Engaging older adults in discharge planning: case studies illuminating approaches adopted by family members that promote relational autonomy

Abstract

Background: Discharge decisions have significant implications for older adults and their involved family members. Evidence of older adult and family members’ engagement in discharge decision-making, however, varies widely. Some recent work shows assumed associations between ageing, diminished participation in healthcare decision-making and increased reliance on family members. Other research suggests that family members adopt strategies to promote older adults’ participation in decision-making. Relational autonomy theory suggests that individuals have differing levels of autonomy and that individuals’ agency can be supported (or marginalized) by others.

Purpose: Using three case studies, we examine traditional and relational conceptions of autonomy and explore how relational approaches could inform healthcare practice.

Methods: Taking a critical feminist bioethics perspective, we present a secondary analysis of three microethnographic case studies focused on discharge planning with older adults in one Canadian inpatient rehabilitation setting. The data consist of observations of discharge planning family conferences and semi-structured interviews with older adults and family members.

Results: Tensions between older adults’ wishes to return home and their diminished participation in discharge decisions, and family members’ assumption of a primary role in discharge decision-making and their wish for the older adult to move to a supported setting were apparent. To reconcile these tensions, the older adults’ family members in these cases employed strategies to promote older adults’ participation in decision-making that were consistent with relational autonomy theory.

Conclusion and implications for practice: The analysis suggests that older adults’ participation in discharge decision-making processes could be better promoted through relational approaches.

Implications for rehabilitation

•  • Adopting an approach guided by relational autonomy might better enable patients to participate in decision-making than would an approach guided by traditional conceptions of autonomy.

•  • Rehabilitation professionals could seek assistance from family members and guide them toward collaborative partnerships.

•  • A range of strategies may be employed to customize relational approaches to enhance autonomy:

•     • having several different conversations with patients to enable multiple chances to contribute knowledge and views;

•      • involving family members or taking the time to explain information several different times and in diverse manners;

•      • showing patients videos or photos of discharge locations;

•      • exploring a breadth of potential discharge options;

•      • accompanying patients to visit different options in person; and

•      • getting patients in touch with individuals who have made similar choices.

•  • It is recognized that taking a relational approach might be time-consuming and that practice contexts may not be conducive to such practice.

Keywords:

• Autonomy
• relational autonomy
• older adults
• discharge planning
• decision-making

Notes

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1 The development of such conceptions of autonomy has been greatly influenced by the work of Immanuel Kant and John Stuart Mill. Kant [40] argued that the ideal of an autonomous being is a rational individual who acts in manners governed solely by his or her own individual reason. Similarly, Mill [41] argued that individuals should be free to develop according to their own persuasions. Both of these philosophers described individuals as self-governing beings free to act within the limitations of not interfering with the same freedom of others.

2 This aligns with the ideas of Kant and Mill; however, the relationship between one’s actions and that of others has been reversed. In the more contemporary conception, autonomy dictates one’s actions should be “free… from interference by others” whereas in Kant and Mill’s work, individuals should limit their actions such that they do not interfere with others’ freedom.

3 Conditions that reflect the influence of Kant and Mill