Synonyms

Assessment; Competency; Decision-making

Definition

The necessary cognitive and functional abilities required to perform a specific task or make a specific decision.

Introduction

The term capacity refers to a person’s ability to perform a specific task or make a specific decision. Determinations of capacity have historically been made by clinicians in clinical settings. This is in contrast to the legal term competency, which is a determination made by the court. At times these terms have been used interchangeably; however, for the purposes of this section, we henceforth use the terms “clinical capacity” and “legal capacity.”

Psychologists are increasingly called upon to make determinations of capacity. The reasons for this are multifactorial. It is widely cited that the number of older adults worldwide has grown exponentially. And while not all older adults develop dementia, they may experience physical and mental changes as they age that place them at risk for impaired capacity. There has also been shift of wealth from the World War II generation to the baby boomers and now to the Generation X, in increasingly diverse families that are separated geographically. Consequently, probate courts are seeing an increase in contested wills and guardianship proceedings (Moye and Marson 2007). The probate law has also shifted from a global and absolute view of capacity towards a more task- or decision-specific standard of capacity, recognizing a person can have capacity in one area but not another. Thus to meet the current legal standard of capacity, the capacity evaluation has also evolved to include neurocognitive, psychological, and functional assessments. Psychologists are often trained in these assessments thus are well suited to conduct capacity evaluations (Lichtenberg et al. 2015).

Yet while psychologists may have the appropriate training to address the functional, cognitive, and mental health components of the evaluation, they are often less familiar with the term capacity or the interventions available to persons with diminished capacity. To further complicate the issue, professionals who often work with the probate laws surrounding capacity (i.e., lawyers and judges) may be less familiar with the unique needs of and challenges in working with older adults. So in 2003, the American Bar Association (ABA) and the American Psychological Association (APA) formed a workgroup to develop educational materials and handbooks for lawyers, judges, and psychologists. The intent of this workgroup was to provide a framework for professionals to draw upon in capacity determinations as opposed to more rigid standards of practice. The workgroup produced the first handbook, Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers, in 2005. The second handbook, Judicial Determination of Capacity of Older Adults in Guardianship Proceedings: A Handbook for Judges, was published in 2006. The final handbook, Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists, was published in 2008. These handbooks are available online at www.apa.org/pi/aging and www.abanet.org/aging (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008).

The following sections will detail the evolution of the legal capacity and guardianship laws; the core ethical principles inherent in decision-making capacity; the requisite functional abilities for determinations of capacity; the role of culture in capacity evaluations; a framework for capacity evaluations; and future directions for the field.

Evolution of Legal Capacity and Guardianship

Over the past 65 years, the legal aspects of capacity evaluations have undergone significant change in the United States and internationally. In essence, there has been a shift towards increased autonomy and limited guardianship, resulting in various legal reforms. Historically, the concept of capacity was global and absolute in that a person deemed incapacitated would have his or her legal rights revoked in a broad range of legal domains (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). This has shifted over time and current legal practice uses the term “capacity” to refer to a person’s ability to complete a specific task or decision (Bailar-Heath and Moye 2014), thus recognizing that a person can have capacity in one area (e.g., medical decision-making) but not another (e.g., driving). Another relatively recent change has replaced the term “incompetency” with the term “incapacity” as the determination of these have evolved to integrate clinical findings into legal findings in a multidisciplinary manner (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). This shift is in keeping with the view of capacity as being decision relevant, which holds that judgments of capacity are for specific abilities at specific time in a specific context and relevant to a specific decision (Buchanan and Brock 1989).

The past few decades have yielded significant reform in legal practice pertaining to adult guardianship in the United States. The ABA defines guardianship as legal decision-making power given to an outside entity or person in response to a determination of incapacity. The term itself is often used interchangeably with “conservatorship” depending on the state or country in which the determination is being made and may be used in reference to guardianship of property specifically (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008; Bailar-Heath and Moye 2014). Criteria for guardianship fall under state and not federal regulation, and thus there is variability across states in how guardianship determinations are made. These decisions are defined by either statutory or case law and are transaction specific. Examples of transaction-specific capacity include testamentary capacity, donative capacity, contractual capacity, capacity to execute a durable power of attorney, and capacity to consent to medical care. Despite the inconsistency in legal definition, basic guidelines for determining diminished capacity include disabling condition, functional behavior, cognitive functioning, and consideration of the least restrictive alternative. These guidelines are commonly expanded upon by state law (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008).

As part of the recent capacity reforms, 32 states have passed comprehensive reform bills, and 261 separate capacity laws have been passed. Currently, more than 30 states now require clinical evaluation for capacity to determine whether an adult may qualify for guardianship (Bailar-Heath and Moye 2014). Further, the majority of US states have done away with the global and absolute determination of incapacity in favor of the relatively recent model of limited guardianship. In the limited guardianship model, a guardian is appointed on for the areas in which the person has been deemed to lack capacity (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). In determining whether a person is in need of guardianship, all states begin with the assumption of capacity and put the burden of proof on the party attempting to establish guardianship. In other words, every person is assumed to have capacity until established otherwise.

In contrast to the variability of laws pertaining to capacity determinations based on state jurisdiction in the United States, international law offers a more unifying standard. Since the 1960s, guardianship law has been of particular concern in many countries. In 2006, the Convention on the Rights of Persons with Disabilities (CRDP) marked a major international milestone in the legal rights of persons deemed to have diminished capacity. The CRDP brought significant changes to the laws of member nations to protect the legal rights, status and autonomy of incapacitated adults, and to provide support to this legally vulnerable population (Bailar-Heath and Moye 2014). Among other things, these changes mark an increase in the emphasis on autonomy and independence, cultural sensitivity, and the consideration of least restrictive alternatives (Doron 2002).

Within the broader legal standards outlined in the CRDP, the laws regarding capacity determinations vary by country. Canada, the United Kingdom, and Portugal define incapacity using the benchmark of an individual’s ability to care for “person or property” (Bailar-Heath and Moye 2014). In Germany, the guardianship model has shifted focus towards a “care and assistance” model that allows the individual to be appointed with a caretaker who carries out specific tasks as defined by the court, protecting the incapacitated individual from losing his or her legal rights. Sweden offers two possibilities for legal support for incapacitated persons. In both, the individual is appointed an administrator, mentor, or trustee that is responsible for assisting him or her. Additionally, the person may forfeit legal capacity in specified domains only or may not lose any of his or her legal rights. Israel is gradually transitioning from guardianship laws that eradicate the legal rights of the individual in all domains, to the appointment of a guardian and retention of legal competence (Bailar-Heath and Moye 2014).

In Hong Kong, the courts that determine guardianship appointment are multidisciplinary panels made up of lawyers, someone who has personal experience with incapacitated individuals, and either physicians, psychologists, or social workers. The structure of the panels in Hong Kong illustrates the shift towards a psycholegal construct of capacity that has been the recent trend in numerous countries. Similarly, Australian guardianship tribunals include members of the community as well as legal professionals, and various provinces in Canada require collaboration of legal and clinical professionals (Bailar-Heath and Moye 2014).

The legal aspects of capacity evaluations are complicated by variance in laws according to country and state jurisdiction. However, recent reforms both in the United States and internationally point to a shift in consciousness towards providing those who are legally determined to be incapable of safely making decisions about their person or property the least restrictive guardianship and preserving many of their legal rights. By including clinical assessments in legal proceedings that determine capacity, the system is beginning to allow for a more holistic view of the individual’s abilities as opposed to the historically broad revocation of legal rights.

Principlism in Health Care

The concept of capacity spans the fields of health care and law. Yet health-care ethics is a third area which is central to the concept of capacity. Principlism is system of ethics deployed in health care that based on four moral principles of: (1) respect for autonomy, (2) beneficence, (3) nonmaleficence, and (4) justice.

The principle of respect for autonomy, also referred to as self-determination, is the person’s ability to make his or her own decisions. This principle is rooted in the longstanding belief of the importance of personal freedom and individualism. Health-care providers are tasked with ensuring that autonomous decisions are intentionally made, with substantial understanding, and free from coercion (Beauchamp 2007; Beauchamp and Childress 2011).

Beneficence may be viewed as a group of principles that both prevents harm and also provides benefits that outweigh costs and risks. This principle reflects the moral obligation to act for the benefit of others and is often considered a foundational value in health-care ethics. It could be argued that the obligation to promote patient welfare is of the utmost importance in medicine. Beneficence obligates health-care providers to assist older adults in furthering their interests, often by removing or minimizing risk and harm to the patient (Beauchamp 2007).

The principle of nonmaleficence prevents providers from causing harm to others, or put simply is the “do no harm” principle. While beneficence includes the prevention of harm or reduction of risk for the ultimate benefit of the patient, nonmaleficence is the intention to avoid unnecessary harm or injury to the patient. As noted by Beauchamp (Beauchamp 2007), nonmaleficence is one of the most frequently cited codes in health-care ethics. Some have advocated to place the greatest emphasis upon this obligation, even if that is to the detriment of other obligations, including the respect for autonomy. Nonmaleficence obligates providers to inflict the least amount of harm to achieve a beneficial outcome.

Finally, the principle of justice requires the fair distribution of benefits, costs, and risks (Beauchamp 2007). Put another way, this principle obligates providers to act on the basis of unbiased decision-making in the face of competing claims. Thus the principle of justice extends beyond equitable access to treatment, as it obligates providers to be aware of their own biases to ensure the fair distribution of health-care resources.

These four principles are not hierarchical; thus clinicians have an obligation to uphold each of them. While this is the ideal, ethical clinical practice dictates that the clinician must examine the balance of these principles by examining their respective weights on a case-by-case basis. Thus to weigh the respective weights is to carefully evaluate the risks involved in the situation. There are no hard and fast rules that dictate that one principle take precedence over another. To further complicate the matter, different professionals may place a greater emphasis on different principles. When faced with the same clinical case, providers may recommend different treatments based on their evaluation of the potential risks and benefits involved. For example, a provider may recommend an older adult with a history of falls and mild cognitive impairment be discharged to home with the assistance of home health aides in order to promote the respect for the patient’s autonomy. However, another provider, when presented with the same clinical scenario, may recommend the patient be discharged to an assisted living facility in order to promote the principle of beneficence (i.e., prevent the patient from sustaining future harm). As is highlighted in this example, determinations of capacity are often a balancing act between these foundational principles of health-care ethics.

Essential Functional Abilities

Assessment of functional abilities is a core component of capacity evaluations. In the field of geropsychology, the concept of functional abilities often refers to a person’s ability to perform activities of daily living (i.e., bathing, grooming, eating) and instrumental activities of daily living (i.e., shopping, bill payment, household chores). Yet in capacity evaluations, the legal concept of functional abilities also refers to the intact decisional abilities that are generally agreed to convey capacity (Lichtenberg et al. 2015). These abilities, which are drawn from case law, include understanding, appreciation, reasoning, and expressing a choice (Grisso 2003; Smyer 2007).

In the context of capacity assessments, understanding refers to the ability to comprehend the nature of a proposed decision, including an awareness of its risks and benefits. The ability to adequately understand a proposed decision is impacted by several factors including the person’s intelligence, educational level, and the method by which the information is presented to them. The risks and benefits of a decision must be presented to a person in a manner that promotes their understanding.

While there are different interpretations of appreciation, it is generally thought to refer to the ability to understand the relevance or applicability of a decision to the older adult. At the most basic level, older adults must recognize that a decision must be made, that they are the decision-maker, and it is their life that will be affected by the decision. Thus it is not surprising that appreciation is greatly impacted by the degree of patient insight, as well as the type of decision to be made and the complexity of that decision.

Reasoning entails the process of rationally comparing different treatment options or proposed solutions in a consistent manner. Older adults must demonstrate that they can weigh the risks and benefits of the proposed choices as well as the possible consequences. The ability to reason directly impacts understanding and appreciation. If a person cannot rationally reason or logically manipulate the presented information, it is not possible to fully understand or appreciate the issues in the decision (Grisso and Appelbaum 1998).

Older adults must also be able to express a choice; those who are unable to outwardly communicate a choice or who waver in their choice are seen as lacking capacity (Lichtenberg et al. 2015; American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008; Grisso 2003). That choice should be consistent with the person’s value or beliefs; however, it is accepted that a person’s value and beliefs may change over time. The importance of expressing a choice should not be minimized as there are situations in which a person may be able to understand, appreciate, and rationally reason about a decision; however, due to a physical condition, such as stroke, is unable to express a choice. In situations such as this, it is impossible to know what that person’s preference or desire would be.

In addition to these four functional abilities, the role of values in the determination of capacity cannot be overstated. The ABA and APA Assessment of Capacity in Older Adults Project Working Group (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008) defined values as “an underlying set of beliefs, concerns, and approaches that guide personal decisions.” This definition is useful as it not only defines values but also highlights the relationship between values and decision-making. As highlighted in Moye (Moye 2007), the “extent to which a person’s expressed choice is consistent with their values is an indicator of capacity”; thus, it is an essential component to the assessment of these functional abilities. An understanding of a person’s values will also greatly assist in the development of appropriate treatment recommendations. Providers should also be aware of their own values so that any inherent biases regarding the decision at hand can be appropriately addressed.

The Role of Culture in Capacity

In addition to being one of the fastest growing segments of society, older adults are one of the most culturally diverse groups. That diversity is projected to continue to expand in coming years as evidenced by recent US census data. In 2014, 14% of the adults in the United States were age 65 or older. A closer analysis of this census data reveals that within this older segment of the US populace, approximately 1 in 7 (14%) sampled identified as a racial minority. That percentage of racial minorities is projected to steadily grow to 18% by 2030 and 23% by 2050 (U. S. Census Bureau 2014). As noted by Karel (2007), within these racial groups are further subgroups (denoted by their countries of origin) with their own values and beliefs. These values and beliefs are often the foundation for their views on aging, health care, family and familial roles, finances, and end-of-life. Among older White Americans, there are further ethnic, regional, and religious subgroups. And not surprisingly, these subgroups have strong values and beliefs that influence their views on many of the abovementioned issues.

There are also cross-cultural differences within the aforementioned principles of health-care ethics. In Western cultures, the principle of respect for autonomy or self-determination is strongly valued. This is evident in the widespread use of advance care directives and durable powers of attorney, which are designed to foster patient autonomy in situations where patients are unable to make their own decisions. This emphasis on patient autonomy is unique to Western cultures, as other cultures encourage collective decision-making that involves the patient’s community and family. In cultures that value beneficence, providers are obligated to encourage hope above all else. This is contrasted with those cultures that value nonmaleficence, in which providers protect patients from harm by not directly addressing seemingly negative outcomes such as death or end-of-life (Searight and Gafford 2007).

Conceptual Framework of Capacity

The ABA-APA Working Group on the Assessment of Capacity in Older Adults detailed a nine-part framework for conceptualizing capacity assessments (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). The model builds off of the frameworks for guardianship as well as the framework for capacity assessment previously developed by Grisso (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008; Grisso 2003; Moye 2007). Components of the nine-part framework proposed by the ABA-APA work group includes the identification of: the relevant legal standards, functional abilities of capacity, relevant medical or psychiatric diagnoses contributing to incapacity, cognitive function, psychological and emotional factors, values and preferences, risks to the individual and of the situation, ways of enhancing capacity, and a clinical judgment of capacity.

While a capacity assessment is a clinician’s opinion about a person’s ability to perform a specific task or make a specific decision, that task or decision has a specific legal standard. A clinical judgment regarding a person’s capacity can then have a direct impact on that person’s legal rights henceforth. Therefore, a familiarity with the legal standard is a requisite initial step in the approach to a capacity assessment. The expectation here is not that a provider becomes an expert in the legal standards surrounding the capacity in question, but more that the provider becomes familiar with the legal standard. This can be accomplished through a review of a state’s statutory or case law or through a consultation with an attorney. Information gleaned from this review or consultation should be then used to guide the selection of the assessment battery, so as to ensure all aspects of the legal standard are met (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). It should be noted that from the legal perspective, all persons are presumed to have capacity until proven otherwise.

The ABA-APA framework builds off of the previous work by Grisso (1986) to expand the concept of “function” to also include the identification and evaluation of the functional elements essential to the questioned capacity. Capacity assessments should include a tailored evaluation of the specific task or specific decision which can be accomplished through specific questions in a clinical interview as well as through direct assessment or observation of the person’s functioning (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). This portion of the capacity assessment will vary based upon to the type of decision-making capacity being assessed. For instance, if the assessment is one of financial decision-making, the provider should include a structured assessment of financial decision-making. If the assessment were one of testamentary capacity, the provider should include specific questions in the clinical interview designed to demonstrate a person’s ability to describe a will, to describe the nature and extent of one’s assets, to name potential heirs, and to describe plans for distribution of one’s wealth. This focus on functional abilities specific to the task or decision to be made is a defining feature of the capacity assessment.

The purpose of establishing or documenting a diagnosis in the capacity assessment is to identify a possible “causal factor” for potential incapacity (Grisso 2003). Older adults are vulnerable to many physical and psychiatric illnesses that may impact capacity including dementia, delirium, neurodegenerative disease (e.g., Parkinson’s, Alzheimer’s), stroke, and many more. Yet these conditions can have markedly different long-term outcomes, thus it is important to recognize the role of the prognosis of the condition in judgments of decision-making capacity. For instance, Alzheimer’s disease is a progressive neurodegenerative disorder for which there is no cure. This is contrasted with delirium, which is a life-threatening medical condition in which a person’s cognition can rapidly fluctuate, though with medical intervention can fully resolve. In both of these conditions, patients will have impaired decision-making ability. Yet in the case of delirium, patients are often able to fully recover decision-making abilities while those patients with Alzheimer’s disease are not likely to regain their decision-making ability (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). While a diagnosis can serve as a causal factor for the impaired decision-making, it can also serve as a prognostic indicator as to if capacity is likely to be regained. Yet a medical or psychiatric diagnosis by itself is insufficient to establish a patient’s decision-making capacity as patients with impaired cognitive function due to a medical or psychiatric disorder may still retain the ability to make some decisions. Thus the focus should not be on the presence of the diagnosis but on the influence of the diagnosis on the person’s decision-making.

Most states include a comment on a person’s cognitive function as a necessary element in the determination of capacity. The causative role that many diagnoses have on decision-making is often through their effect on cognitive functioning. Impaired cognitive functioning can result in impaired insight or impairment in the cognitive abilities necessary to perform a specific task or make a specific decision. This portion of the capacity assessment should include assessments designed to comment directly on the cognitive functions necessary to perform a specific task or specific decision, in addition to measures of overall cognitive function. For instance, assessments of financial capacity may include measures of written arithmetic whereas an assessment of driving capacity may include measures of visual attention and processing speed (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). As with the determination of medical and psychiatric diagnoses, the purpose of the cognitive assessment is to characterize the level and nature of cognitive impairment and determine if (and how) the decision-making process is impacted by cognitive status.

Similar to the cognitive assessments, the purpose of the screening for symptoms of mental health disorders is to detect possible underlying factors that may impact a person’s decision-making ability. Mental health disorders, like psychotic spectrum disorders and severe mood disorders, can impair a person’s insight and ability to rationally weigh the risks and benefits of the proposed choices as well as the possible consequences. Many mental health disorders are amenable to intervention which presents with greater likelihood that the patient will regain decision-making ability (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). It should be noted that many patients with clinically significant mental health symptoms are not captured by strict criteria-based diagnostic categories (Lyness et al. 2015), thus again the focus of these measures is not just diagnosis but to comment on the impact of the mental health symptoms on cognitive and functional abilities relevant to the questioned capacity.

As aforementioned, values are the beliefs, concerns, and experiences that directly inform one’s decisions. The ABA-APA handbook distinguishes values from preferences, as former refers to “preferred option of various choices that is informed by values.” Assessment of values and preferences is an essential component to a capacity assessment as one of the requisite functional abilities is the expression of a choice that is consistent with a person’s values. It should be noted that values and preferences can change over time thus a change in person’s values may not represent impaired decision-making capacity (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008). In addition to conveying capacity, knowledge of a patient’s values and preferences can assist in the development of effective treatment recommendations that are more likely to be accepted by the patient.

Some have argued that at its most basic, a capacity evaluation is a type of risk assessment (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008; Moye 2007; Ruchinskas 2005). The provider must consider all available data, including medical and psychiatric diagnoses, cognitive and functional impairment, and patient values and preferences, in the context of the risk of the situation. In addition to evaluating the patient in terms of the risk of the situation, the provider should also take account of social and environmental supports, as these may serve to mitigate or exacerbate the initial risk (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008; Moye 2007). For instance, the discharge of an older adult with limited mobility to independent living would carry more risk if that older adult lived in a two-level home and had no immediate family in the area to provide assistance. Those risks would be mitigated, however, if the older adult had the financial means to install a stairway lift and employ regular home health aides to assist him. Thus these risks were mitigated with effective interventions to enhance the older adult’s capacity. All recommended interventions should match the level of risk in the situation so to ensure the deployment of the least restrictive means necessary (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008).

All capacity evaluations should include considerations of what can be done to maximize a patient’s functioning. As noted by Moye (2007), many of these recommendations are practical in nature and include things such as hearing or visual aids or medication management systems. Other interventions may include work with occupational or physical therapy as well as additional training or counseling. Efforts to maximize patient functioning represent opportunities for potential clinically impactful interventions (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008).

In the final component of the ABA-APA framework, the provider takes into consideration all of the data gathered through the capacity evaluation and provides a clinical opinion regarding the patients questioned capacity. This clinical opinion is oft expected to be presented in the form of a dichotomous conclusion (e.g., yes or no). There will be situations in which the determination of capacity will be clear based upon the available information such as when a patient is grossly impaired across multiple cognitive and functional domains or is unable to express a choice due to significant neurological impairment. Other decisions are more complex due to varying levels of impairment across multiple domains. In situations such as these, providers are encouraged to review the available data in the context of the patient’s values and preferences as well as any environmental supports or risks (American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group 2008).

Conclusion

The rapid global growth of older adults has compelled geropsychologists to gain the requisite knowledge and skills to address issues surrounding capacity. This topic is particularly relevant to geropsychologists as these professionals understand the physical and mental changes that occur in late life and can often increase the risk of impaired capacity. Geropsychologists are also trained in the psychological, neurocognitive, and functional assessments that are included in the capacity assessment. Yet while geropsychologists have the clinical expertise, they are often less familiar with the legal standards required to determine capacity. The legal and health-care fields continue to evolve in their definitions of capacity as the focus has shifted towards one that recognizes capacity to be decision and domain specific as opposed to a global judgment of ability. Geropsychologists may find capacity evaluations to be a type of risk assessment that requires the balancing of the four moral health-care principles, which requires an understanding and appreciation of the role of culture on these principles. While there are no current “gold standards” for the assessment of capacity, there are conceptual frameworks as well as other assessment-specific tools available to assist those in evaluations such as these. Psychologists who work with older adults are encouraged to explore these frameworks and suggested assessments as they move towards achieving competency in assessment of decision-making capacity.

Cross-References