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Aging and Risk: Walking the Tightrope of Decisions

Is it time to step in and take a more active role in your parents’ daily lives? This question of aging and risk represents a common quandary experienced by adult children when their parents’ daily routines begin to change due to alterations in physical health, functional ability, and/or cognitive processing.  It is a question fraught with social, moral, ethical, and legal considerations which can make the children feel like they are walking a tightrope.

A question or suggestion from a child which casts doubt on a parent’s ability to independently make decisions and/or carry out daily activities can elicit a wide range of reactions from the parent.  Some parents may feel a sense of relief and readily accept assistance.  Others may feel threatened or be unable or unwilling to objectively evaluate their situation and react with uncertainty, resignation, resistance, or outrage.         

For the parents who may be reading this article, consider that the most likely reason your children are seeking involvement is that they love you and naturally want to protect you.  The challenges arise when parents and children have differing opinions about how much risk is an acceptable part of daily life.

The level of risk (susceptibility, danger, loss, peril, and/or a hazard) associated with an action or lack of action is an aspect of life which influences our decisions and behavior.  We routinely accept certain risks without really thinking about them, such as traveling in a car. Other risks are optional and are embraced by some while easily avoided by others, such as mountain climbing.

A common term within the realm of financial planning is “risk tolerance”, or how much of a loss an individual is willing to accept as part of a financial investment strategy. Risk tolerance can also be applied to daily life. 

When physical or cognitive changes alter the level of risk in an individual’s home environment and with a daily routine, the management of risk becomes more complex. A change in functioning may occur, but the parent may express a preference to “do it myself” or have strong feelings about remaining in the family home “no matter what.” The parent’s and the child’s opinions about the level of risk may conflict at this point.

Geriatric psychiatrist Sandi Culo, in a 2011 article in the British Columbia Medical Journal, mentioned a couple of ways to identify the severity of risk: either as “tolerable or intolerable” and “actual or potential.”  How they combine (potential tolerable, actual tolerable, potential intolerable, and actual intolerable) can provide guidance for when a situation requires intervention by a family member versus when additional assessment or education may be beneficial for the older adult.

Although the severity of a risk may be a judgement call by the specific individual, generally, when the risk threatens the immediate safety of the individual, it should be considered as intolerable. A second essential part of the equation is the individual’s capacity to accept or ignore a risk. Capacity is more difficult to determine because it is a fluid concept.

In the article, Dr. Culo stated, “Decision-making capacity requires that an individual have an understanding and appreciation of the situation or problem at hand. Articulation of alternatives, choices, benefits, and risks is expected. The person must be aware that the issue in question relates to him or her specifically.”

There is no specific test for capacity, nor do certain medical diagnoses automatically indicate a lack of capacity.  Cognitive assessment which includes a range of skills (memory, language, reasoning, problem-solving, planning) as well as assessment of functional ability, both play important roles when the courts are called upon to determine incapacity. 

Capacity can vary depending upon the situation and specific decision which is being made.  To further complicate the issue, an individual may possess the capacity to make a certain type of decision, but may lack the ability to act on the decision. This inability directly impacts the level of risk of that decision.

The determination of the level of risk in a decision/situation may include the following considerations:

  • Will this decision create an immediate and serious danger? (Actual risk)
  • What types of undesirable consequences might occur? (Potential risk)
  • What is the likelihood of each undesirable consequence actually happening?
  • Which consequences might the individual be willing to live with (tolerability) and which ones are unacceptable or would create serious danger (intolerability)?
  • Which consequences are tolerable or intolerable for the family?
  • Have all of the options for this particular decision been considered?
  • How do actual/potential benefits and level of risk compare to each other?

Creating a numerical scale to quantify the value of benefits and risks (1 point for lowest risk or benefit up to 5 points for highest risk or benefit) can serve as a starting point for comparisons and conversations about the choice(s) at hand.

Finding balance on a tightrope is tricky.  As difficult as it may be, at times family members of older adults must accept greater levels of risk and respect the choices and decisions of their loved ones, even when they do not agree with those decisions.  When possible, an adult’s right to self-determination should be honored even when the choices which are being made appear to be inconsistent with expressed goals or generally unfavorable to personal health and wellness. A medical professional should be consulted if the capacity to make certain decisions is in question.

Karen Kaslow, RN, BSN