Photograph of older man who is deliberating about something; photo source: Administration on Aging, DHHS Learning Activities

Complex Decisions Competency

Guide older adults and their families/caregivers in making complex decisions that arise with aging.


                             
Develop your Complex Decisions Competency by completing some or all of these learning activities. Choose the ones that are the most useful and appealing as you prepare to demonstrate your Complex Decisions Competency. You might want to explore them all, to see what resources are here for sharing with others in your work setting or community.

 

Photograph of two older adults standing by the kitchen door of their farmhouse in the 1930s. The hired man is sitting on the step beside the pump.

Introductory Video for the Complex Decisions Competency

If you prefer, you can read a transcript of the video.

Overview of Learning Activities:  Learning Activities for the Complex Decisions Competency are divided into five sections. The first two sections are for all persons to complete. Choose one of the remaining three sections on which to focus.

Examine both of these sections:

Choose one of these sections for your focus:

When you make your selection, you might consider these questions:

Guiding Families in Making Decisions

Drawing of family members making decisions together  Older adults and their families/caregivers face complex decisions that arise when the older adult's function changes. The need for decision making occurs with "everyday decisions," such as how to manage money and how much help to give with bathing, and with more long-range decisions that need to be made during times of transition. Nurses and other care providers often have an advocacy role in helping families make such decisions. This section provides you with some tools that you can use to assist families and older adults who need to make decisions. 

 

Read an Article Picture of two journal articles

Decision-Making Guide

Lewis, M., Hepburn, K., Corcoran-Perry, S., et al. (1999). Options, outcomes, values, likelihoods: Decision-making guide for patients and their families. Journal of Gerontological Nursing, 25(12), 19-25.

This classic article describes a tool to guide family caregivers with making decisions in situations where there may be conflict, frustration, and lack of consensus among family members. You can also use this tool to assist you as the person who is guiding families in decision-making.

Picture of the letters http: Click on the Internet 

Note: The internet link provided here was active at the time these Older Adult Focus materials were prepared. If the link is no longer active, try searching for the same or similar content using the name of the organization or the title provided.

Family Caregiver Alliance

http://www.caregiver.org

Click Fact Sheets & Publications and then Caregiving Issues and Strategies to locate the fact sheet Helping Families Make Everyday Care Choices (for Providers)

Families who provide care for older adults who are cognitively impaired face numerous issues that require decisions. This fact sheet is designed for health care professionals who are working with these families. It provides guidelines for structured discussions between family caregivers and the care recipient that help families consider both the preferences of the older adult and the needs and situation of the family caregivers. This approach helps balance potentially competing autonomies in families.

Read the fact sheet and reflect on these questions:

Legal Rights of Older Adults; Elder Abuse

Every health care professional who works with older adults needs some basic information about legal rights of older adults and about elder abuse. This section gives you this basic information and provides you with resources that you can explore at a deeper level if you need them in the future.

Picture of the letters http: Explore Two Useful Internet Sites

Note: The internet links provided here were active at the time these Older Adult Focus materials were prepared. If a link is no longer active, try searching for the same or similar content using the name of the organization or the title provided.

American Bar Association Commission on Law and Aging

http://www.abanet.org/aging

Scan the Resources that are available and select one topic that is of interest or is not familiar to you.

National Center on Elder Abuse (NCEA)

http://www.ncea.aoa.gov

Familiarize yourself with this website that provides information about elder abuse. Be sure to click the following two links that are located in the left column of the home page:

Be sure that you can answer the following questions:

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Decisions about Relocation

The decision about relocating an older adult to a different living environment involves many considerations, including the following:

Picture of an older man sitting in a chair talking on the telephone; a picture of his multigenerational family is hanging on the wall.
  • The person's functional abilities
  • The person's preferences
  • Available alternatives
  • Finances

This section provides you with some resources to guide older adults and their families in making relocation decisions.

Picture of the letters http: Click on the Internet 

Note: The internet link provided here was active at the time these Older Adult Focus materials were prepared. If the link is no longer active, try searching for the same or similar content using the name of the organization or the title provided.

Family Caregiver Alliance

http://www.caregiver.org

Click Fact Sheets & Publications and then on Caregiving Issues and Strategies. In the list of Fact Sheets, find the following:

Read these three fact sheets and ask yourself the following questions:

Read an Article Picture of two journal articles

Autonomy in Long-Term Care 

Hickman, S.E. (2004). Honoring resident autonomy in long-term care. Journal of Psychosocial Nursing, 42(1), 12-16.

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Decisions about Driving

Many older adults in the United State equate driving a car with independence. Driving issues can be very emotional for older adults. This section provides you with resources that explore this complex issue. Before you begin, consider these questions:

Picture of an older woman driving a car with a bag of groceries in the passenger seat
  • What physiological changes of aging contribute to driving difficulties for older adults? Do you need to consult a textbook for a quick review?
Picture of the letters http: Find Resources on the Internet 

Note: The internet link provided here was active at the time these Older Adult Focus materials were prepared. If the link is no longer active, try searching for the same or similar content using the name of the organization or the title provided.

American Automobile Association Foundation for Traffic Safety

http://www.seniordrivers.org

This website for older drivers and their families includes resources in these areas of focus:

  • Measuring driving skills (assessment)
  • Education and training to keep driving safely
  • Planning for continued mobility post driving

Explore the site.

  • Take an online driving skills assessment.
  • Find a resource for an older adult who wants to keep driving safely after the age of 75.
  • Which one of these resources would you recommend to a family member who is concerned about the number of "fender benders" an older parent has had recently.
  • What is the STP Exchange? How might it be useful?
  • Accidents involving what type of turn (right or left) are more common for older drivers than younger drivers? What factors contribute to this difference?
Drawing of an ear listening to a story Listen to a True Story about How One Community Handled a Driving Issue

Listen to Fred Drives to Town, narrated by Linda Felver, Ph.D., R.N. If you prefer, you can read a transcript of the story.

  • What is your initial reaction upon listening to this story?
  • What resources do you now have that might have been useful for Fred's daughter? For Fred himself?
  • If you were a family friend in this situation, how might you have proceeded?
Read Some Articles Picture of two journal articles
Do you remember the Beers List of medications that are potentially inappropriate for older adults? You encountered it in the Adapting Care Competency. Look at it again. What is the therapeutic use of benzodiazepines? What are the names of some benzodiazepines that have a long half-life? This information will be useful to you as you read the following article.  Drawing of a pill bottle

Long-Acting Benzodiazepines and Automobile Accidents

Hemmelgarn, B., Suissa, S., Huang, A., et al. (1997). Benzodiazepine use and the risk of motor vehicle crash in the elderly. Journal of the American Medical Association, 278(1), 27-31.

  • This classic article showed that long-acting benzodiazepines are associated with an increased risk of injury accidents but that short-acting ones are not. 
  • Given the pharmacological effects of benzodiazepines, and the physiological changes of aging that affect drug metabolism and excretion, explain these results.
  • If you work with older adults who drive, take medication histories to find out if they use long-acting benzodiazepines. What will you do if you discover that one of them does?

Now choose one of the following articles to read. One of them focuses on rural older drivers; the other focuses on urban older drivers. 

Rural Older Drivers

Johnson, J.E. (2004). Why rural elders drive against advice. Journal of Community Health Nursing, 19(4), 237-244.

  • Which of the factors mentioned in this article apply to the story Fred Drives to Town?

  • Do you know a rural older adult who continued to drive after being advised to stop driving? What factors were involved in his or her decision to continue driving?

  • Do you know a rural older adult who has stopped driving? What impact has that decision made on his or her life?

  • How could you assist an older adult who is making a driving decision?

Urban Older Drivers

Johnson, J.E. (2004). Urban older adults and the forfeiture of a driver's license. Journal of Gerontological Nursing, 25(12), 12-18.

  • Do you know an older adult who gave up his or her driver's license? Which factors mentioned in this article were considered in making that decision? What impact has that decision had on the person's quality of life?
  • How could you assist an older adult who is making a driving decision?

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Decisions at End of Life

End of life is a time that can involve many complex decisions. Some of those decisions can be made and documented as advance directives before they are needed. 

Picture of an older man who is in a wheelchair talking with a nurse who is holding a clipboard    This section provides you with tools and guidance for working with older adults and their families who are making end-of-life decisions.
Picture of two compact discs Explore TNEEL Modules

TNEEL stands for Toolkit on Nursing Excellence at End of Life Transition. If you do not have a TNEEL CD-ROM, you can order this excellent resource from http://www.tneel.uic.edu. You need the following instructions, so take notes or print this page before you leave these Focus on Older Adults materials.

Using the TNEEL CD, go to the Ethics section and review the following four modules:

  • Healthcare Decision Making
  • DNR Decisions
  • Forgoing Medical Therapy
  • The Nurse's Role

These directions focus on areas that will be most useful in working with older adults, but feel free to explore further if you wish. Here are specific directions:

Put the TNEEL CD into your computer's CD drive. 

  • If the TNEEL CD opens automatically, you will see a round Navigation Menu. Click on the round Ethics icon in that menu.
  • If the TNEEL CD does not open automatically, open it by double clicking on the CD icon (on a PC computer, look in My Computer for the icon; on a Macintosh computer, look on the desktop for the icon) and you will see a list of folders. Open the folder titled Ethics and double click on the file ethics.htm.

You are now at the Ethics section. Click on Healthcare Decision Making. The left column provides a series of links. After reading the overview, you can work through the links in order or skip down to Myths, Definitions, or Pre-Assessment. The Instructional Materials will give you the background to work through the Case Studies. For a focus on older adults, look at these case studies:

  • Case 2: 62-year-old man
  • Case 4: 75-year-old woman
  • Case 5: 68-year-old man

In the Post-Assessment, focus on Question Set # 2.

You can work through the other three modules in a similar fashion. In each module, the Instructional Materials provide the background for working through the Case Studies. Here are the specific case studies and post-assessment questions that are most useful for a focus on older adults in each of the four modules.

Module Case Studies Post-Assessment
Healthcare Decision Making
  • Case 2: 62-year-old man
  • Case 4: 75-year-old woman
  • Case 5: 68-year-old man

                            

Question Set #2
DNR Decisions
  • Case 1: Mr. Williams
  • Case 3: Providing futile therapy in the ICU?

                          

Question Set #1
Question Set #2
Forgoing Medical Therapy
  • Case 1: Mrs. Gregory
  • Case 5: Mrs. Abel & Mrs. Cain

                                

Question Set #1
Question Set #2
The Nurse's Role
  • Case 1: Mrs. Sando
  • Case 2: Mr. Leary
Question Set #1

                   

Picture of a movie film Watch a Movie

Thinking about the end of life can be difficult for you and others. Watch the movie The Bucket List, in which two terminally ill older men leave a cancer ward and take a trip with a wish list of to-dos before they die. Think about what you might want to put on your "bucket list". How might your list compare with that of an older adult you know?

Picture of the letters http: Click on the Internet to Understand Advance Directives and POLST

Note: The internet links provided here were active at the time these Older Adult Focus materials were prepared. If a link is no longer active, try searching for the same or similar content using the name of the organization or the title provided.

National Hospice and Palliative Care Organization (NHPCO)

http://www.caringinfo.org

  • Use the Search function on this site to find advance directives.
  • What are advance directives?
  • Who completes an advance directive? When does it go into effect (become legally valid)?
  • Download the advance directives forms for your state.
  • While you are on this site, you could explore it to learn something about hospice.
  • Complete the advance directives form for yourself. Discuss how you made your decisions and share your experience with a family member or friend.
  • Ask some older adults if they have completed advance directives. Discuss with them the barriers and supports for completing advance directives.

Physician Orders for Life-Sustaining Treatment (POLST)

http://www.polst.org

Click the Patients and Families tab and read the FAQs to learn about the POLST Paradigm.

  • Why was POLST developed?
  • Who completes the POLST Paradigm form? When does it go into effect (become legally valid)?
  • How is a POLST Paradigm form different from an advance directive? (Who completes an advance directive?)
  • If your patient has a POLST paradigm form in the medical record and will be transferred to another unit or another health care facility, what should happen to the POLST Paradigm form?

Click your state on the map to discover the status of POLST implementation in your state.

Click the Programs tab and download a POLST Paradigm form.

  • Look at the advance directive forms that you completed and decide how you would direct your physician or nurse practitioner to complete the POLST form if you had a terminal illness.
  • Discuss how you made your decisions and share your experience with a family member or friend.

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After you have completed some or all of these Learning Activities, proceed to the Competency Demonstration.

Developed by J. Hagan and L. Felver; Revised 2010