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.
Domain of occupation
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.
Moats, G. (2007). Discharge decision-making, enabling occupations, and client-centred practice. Canadian Journal of Occupational Therapy, 74(2), 91-101.
This model aims to assist practitioners in understanding decision-making process of people with stroke in community participation. It is depicted as a scale with the fulcrum in the middle, with the facilitators and barriers placed on either end with different amount of the impacts (factors placed further from center represents higher impact on decision making). The balance scale represents the concept of weighting thought, desire, or request for going out into the community that from oneself, caregiver, or significant others.
The Model of Children’s Active Travel (M-CAT) addresses factors that influence parents’ or children’s decision making on the children’s active travel using a simple and comprehensive approach. Active travel is, by walking or riding bicycle, travelling between local destinations, such as school or park. The factors impact decision-making process of the parents and the child of active travel consist of: (1) objective element of the child, parents, family and environment, (2) perceptions of the parents and child around these objective elements, and (3) outcome.
The Canadian Model of Client-Centered Enablement (CMCE) is a model using visual metaphor to show the therapist-client relationship and client-centered enablement. According to the model, enablement is the core of occupational therapy, which helps guide reasoning and choices in the therapy. It is made up of two lines and a series of “enablement skills”. The two lines in the model represent clients, who may be individuals, groups, communities, organizations, or populations, and therapists, respectively.
This integrative framework mainly consists of two elements: (1) the factors influencing clinical reasoning (CR), and (2) the evolving CR process underlying the choice of teaching strategies. First, both internal factors (relate to occupational therapists, such as knowledge and experience, personal habits) and external factors (relate to client, environment, task, and interaction of them, such as emotional/cognitive/physical availability, previous knowledge) influence CR of therapists.
Data Driven Decision Making (DDDM) is a framework for therapists to implement clinical reasoning within occupational therapy process and has a focus on the use of observation, testing and intervention results to guide and measure outcomes. This framework consists of 11 steps. Step 1, the therapists have to identify the participation challenges and goals. In step 2, therapists need to describe the level of the client’s functioning in each part of the body or the brain.