Mrs. Chen refuses to take her blood pressure medication. Mr. Rodriguez insists on keeping his walker in the closet instead of using it. Ms. Williams has started a romantic relationship with another resident and her daughter is furious about it.
Every day in senior living communities, residents make decisions that staff and families view as problematic. We often call them "bad" decisions, but that label reveals more about our perspective than about the decisions themselves. What looks irrational to us may make perfect sense to the person making the choice. What we see as risky, they may see as essential to living life on their own terms.
This creates one of the most challenging ethical dilemmas in senior living: How do we honor a resident's right to make their own choices while also fulfilling our responsibility to keep them safe and healthy? When do we intervene, and when do we step back? And who gets to decide what counts as a "bad" decision in the first place?
These questions matter because how we answer them shapes the daily experience of the people we serve. Get it right, and we create communities where residents maintain their dignity and autonomy. Get it wrong, and we risk either abandoning people who need help or turning our communities into places where safety trumps everything else, including the things that make life worth living.
Understanding ethical dilemmas in senior living is essential for effectively managing and mitigating risks associated with resident care and well-being. Ethical dilemmas often arise when conflicting interests or values exist among residents, families and care providers. Addressing these dilemmas proactively can help prevent issues such as care abuse, financial exposures, grievances, complaints from residents and their families and noncompliance with prescribed care and treatment plans.
Before we can talk about navigating difficult decisions, we need to be clear about what grounds our work. Resident rights aren't nice-to-haves or aspirational goals. They're fundamental to everything we do.
The legal foundation is straightforward. Federal regulations for nursing homes and state regulations for assisted living facilities establish specific rights that residents retain when they move into our communities. These include the right to participate in their own care planning, the right to refuse treatment, the right to privacy and the right to make choices about their daily lives.
But the ethical foundation runs deeper than compliance. It rests on respect for people, the recognition that older adults remain whole human beings with the same inherent worth and right to self-determination they've always had. Moving into senior living doesn't diminish that. Needing help with daily activities doesn't erase the need for it. Even cognitive decline doesn't eliminate it.
The best organizations don't just post resident rights on the wall. They embed these principles into their mission and let them shape everything, from staff training to policy development to conflict resolution. When push comes to shove and a difficult decision needs to be made, these organizations ask first: "What do the residents' rights require of us here?"
While there are various ethical principles or concepts that guide practice in senior living, the following five core principles are fundamental to ethical practice:
Here's where it gets messy. These principles don't always point in the same direction. Sometimes they directly contradict each other.
A resident with mild dementia wants to keep driving. Autonomy says it's her choice. Non-maleficence says we can't stand by if she might hurt herself or someone else. Her family is pushing for intervention. She's angry at what she sees as control and infantilization. How do we honor all of these competing values?
Or consider the resident who decides to stop cancer treatment because he's tired of feeling sick. His decision conflicts with his family's deeply held religious belief that life must be preserved at all costs. It conflicts with the aggressive treatment approach his oncologist recommends. However, it aligns perfectly with his own longstanding value of prioritizing quality over quantity in life. Whose values should guide the decision?
Then there are situations where individual choices have a ripple effect on the community. A resident refuses to bathe, and the odor is driving her neighbors away. Her autonomy is clear. But what about justice for the other residents who deserve a comfortable environment? What about the impact on community well-being?
We also struggle with defining harm itself. Is it harmful to let someone eat an unhealthy diet if that's what pleases them at this stage of life? Is it harmful to prevent romantic relationships between residents with dementia? Is it more harmful to be lonely or to be unsafe?
These aren't academic questions. They show up every week, sometimes every day, and they don't come with clear answers.
When we're worried about a resident's decisions, we often wonder: "Does this person have the capacity to make this choice?" It's a crucial question, but we need to be precise about what we're asking.
Decision-making capacity is different from competency. Competency is a legal determination that only a court can make. Capacity is a clinical assessment that healthcare professionals can conduct. When we discuss whether a resident can make a particular decision, we're referring to their capacity.
Here's what's essential: Capacity isn't all-or-nothing, and it's not permanent. Someone might have the capacity to decide what to eat for breakfast, but not the capacity to manage complex financial decisions. They might have capacity today, but not tomorrow if they're having a bad cognitive day. This is what we mean by decision-specific and time-specific capacity.
Healthcare professionals assess capacity by looking at four domains:
All four domains must be present for someone to have the capacity to make a particular decision.
In nursing homes, capacity assessment is relatively straightforward because medical staff are on-site. However, in assisted living and independent living, the situation becomes more complicated. We're not healthcare providers in the same way. We can't diagnose or formally assess capacity. However, we're often the first to notice when someone's decision making appears to be off.
This puts us in a difficult position. We need to recognize warning signs and know when to raise concerns, but we also need to avoid overstepping our role or making assumptions based on age bias. In many communities, staff often interpret confusion or refusal as incapacity when, in fact, it is frustration or mistrust. Assessing capacity ethically means avoiding both overprotection and neglect.
Specific patterns should trigger concern. When a resident suddenly starts making decisions that contradict their long-held values or patterns without a clear explanation, that's worth attention. If someone careful with money starts giving it away indiscriminately, or if a person who has always maintained their appearance stops caring about hygiene entirely, something may have changed.
Refusal of clearly beneficial care, especially when the person can't articulate a reason or when their reasoning seems disconnected from reality, raises questions. This is different from refusing care based on personal values or preferences, which is their right.
Mental health conditions can affect capacity. Severe depression can impair judgment. Anxiety can lead to decisions driven more by fear than by rational assessment. Active psychosis obviously affects the ability to process reality accurately.
However, here's the critical part: None of these red flags automatically indicate that someone lacks capacity. They mean we need to look more closely, involve the appropriate professionals and not jump to conclusions.
So, what do you actually do when you're concerned about a resident's capacity?
First, document what you're seeing. Be specific about behaviors and statements, not your interpretations. "Mrs. Smith said she doesn't need her insulin because her neighbor's crystals cured her diabetes" is the documentation. "Mrs. Smith is making irrational decisions" is not.
Next, talk with the resident. What appears to be impaired capacity is often a misunderstanding or a communication failure. Ask questions that help you understand their reasoning. "Help me understand your thinking about this" often reveals more than you expect.
Involve the appropriate healthcare providers. This might be the resident's physician, a psychologist, or other professionals, depending on the situation. They can conduct formal capacity assessments if needed.
Throughout this process, respect the resident's privacy. Just because you have concerns doesn't mean you should be discussing them with everyone. Share information only with those who have a legitimate need to know and a role in supporting the resident.
If a capacity assessment concludes that a resident lacks capacity for a particular decision, make sure there's a clear process for appeals or second opinions. People have been wrong before. The resident or their family should have the ability to challenge the assessment.
And remember, even when someone lacks capacity for certain decisions, they may still have capacity for others. The goal is to preserve as much autonomy as possible while providing appropriate protection.
When we label a decision as "bad," we should pause and ask: Is the decision actually problematic, or are we missing something? Often, what appears to be a poor choice has its roots in something that can be fixed.
More often than we'd like to admit, "bad" decisions stem from communication breakdowns.
We haven't always given residents complete information. We explained the medication, but not the side effects. We described the activity, but not when it happens or what it involves. They made a decision based on partial information, and now we're judging that decision as if they had all the facts.
The information was there, but they misunderstood it. Medical jargon, complex care plans and financial details — these can all be confusing. Add in hearing loss or language barriers, and misunderstanding becomes even more likely. A resident might refuse a service not because they don't want it, but because they think it costs money when it's actually included, or because they thought you said something different than what you meant.
Language barriers go beyond just speaking different languages. Communication style mismatches matter, too. Some staff members are direct and efficient, while others require more context and conversation to be effective. Some staff members use metaphors and examples, while others think more concretely. When styles don't match, meaning gets lost.
Then there are our own assumptions. We assume the resident understands because we've explained it before. We assume they want what most people want. We presume their priorities match ours. These assumptions can lead us to perceive a decision as problematic when, in reality, we have never asked the right questions.
The decision might make perfect sense for the resident's goals, even when those goals differ from what others expect.
Family expectations can create significant pressure. Adult children often want their parents to prioritize safety and health above all else. The parent may care more about independence, social connection, or simple pleasures. When Dad refuses to use his walker because he thinks it makes him look old and he's trying to impress a lady friend, his kids see stubbornness. He sees pursuing what matters to him.
Organizational policies conflict with individual preferences for good reasons — we need rules that protect everyone. But let's be honest: our policies are sometimes more about convenience or liability concerns than genuine safety. When we acknowledge that, we might find more room for accommodation than we initially thought.
The tension between short-term desires and long-term well-being is a genuine concern. Is it a "bad" decision to eat dessert before dinner when you're 90 years old? From a nutritional standpoint, maybe. From a "life is short and I like pie" standpoint, maybe not. These trade-offs require weighing values, and different people weigh them differently.
Cultural and generational differences matter, too. Ideas about family involvement in decisions, appropriate behavior for older adults, end-of-life care and countless other issues vary across cultures and generations. What appears to be a poor decision may actually reflect different cultural values that deserve respect.
Context shapes decision making in ways we can easily overlook.
The transition to senior living can be a stressful experience. People are grieving the loss of their homes, their independence, their identities as they knew them. Decision making under that kind of stress doesn't always reflect someone's best judgment. They might refuse help because accepting it means admitting they need it, and they're not yet ready for that emotional step.
Grief and loss can cloud judgment beyond the move itself. Losing a spouse, losing abilities, losing friends — older adults often carry multiple losses at once. Depression is common and underdiagnosed. Anxiety can make people risk-averse or lead to decisions driven by fear rather than preference.
Medications can affect cognition and mood, influencing decision making. Some cause confusion. Some cause fatigue that makes everything seem more complicated than it is. Some affect emotional regulation. When we see a sudden change in someone's decision-making patterns, medication changes should be on the list of things to consider.
Social dynamics also play a role. Is the resident isolated and making decisions out of loneliness or desperation for connection? Are they being pressured by other residents or family members? Are they trying to maintain status or relationships in ways that affect their choices?
All of these factors are fixable, or at least addressable. Before we conclude that someone is making a genuinely problematic choice, we need to look at what might be driving it.
The best time to address potential conflicts about decision making is before they happen. Communities that handle these situations well start building the foundation during the admission process.
The admission conversation shouldn't just cover logistics and paperwork. It should include an honest discussion about philosophy and values.
Be clear about your organizational philosophy. What are your core commitments? How do you balance resident autonomy with safety? What role do residents play in decisions about their care? Don't speak in vague generalities. Give concrete examples.
Explain what services you will and won't provide. Be honest about your limitations. If you can't support specific care needs or if residents would need to move if their needs increase beyond a certain point, say that upfront. Surprises later create conflict and erode trust.
Describe how decision making actually works in your community. Who's involved when there's a care change? How do you handle disagreements between residents and families? What happens if a resident makes a choice you think is unsafe?
Discuss scenarios where value conflicts might arise. You don't need to be exhaustive, but discussing a few examples helps people understand how these situations are handled. "Some residents want to keep food in their rooms even though it creates pest problems for the whole building. Here's how we approach that..." This kind of specificity helps set realistic expectations.
Nobody likes having hard conversations, but honesty prevents bigger problems down the road.
Be clear about your capabilities and constraints. If you can't provide certain types of medical care, if staffing levels limit what you can offer, or if financial considerations affect your options, residents and their families need to know this. They can't make informed decisions without accurate information about what you can actually deliver.
Discuss transitions explicitly. Under what circumstances might someone need to move to a higher level of care? What does that process look like? Who makes that determination? These conversations can be uncomfortable when someone is moving in and is excited about their new home. They're much worse when they happen during a crisis.
Talk about money honestly. What happens if someone runs out of funds? What services cost extra? How do financial limitations affect care options? Financial stress creates enormous anxiety for older adults and their families. Clarity helps, even when the news isn't what people want to hear.
Explain the legal and regulatory constraints that affect resident choices. Some limitations on what residents can do aren't about your policies — they're about what the law allows or requires in your setting. When people understand that specific rules aren't arbitrary, they're more likely to accept them.
Even with good prevention, conflicts will arise. Having transparent processes makes them easier to navigate.
Establish protocols for ethical decision making before you need them. Who gets consulted when there's a difficult choice? What steps do you follow? How do you ensure all relevant voices are heard? Put this in writing so staff members aren't making it up as they go.
Access to ethics consultation or an ethics committee can be invaluable. This might be an internal committee or a resource you can call on from the outside. Having someone outside the immediate situation who can look at it through an ethical lens often clarifies things.
Mediation and conflict resolution processes help when residents, families and staff disagree. A skilled mediator can help people move past positions to underlying interests and find solutions that work better than anyone expected.
Appeal mechanisms matter. If a resident or family disagrees with a decision, they should have a clear path to challenge it. This may involve a formal appeal process, access to an ombudsman, or another available avenue. The existence of an appeal process often makes people more accepting of decisions they don't like because they know they have recourse.
Family involvement protocols should respect the autonomy of residents. Yes, family input is often valuable. However, unless a resident lacks capacity or has chosen to involve their family in decisions, the resident's voice takes precedence. Make this clear in your processes.
Risk management programs play a crucial role in promoting good ethical standards among senior living operators by establishing structured frameworks that identify, assess and mitigate potential risks associated with the care and management of elderly residents. These programs serve as a foundation for fostering a culture of accountability, transparency and integrity within senior living communities.
One of the primary functions of risk management programs is to ensure compliance with legal and regulatory requirements. By systematically monitoring adherence to laws governing resident rights, safety protocols and healthcare standards, operators can prevent unethical practices such as neglect, abuse, or fraud. This proactive approach not only safeguards residents but also reinforces the ethical responsibility of operators to uphold high standards of care.
Furthermore, risk management initiatives encourage the development of comprehensive policies and procedures that emphasize the importance of ethical decision making. These policies often include guidelines for staff conduct, reporting mechanisms for unethical behavior and methods for handling complaints. Such measures create an environment where ethical considerations are integrated into daily operations, promoting a culture of honesty and respect.
Training and education are integral components of effective risk management programs. Regular training sessions on ethical standards, resident rights and professional conduct help staff understand their ethical obligations and the importance of maintaining integrity in their roles. This ongoing education fosters a shared commitment to ethical practices among all staff and management levels.
Additionally, risk management programs facilitate the implementation of incident reporting and investigation processes. Transparent handling of incidents and errors encourages accountability and continuous improvement, reinforcing ethical standards by demonstrating a commitment to learning from mistakes and preventing future issues.
Informed consent is considered a key component of risk management in senior living and can significantly reduce liability for senior living operators when residents make care decisions that may seem risky. Informed consents provide written evidence that a resident and/or legal representative were fully informed of risk, benefits and alternatives of care decisions. The documentation can provide some protection from legal claims of negligence if a resident later experiences harm due to their choice. It is advisable for all senior living communities to work through their legal counsel experts to ensure that state and federal regulations are followed and informed consent forms and procedures address elder rights statutes, privacy laws like HIPPA.
In summary, risk management programs are crucial in promoting high ethical standards for senior living operators by ensuring compliance, promoting ethical policies, providing staff training and promoting transparency. These elements collectively contribute to creating a safe, respectful and ethically sound environment for both residents and staff, ultimately enhancing the quality of care and fostering trust within senior living communities.
This distinction is one of the most valuable tools for resolving conflicts.
When disagreements arise, people stake out positions — what they say they want. "I won't use a walker." "My mother needs memory care immediately." "This resident must follow our dining schedule." But positions are just the surface. Underneath are interests — why they want it — and that's where solutions hide.
The resident who refuses the walker? His position is clear, but his interests might be maintaining independence, avoiding stigma, or keeping up with his walking group. The daughter pushing for memory care might be terrified after her mother got lost, exhausted from worry, or trying to keep a promise to her late father. The community insisting on dining schedules might need to manage staffing, prevent complaints, or simply find it easier to coordinate.
When you focus on interests instead of positions, creative solutions emerge. The walker-refusing resident might accept a different mobility aid that feels less stigmatizing. The worried daughter might feel better with increased monitoring rather than an immediate move. The dining schedule conflict might resolve with a compromise on timing or location.
Getting to interests requires asking "why" and genuinely listening. "Help me understand what concerns you about using the walker." "What would make you feel better about your mother's safety?" "What would happen if we made an exception?" Sometimes you need to ask several times before reaching the real issue. The resident who says "I just don't like it" might eventually reveal the walker's clicking reminds him of his wife's oxygen tank.
Keep in mind that interests shift over time. The solution that worked six months ago might not fit anymore. Someone who refused help with bathing out of pride might later refuse it out of fear. Same position, different interest, requiring different solutions. Regular check-ins prevent minor misalignments from becoming major conflicts.
This approach transforms conflicts from battles over who's right into conversations about what matters. Instead of winners and losers, you create problem-solving partnerships.
Let's examine how these principles and practices are applied in real-life situations.
Mr. Jackson has heart failure. His doctor prescribed medication that will help him live longer and feel better. He refuses to take it. The staff is worried. His daughter is upset. She keeps telling them to "make him" take his medication.
First question: Does Mr. Jackson have the capacity to make this decision? You document his statements and behavior. You talk with him. He explains that the medication makes him feel weak and dizzy, and that he'd rather feel like himself for whatever time he has left than feel lousy to squeeze out a few more months. His reasoning is clear. He understands the consequences. He has capacity.
Next: What are the underlying interests? His position is, "I won't take the medication." His interest is feeling like himself and maintaining quality of life over quantity. The staff's position is "You should take it." Their interest is in keeping him healthy and fulfilling their responsibility for his well-being. His daughter's position is "Make him take it." Her interest might be avoiding the pain of losing her father, or feeling like she's doing everything possible, or honoring what she thinks he'd want if he understood better.
With this understanding, you have options. Could a different medication or adjusted dose reduce side effects while still providing benefit? Could you schedule the medication at a time when dizziness is less of an issue? Can you help the daughter understand that respecting her father's autonomy, even when she disagrees with his choice, is also a form of caring?
You document everything. You make sure he truly understands the risks. You involve his physician in the conversation. You offer to revisit the decision if he changes his mind or if his symptoms get worse. But ultimately, if he has capacity and has made an informed decision, you respect it — even though it's not the choice you'd make.
Ms. Williams, who has mild cognitive impairment, has started a romantic relationship with Mr. Chen. They hold hands at meals. They spend time in each other's apartments. Her daughter is furious, saying her mother would never behave this way and that Mr. Chen must be taking advantage of her.
Capacity becomes complicated here. Does Ms. Williams have the capacity to consent to this relationship? You observe how they interact. You talk with each of them separately. They both express genuine affection. They both clearly want to spend time together. Neither shows signs of coercion or pressure.
Her daughter's interests are protecting her mother and preserving her mother's dignity, according to the daughter's understanding of what that means. Ms. Williams' interests are companionship, affection and connection — basic human needs that don't disappear with age or cognitive changes.
The ethical principles pull in different directions. Autonomy says it's Ms Williams' choice. Beneficence could go either way, depending on whether you think the relationship benefits her. The daughter appeals to what she believes her mother's "real" values would be, but people's values and desires can change, and Ms. Williams gets to define her own values now.
If both parties have capacity and the relationship appears consensual, the staff's role is to support it while monitoring for any signs of exploitation or harm. This might mean educating the daughter about sexuality and relationships in older adults with cognitive changes. It might mean having frank conversations about safety and boundaries. It certainly means respecting Ms. Williams' right to make her own choices about relationships.
Mr. Rodriguez keeps his walker in the closet. He's fallen twice in the past month. Each fall creates enormous anxiety for staff and increases their risk of serious injury. He says the walker makes him look old, and he doesn't need it in his own apartment.
Safety concern? Absolutely. Does that override his autonomy? Not automatically.
Start with understanding. Why does he resist the walker? Is it vanity, as he says? Is it denial about his physical changes? Is the walker actually awkward or uncomfortable to use? Is he afraid of looking weak in front of other residents, and if so, could a different mobility aid work better?
What are the real risks? Two falls in a month are concerning. But were they serious? Did they happen in situations where a walker would've helped? What does his physician say about his actual fall risk?
What are the consequences of different choices? If you insist on using a walker, you might increase his safety, but you may also damage your relationship with him and his willingness to trust you about other things. If you do nothing, he might fall and hurt himself badly. Are there middle grounds? More frequent monitoring? Physical therapy to improve strength and balance? A different type of mobility aid? Removing fall hazards from his apartment?
This is also where organizational policies come in. Do you have a policy about fall risks? Is it flexible enough to allow for individual circumstances, or does it mandate specific interventions? If your policy's too rigid, you might need to reconsider it. If it's appropriately flexible, you have room to work with Mr. Rodriguez on a solution that respects his autonomy while also addressing legitimate safety concerns.
The key is treating him as a partner in problem solving rather than someone to be managed. "Mr. Rodriguez, I understand you don't like the walker. I'm worried about you getting hurt if you fall again. Can we talk about options that might work better for you?" is a very different conversation from "You need to use your walker or you'll have to move."
And remember why this matters. Every day, you're helping to create the environment in which people live the final chapters of their lives. When you get this right — when you honor autonomy while providing appropriate support, when you respect choices even when they're hard to watch, when you work through conflicts in ways that preserve dignity, you're doing more than following regulations or best practices. You're affirming that people remain people, worthy of respect and self-determination, throughout.
Navigating resident decision making isn't about finding the "right" answer to every situation. It's about asking the right questions, involving the right people and staying grounded in core principles even when they pull in different directions.
The work is challenging because it requires holding multiple truths simultaneously. We have a genuine responsibility for resident safety. Residents have genuine rights to autonomy. Families have legitimate concerns and perspectives. Organizations face real constraints. All of these can be true simultaneously, and honoring all of them requires nuance, judgment and often, a higher tolerance for uncertainty than we'd like.
The communities that handle this well share specific characteristics. They're clear about their values and transparent about their limitations. They invest in prevention — building relationships and having hard conversations before crises hit. They focus on understanding interests rather than just negotiating positions. They recognize that capacity is complex and decision-specific, not a simple yes-or-no judgment. They involve residents as partners in problem-solving whenever possible.
Most importantly, they start from a place of respect. Not the polite, superficial respect of calling someone "Mr." or "Mrs." That matters, but it's not enough. We're talking about the more profound respect that says, 'This person's life is their own.' Their values count. Their choices matter. Even when we disagree, even when we're worried, even when they're making a decision we'd never make — they remain the author of their own story.
That's not easy. It requires letting go of the idea that our job is to keep people safe above all else. Our job is to support people in living the lives they choose, with as much safety as they are willing to accept, for as long as they're able to choose. When capacity fades and choices need to be made for someone rather than by them, we make those choices in the way that best honors who they are and what they've told us matters to them.
None of this eliminates the difficulty of individual situations. You'll still face judgment calls where reasonable people disagree. You'll still have moments where every option feels flawed. You'll still lose sleep over whether you made the right call. That's the nature of ethics — it's not about avoiding hard choices but about making them as thoughtfully and humanely as possible.
The good news is that you don't have to do this alone. Build ethics into your team conversations. Consult with colleagues who bring different perspectives. Use ethics committees or consultants when you're stuck. Learn from each situation to handle the next one better.
That's not just good ethics. It's what we'd want for ourselves.
WTW hopes you found the general information provided in this publication informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, WTW offers insurance products through licensed entities, including Willis Towers Watson Northeast, Inc. (in the United States) and Willis Canada Inc. (in Canada).
This article may contain information or materials created or provided by third parties over whom Willis Towers Watson has no control or responsibility. These third-party information or materials are not under Willis Towers Watson’s control, and Willis Towers Watson is not responsible for the accuracy, copyright compliance, legality, or any other aspect of such third-party information or materials. The inclusion of such third-party information or materials does not imply endorsement of any third parties by Willis Towers Watson or any association of Willis Towers Watson with any third parties.
Jason Lesandrini, PhD, is an expert in ethics and leveraging innovative techniques to build ethical capacity, leaders, team and culture. Dr. Lesandrini provides leadership and resources to promote ethical behavior, decision-making and conduct aligned with organization's mission, vision and values.
As an educator, Dr. Lesandrini serves as a faculty member for the Physician Assistant Programs at Mercer University and South College and teaches undergraduates at Georgia Tech. He has also worked as an ethics resource for numerous national professional organizations including The American College of Healthcare Executives, The National Hospice and Palliative Care Organization, The American Board of Medical Specialties, and others.
