| As the new millennium brings forth the largest population of people over 80, social workers face the increased prospect of helping the frail elderly complete living wills/health-care directives as part of the advanced-planning process. Nursing-home social workers are often inexperienced graduates with little or no training in the process of health-care directives, a complex task involving clients, families, and other professionals. Significant accumulated losses in the frail elderly---personal, physical, cognitive---add to the challenge as those losses complicate self-determination and informed consent.; This qualitative study examines social workers in a Midwestern, nonprofit, faith based nursing home as they assisted clients with the advanced-planning process. The research reviewed the mandatory procedures for their relevance to a ritual of care that would facilitate meaningful exchange about end-of-life planning. The social workers were interviewed, their client interviews observed, and follow-up interviews conducted with social workers and clients. Findings were organized around four themes: procedure versus ritual, personal versus professional, best- and worst-case scenarios, and self-determination versus co-determination.; Despite their commitment to a ritualization of the advanced-planning process, the social workers varied in defining ritual and performing the procedures. Second, though each had experienced personal challenges with an aging relative, few had completed living wills of their own. Third, worst-case scenarios occurred with clients with severe hearing and sight loss or cognitive decline, especially with those clients not legally declared incompetent. Last, despite the social workers commitment to self-determination, they often played an active role in constructing the health-care directive at the client's or family's request. This process would be more accurately described as co-determination.; The lack of research on this topic and the decline in geriatric education for social workers have major implications for educational priorities in the profession. The rising population of frail elderly requires a rethinking of how their needs and those of their families are met by policy and agency procedures. It is essential to revisit the concept of self-determination as it applies to frail elderly, not only within social work but among all health-care professions. Ultimately, there is leadership potential for social workers who, as part of health-care teams, can advocate for meaningful exchanges amid the demands for an efficient and sanitized end-of-life planning process. |
