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Negotiated Model of Decision-Making

  • This model aims to guide occupational therapists in decision-making with the elderly who have cognitive impairment to continued community living. Client-defined decision-making processes are suitable for non-cognitively impaired, non-dependent people, while negotiated decision-making processes are suitable for clients with cognitive impairment, dependent on others/putting others at risk. The later process gives balanced attention to both safety and autonomy and focuses on enabling engagement in meaning occupations. It is client-centered as the client’s wishes, or family’s wishes for the client (when acting as proxy decision-maker), are considered and included in the process. It is a dynamic model that allows for flexibility on the extent of the client and family’s participation. The level of participation of the family in the decision-making process depends on the three factors of the elderly: (1) amount of cognitive impairment, (2) if the client is putting others at risk, and (3) the level of help required. For example, when the client has significant cognitive impairment, the level of family participation will be higher and that of the client’s participation will be lower. Occupational therapy assessments include an exploration of meaningful occupations, and the extent of the meaning is connected to the environment. The therapist also conducts a home visit to help shifting the power dynamic in favor of the client and to facilitate understanding of how the environment is (or is not) connected to the client’s occupation. Then the therapist works with the client and/or family to determine if those occupations can be done in the environment with or without modifications, or if they can be transferred in some way to other environment, for example care home. The therapist also explores safety risk in the environment. Of note, the therapist should understand the ethical tensions between autonomy and risk avoidance and understand that a simplistic approach to these questions are not possible.  

Summarized by

  • Macey Cho

Type

  • Model (practice)

Population

  • Elderly

Disability

  • Cognitive disability

Domain of occupation

  • Unspecified

Application Note

  • Therapists must understand the broader socio-cultural environment that may affect the process, for example ageism, own values, family’s value, and take active steps to minimize the effects of these issues by advocating for the client, meanwhile considering fairness in resource allocation.

Key Reference

  • Moats, G. (2007). Discharge decision-making, enabling occupations, and client-centred practice. Canadian Journal of Occupational Therapy, 74(2), 91-101.

Year Published

  • 2007

Primary Developer

  • Gillian Moats

Primary Developer Email

  • jmoats@deerlodge.mb.ca

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Model Type

Population

Disability

Domain of Occupation

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