When an elderly person is no longer able to function without help, families often find themselves drawn into a confusing quagmire of decision-making in which straightforward answers are hard to come by. Loss of independence can occur gradually, as from progressive dementia or a chronic medical disorder, or suddenly, as from a stroke or injury. Sometimes the precipitant is the unexpected death of a spousal caregiver. Whatever the cause, one of the chief challenges that arise is achieving a balance between safety and independence.
Finding such a balance is essentially a matter of “doing the right thing” for the good of all concerned. In other words, it can be best thought of as an ethical decision. Although the concept of ethics can be hard to pin down, Tomas Paul and Linda Elder of the Foundation for Critical Thinking offer this definition: “A set of concepts and principles that guide us in determining what behavior helps or harms sentient creatures.”
Safety concerns are almost always more dominant in the thinking of family members than of their elderly loved ones, especially if a serious event has occurred. When an elder falls and is discovered on the floor hours later, leaves the stove burner on overnight or gets lost driving to the grocery store, an adult daughter would be justifiably alarmed. Placing safety as the top priority might seem to warrant having the elder move to an assisted living home, move in with family members who have the time to provide oversight or hire caregivers for round-the-clock assistance.
Elderly individuals almost never ascribe the same importance to warning signs about safety as do their concerned family members. To the elder, continuing to live in familiar surroundings and make independent decisions will often be more important than achieving perfect protection against safety risks—even if this were possible.
How can ethical thinking guide families through these conflicting perspectives? There can be no off-the-shelf prescription, but here are some suggestions:
- Think of safety and independence as end-points of a continuum, not as an “either-or” choice. The best solution for any given individual will be a compromise between the two.
- Recognize that psychological safety is as important as physical safety. For example, accepting some risk of physical safety by remaining at home may actually enhance psychological safety. All of us know of elderly individuals who were moved to a nursing home “for their own good”, only to decline inexorably.
- As an ethical matter, remember that even disabled elders have an obligation to respect reasonable limits on the caregiving responsibilities of family members. For many impaired seniors, exhausted children become enablers for postponing obviously needed outside help by acceding to every parental expectation.
- Consider all long-term care options in your planning, not just where the elder should live. Home care, adult day care, meals on wheels, support groups, home accessibility modifications, volunteer services and geriatric care management consultation are just some of the community resources that are available.
- Approach decision-making as a negotiation in which the interests of the elder and involved family members are considered fairly. Both are important.
- Understand that any ethically-based long-term care decision must necessarily be reconsidered in light of changing health, social or other factors. No decision should be regarded as permanent.