Dementia as Social Experience by Gaynor Macdonald Jane Mears

Author:Gaynor Macdonald, Jane Mears [Gaynor Macdonald, Jane Mears]
Language: eng
Format: epub
ISBN: 9780367902643
Barnesnoble:
Publisher: Taylor & Francis
Published: 2019-11-28T00:00:00+00:00

The relational decision-making model

The relational model described below supports the older person with cognitive impairment to participate in the decision-making process, by listening to their expressed preferences and identifying and expanding options that are congruent. It involves family members and incorporates their knowledge and concerns, recognising the significance of these relationships. The relational model also identifies where the imposition of value judgements and conflicts of interest may result in unnecessary restrictions, manipulation or control. The model recognises the need for support in decision-making, aligning with comparative approaches in the emerging area of supporting decision-making in the disability sector, where service providers are encouraged to facilitate the participation of the individual in decision-making about their goals (Bigby and Douglas 2015).

Where significant barriers prevent the resolution of the problem using this relational approach, the legal capacity model, as guided by common law, acts as the default mechanism. The traditional legal capacity approach, as a default, enables essential consent for treatment by healthcare professionals, through the person either having a legal capacity to make the decision, or the substitute decision-maker taking responsibility for the decision. This acknowledges law’s function in mediating the problems that arise in human relationships (Kerridge et al. 1998; Naffine 2009).

As different laws have different purposes, there may be a perceived tension in the medical setting with interpretations of other aspects of law, which may contradict the relational approach. For instance, duty of care can often be interpreted by health professionals through the lens of risk aversion, and may be used to impose protections on the patient, rather than that of balancing risks and benefits and minimising risks. This form of medical paternalism can be justified by the health professional through reference to the law, and works against the relational approach. In general, greater education about the law in health settings will be of benefit to health professionals in understanding the role of law in everyday practice (White et al. 2016).

I propose five main stages of the relational decision-making model, followed by the default position. They are: assuming capacity; knowing the person and their preferences; identifying and creating congruent choices; supporting the person in the decision-making process; and assisting with the plan and its implementation. Where a shared resolution is not obtained, a default capacity approach can indicate if the person is unable to participate meaningfully and substitute decision-making is required. If so, the substitute decision-maker becomes an advocate for the older person, to keep the preferences and life meaning of that person central. The model relies on the development of relationships between health professionals and the older person. I elaborate below, using Andrei’s case study to illustrate how this model would have impacted in each stage. It commences at the point that a significant decision is required with no simple negotiated resolution apparent.

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