The strengthened Aged Care Quality Standards emphasise the importance of older people ‘living the life they choose’ (ACQSC 2024).

This is highlighted in Standard 1: The Person - Outcome 1.3: Choice, independence and quality of life, which states that older people should be able to ‘exercise choice and make decisions about their care and services, with support when they want or need it’ (ACQSC 2024).

How do we ensure a choice is given and that older people are not subjected to a predetermined routine that primarily benefits the operators rather than aligning with the older person’s preferences?

The provision of choice to older people receiving care and services often depends on the presence, time and willingness of the caregiver. While some choices are readily accommodated, there are instances where the caregiver may deny opportunities for choice based on personal factors, such as convenience or a lack of resources, for example.

The institutional nature of aged care also frequently restricts older people from exercising choice. For instance, they may be limited to the items on a predetermined menu without alternatives.

Real examples like these common denials of choice highlight the urgent need for change.

Furthermore, as part of the aged care reform roadmap, upcoming rights-based legislation changes coming into effect in 2024 will play a crucial role in empowering older people and their right to enforce their choices, requiring a shift in the approach to aged care (DoHaAC 2023).

Overall, reevaluating the approach to choice in aged care is essential to prioritise person-centred living and ensure that every older person can live according to their own preferences, whether in their own homes or within an aged care facility.

Addressing the Lack of Real Choice in Aged Care

To ensure genuine choice in care and services, a different approach is needed. Many aged care facilities operate on a provider-driven routine, where tasks are assigned to staff members who must complete them within their shifts. However, this institutional model can result in older people being directed rather than being able to live according to their own preferences.

A common mistake in aged care is the use of the term ‘options’. Options imply that individuals have choices when in reality, they are limited to selecting from predetermined alternatives. For example, older people in an aged care facility may not be able to freely explore different restaurants for dinner. Instead, they are presented with a menu of limited options. If none of the options align with their preferences, they may go without a satisfactory meal.

Some aged care providers have implemented flexible systems that prioritise individual choice, especially in meal selection. Rather than offering a list of options, older people are given the freedom to choose what they want to eat for dinner. Although this poses challenges for many providers, ensuring personalised food choices significantly improves satisfaction.

The consequence of not providing real choice is that older people are unable to ‘live the life they choose’ and instead find themselves trapped in an unfamiliar and unwelcome routine.

Balancing Choice and Safety in Aged Care

Navigating choice in aged care becomes complex when there are situations where fulfilling someone's choices could pose a safety risk or constitute neglect.

It is crucial to prioritise the person's safety while considering their preferences. If a person's choice poses a risk to themselves or others, follow these steps:

1. Understand the reasons behind their choice.
2. Engage in dialogue, negotiating alternative options that ensure safety.
3. Seek assistance from other staff members, including nurses and managers, when necessary. Avoid attempting to resolve the situation alone if you lack the authority or expertise.

For instance, if a person refuses to shower for several days, their choice must be assessed in the context of safety. Accepting this choice when it poses a risk is a form of abuse. Investigate the underlying reasons for their resistance and explore ways to address their concerns.

Building a trusting relationship with the person is essential in assisting their decision-making process. Trust should never be exploited for manipulation but used to collaboratively work towards satisfying their choices.

This applies even to individuals living with dementia, who can still make choices and receive support accordingly.

Remember, your role is to always act in the person's best interest, ensuring a balance between honouring their choices and maintaining their wellbeing.

An Approach to Ensuring Real Choice in Aged Care

A real choice should revolve around three key elements:

1. Offering a choice to the person
2. Perceiving choice as the provider
3. Perception of choice by the person making the request.

Putting this into Practice

Let’s take a look at each of these elements in more detail.

Element One: The way choice is offered to older people

‘The way I approach someone must be open and willing to listen to what they want. I am there to assist them achieve their choices and not to direct or influence them.’

Element one is about what influence you have over someone’s choices, and your approach must be one of being open to what they want and flexible enough to make changes to any routine to meet these choices.

While you may have certain tasks to complete in the course of your work, these have to be in the order the person wants them and not what you want. This is underpinned by the principle of choice.

Examples of how staff can improve how a choice is offered include:

• Knowing the person and their habits and fitting your schedule around these. Being flexible so you can adjust your routine to suit their choices
  • Remember, providing options is not giving them a choice - avoid restricting options and instead focus on providing what the person truly desires
• Avoiding exerting undue influence or manipulation.

Element Two: The way choice is perceived by the person enabling it

‘I must act in a way that allows people to make their own choices and not what I want them to do to make it easy for myself.’

Element two is about how you see choices. Limiting things in your own mind about what the person wants will influence them in their choice. For someone to live the life they choose, they must be able to make the choices they want. In practice, choices can sometimes be difficult to enable, but it helps to keep an open mind and take a moment to listen to the person first.

Consider the following scenario.

A resident named George (85) was asked what he wanted to do as an activity. ‘I have always wanted to jump out of a helicopter,’ George responded. The staff were initially floored by the unexpected request.

Despite this, one staff member explored the possibility further, discussing with George if he would like to at least take a ride in a helicopter first before deciding to jump out of one.

The aged care facility happened to be near an airport, so the staff contacted the local helicopter operator and asked if they would be willing to give George a ride. They were very accommodating and offered to do so for no charge. George had an hour's flight over the city and the surrounding countryside.

George said, ‘It was fantastic.’ When staff asked him if he still wanted to jump out of a helicopter, however, George replied, ‘No way!’.

While George’s choice was extreme, the staff kept an open mind, and instead of immediately saying no, they were able to change their thinking around the request, dig deeper and come up with a compromise that George was happy with.

Examples of how providers can improve how they perceive choice include:

• Listening attentively, understanding a person's requests, and refraining from immediately saying no
• Viewing yourself as an assistant in helping individuals achieve their desired choices
• Trying to place yourself in the person’s shoes - what would you want in their situation?
• Offering choices selflessly without expecting anything in return.

Element Three: The way the choice is perceived by the person making it

‘How would the person rate their choices being met?’

Element three is about making sure the person’s choices are delivered in a way they are satisfied with. Quality of delivery is key to them feeling like they have been listened to and respected, and that the choice was provided in a caring manner that met their expectations.

As the person who is enabling them to make their choices, you should seek feedback from them on how it went and if there is anything you could improve on.

Examples of how staff can help improve the perception of the choice maker include:

• Providing a safe environment with open communication to enable people to make choices confidently, without fear or limitations
• Ensuring their reasonable and achievable choices are always met.

Conclusion

Always reconfirm what the person’s choice is so you are clear about what is to be achieved. Make sure you understand the choice and are able to deliver this in a quality manner. Ask for feedback on how you went meeting the choice and what you could do better next time. This will help you to make sure future choices are provided with quality.