The Importance of Autonomy in the Well-Being of the Older Adult

April 26, 2023

group of older adults sitting outdoors smiling and laughing together during sunset in springtime

Studies show that maintaining a sense of autonomy is an important factor in keeping the older population living a satisfying life. “Autonomy is the ability of the individual to make and carry out decisions about how, with whom, when, and where to spend one’s time” (Bennett et al, 2015). It is imperative for health care professionals and caregivers to understand that encouraging a sense of autonomy for older people greatly enhances their well being, irrespective of their physical or mental abilities. Naturally, the understanding of an individual’s need for autonomy has to be balanced with the necessity for security and health. By bridging the widening gap between autonomy and caregiving with empathy and respect for the elderly person, we have the obligation to encourage a sense of self-efficacy. Each life stage of a client in our care comes with its own set of challenges, but the common denominator needs to be compassion and fostering a sense of independence. Autonomy looks different when moving from the functioning, to the frail, and ultimately incapacitated elderly, but must never be put on the back burner.

Functioning Older Adult

By adopting a holistic view of the whole person and validating the older adults’ various personalities, life experiences, and preferences, we can facility a deeper understanding of where they are coming from. Autonomy runs deep in the fabric of American society and it encompasses such principles as: Control, freedom, agency, and individualism. Those values are ingrained in people and they do not merely vanish as one gets older and less physically or mentally capable. It is imperative to continue nurturing those ideals in the elderly equal to physical care. Once it has been established that self-worth has to play a centered role in the caretaking of the elderly, authenticity needs to ensue. It is vital to make sure the choices given in a residential or home care environment not be inauthentic. One has to be cognizant of the fact that what may appear to be a choice really isn’t if the choice isn’t significant or worth making. For true autonomy to take place the older adult has to be able to identify with his/her own choices. The care recipients should also feel free to make choices when they realize that help is needed. Feeling unable to take on a task does not make one dependent, if intrinsically the individual senses the need for help. If someone else is telling the elderly person that he/she ought to seek help for the task, that is a different story and they may feel judged as being incapable. Sometimes there is a blurry line between autonomy and self-sufficiency. If the elderly hire somebody to drive them it can be questioned who then is the autonomous one? However, “asking for help enables autonomy and control – as long as it is on the elder’s terms” (Applewhite, 2016, p. 208). When people’s competence is questioned they become more dependent and their autonomy and identity erode. By understanding that the older adult’s sense of self is already threatened in society due to ageism, those of us who are interacting with the elderly daily have an opportunity to counteract that bias. With that in mind, however, there may also be situations in which dignity outweighs autonomy and staff has to be able to judge that. Gallagher et al., 2008, hypothesizes that if a resident refuses to take a bath, consideration of his best interests will have to balance autonomy and independence against some account of the dangers of self neglect, the distress or offense caused to others, and his human dignity (p.9). Being allowed to feel and act true to one’s own wishes is a matter of dignity.

Though not interchangeable with autonomy, dignity is also essential in keeping with the sense of being respected and valued no matter one’s circumstances. By respecting someone else’s self-worth in undignified circumstances we invariably express and enhance our own dignity. Bennett et al. (2015) conclude that the area in which autonomy should be understood, whether behavioral or interactional, need to be valued by employer, employee, and family. E.g. when a son, who pays for his mother’s stay, brings in a list of visitors he forbids his mother from seeing, whose authority should be prioritized in such a situation? If autonomy is valued, clearly the mother’s wishes should take precedent, and as health care professionals we need to emphasize that our focus is to provide care on the older adult’s own term.

Frail Older Adults

In situations with the frail elderly, the task of establishing a sense of autonomy for the client becomes more difficult. The effort to foster independence is still vital for this population as well. “When despite their frailty older people experience autonomy they become more alert both mentally and physically and their self-rated well-being improves (Andresen and Puggaard, 2008, p. 2). Researchers have proposed the significance of making autonomous decisions notwithstanding frailty, reliance and limitations of action. With functional decline the frail elderly’s ability at certain tasks naturally drops, but their perceived sense of autonomy can still be nourished. According to Gallagher et al. (2008) autonomy stresses freedom and influence over one’s life and dignified care includes those principles as well as a holistic and person-centered approach, involvement, communication and esteem (6). Those values are essential in maintaining autonomy even with the frail elderly, and care must be taken to foster that sense whenever possible.

Incapacitated Older Adult

The health care professionals caring for the incapacitated elderly face an even greater challenge. In this realm it would be necessary to err on the side of caution. It may be an opportunity to interpret autonomy as decisional capacity and maintaining that ability for the patient for as long as possible. “As a practical matter, the health care professional should assume, until there is contrary evidence, that an adult patient has decisional capacity. Advanced age of the patient is not warranting for a contrary presumption” (Hill, 1989, p. 84). According to High (1989) an incapacitated patient keeps the rights of autonomy without the capability of acting on those rights. However, when it has been established that the patient has lost the ability for decisional capacity, “honoring someone’s autonomy is done by assisting in facilitating proper surrogate decision-making and providing optimal beneficial care while guarding against undue paternalism” (Hill, 1989, p. 85). Ditto (2006) contends that when a previous capable person becomes decisionally incapacitated because of illness or injury their right to autonomy is not diminished. A surrogate, who has to remove his/her own wishes from the equation, should then carry out the substituted judgment of the incapacitated person (137).

The old Mexican saying: “The appearance of the bull changes when you enter the ring” (Applewhite, 2016, p. 211) is something worth remembering. It is important to foster a sense of value for an older person, no matter his/her purportedly worth. One day we will all enter the ring of home- or institutionalized care and the bull will look different. It is imperative not to draw conclusions as to how older people may be feeling or what they may be needing thus making decisions for them. Instead we should try to inquire, honor their wishes, and ultimately foster their sense of autonomy. The psychologist’s delusion is to think that we know what another person is experiencing; however, projecting is different than emphasizing and we often make mistakes (Applewhite, 2016, pp. 211, 213).

Lisbeth Smith, B.A., MSG is a Care Manager with Elder Options, serving primarily the South Lake Tahoe Basin. Lisbeth has had lifelong empathy for older adults that ignited when she worked at a nursing home in Denmark in the 1970’s but was distressed by the lack of time she was allowed to spend with each resident. The field of Care Management allows Lisbeth to develop meaningful relationships with each client she serves.