacity, for clinicians required to initiate court applications, and for hospital teams attempting to balance liberty with duty of care. Challenges are amplified when patients have no family or informal supports: social isolation heightens risk, increases the moral burden on clinicians, and deprives patients of advocacy at critical moments (HSE 2024).

A related consequence is the impact of legal delays on transfers of care. The time needed to secure authorisation for discharge or alternative placement routinely postpones transitions to community or long-term care settings. These delays lead to predictable deterioration: unmet care needs escalate, health declines, and patients are often re-admitted to acute hospitals, exposing them again to the risks of hospitalisation and the uncertainties described by the authors. In this way, the current statutory gaps contribute to a cycle of avoidable instability that disproportionately harms older adults with cognitive impairment.

Secondly, we strongly support the authors’ call for strengthened Advance Care Planning (ACP). Recent TILDA data are striking: while roughly a quarter of older adults have discussed their preferences for future care, fewer than 3% have documented them (TILDA, 2024). Given the increasing prevalence of frailty, multimorbidity, and dementia, such low rates of formal ACP are concerning. Under existing ADMCA processes, the absence of clear prior wishes frequently results in bureaucratic delays; whether in appointing Decision-Making Representatives, obtaining legal authorisation, or making urgent treatment decisions. These delays prolong hospital stays, cause distress, and increase pressure on multidisciplinary teams. Conversely, integrating ACP early, ideally before capacity declines, would honour autonomy, reduce uncertainty, and provide clinicians with much-needed guidance. For older adults without family networks, the value of such documentation is particularly significant.

In summary, Doherty and Matthews highlight unresolved legal uncertainties under the ADMCA. We wish to underscore how these issues intersect with cognitive vulnerability, social isolation, and delayed decision-making processes to create conditions that expose older inpatients to real and avoidable harm. Strengthening statutory pathways for discharge and substitute decision-making – alongside a national commitment to embedding ACP across healthcare settings – would meaningfully reduce risk, ease ethical pressures, and ensure care that aligns more closely with the values and needs of our most vulnerable patients.