Integrating Supported Decision-Making into Advanced Directives and Estate Planning Documents: Empowering Seniors for Autonomous Aging in Place

Supported Decision-Making (SDM) is emerging as a vital innovation in elder law, offering seniors and their families a way to maintain control over life decisions even as cognitive or physical challenges arise. At its core, SDM is a voluntary process where an individual, such as a senior with early dementia or age-related impairments, selects trusted supporters (family, friends, or professionals) to assist in understanding complex information, weighing options, and communicating choices, without relinquishing final decision-making authority.  These supporters, often referred to as a person's support network, might be formal agents with authority to make decisions, or simply advocates and/or advisors, creating a collaborative framework tailored to the senior’s needs.  

Over the past decade, these agreements have evolved from relatively simple documents that merely identified supporters to substantive tools that integrate with detailed, advanced directives to weave a robust safety net for vulnerable persons and support seniors holistically.  Advance directives, once limited to health care and often focused solely on end-of-life decisions, have evolved to encompass financial management, aging-in-place preferences, dementia care, guardianship avoidance, and private care agreements.  SDM bridges gaps in standard planning documents and strategies,  fortifying them while offering additional layers of protection, whatever the planning objective. This shift relieves caregivers of the more difficult tasks of setting or balancing goals, allowing them to concentrate on the tactical execution of pre-established wishes.  

As our blog has explored in "Rethinking Elder Abuse Strategies: How Prophylactic Planning Can Safeguard Autonomy and Aging in Place," good planning adopts a range of solutions to address problems, weaving a safety net against failure. Incorporating SDM into advanced directives and other planning solutions can support a senior in ways no other single plan or effort could. This article defines SDM, its significance for seniors and families, and how to integrate it into advance directives and estate planning documents for holistic planning. 

SDM for Seniors and Their Families: A Path to Empowered Choices
For seniors, SDM represents a shift from paternalistic and institutional models to a partnership model, enabling them to remain engaged in decisions about healthcare, finances, and daily living despite challenges such as mild to moderate cognitive impairment. It builds self-confidence through skill-building in problem-solving and goal-setting, while studies show it enhances independence and quality of life. Families benefit by serving as supporters without assuming full control, avoiding the resentment or burnout common in informal caregiving. In practice, SDM can adapt over time, beginning with advice on routine matters and evolving as needs change. This adaptability makes it ideal for aging in place, where home-based decisions like hiring aides or modifying living spaces are key. Unlike rigid advance directives focused on medical crises, SDM encourages ongoing dialogue, aligning with the blog's emphasis on preventing exploitation through proactive tools.
For more information regarding the risks and consequences of guardianship, and how to avoid unnecessary and risky institutionalization, attend an Aging in Place Planning Workshop. Benefits of Integrating SDM with Advanced DirectivesAdvanced directives, such as living wills or healthcare powers of attorney, traditionally address end-of-life preferences but often overlook everyday or evolving needs. By integrating SDM, these advance directives become more dynamic:

• Holistic Coverage: SDM expands beyond medical choices to include financial (e.g., budgeting for home care), aging in place, cognitive care, guardianship utilization, caregiver agreements, as well as other legal decisions (e.g., asset protection), filling gaps in standard directives.

• Dementia Care:  By integrating advanced directives for dementia with SDM, seniors provide robust direction as conditions evolve and needs change. 

• Guardianship Prevention: It serves as an alternative or supplement to guardianship, reducing court intervention risks as highlighted in our "Guardianship Abuse" article.

• Family Collaboration: Supporters can assist in understanding complex options, like experimental treatments or mood-altering drugs, ensuring decisions reflect the senior's values.

• Adaptability for Aging in Place: SDM directives and agreements can specify preferences for home-based support, avoiding institutionalization, or preferring the least institutional setting possible for care.
• Care Choices: SDM directives can create different considerations for care choices, often made based on expense, convenience, and/or proximity, requiring instead consideration of factors that are more reliable indicators of favorable outcomes with reduced risk.  

Outcome Benefits

This integration is not just a better process, though it also offers benefits such as reducing stress and minimizing disputes.  Empowering seniors to direct their care trajectory and foster resilience against cognitive changes means more positive outcomes with less health, financial, and legal risk. The contrast in possible outcomes could not be more apparent.  Traditional guardianship, for example, can strip rights and lead to abuse; SDM promotes self-determination by treating support as an enhancement of capacity, not a replacement, thereby nicely resolving the risks of institutional guardianship.  Similarly, unlike traditional aging-in-place approaches, which often abandon autonomy for convenience, SDM empowers directed decision-making, leveraging home care to prevent short-term institutionalization. For instance, a senior with mobility issues might use SDM to choose home-based physical therapy over a rehabilitation stint in a nursing home, supported by a caregiver agreement incentivizing in-home care. 

While traditional care-site selection often prioritizes proximity or ease, SDM encourages a robust investigation of factors that impact outcomes, including for-profit status and private equity ownership of institutions. Care roles shift too: SDM builds a strategic network of supporters rather than a monolithic, almost dictatorial decision-maker, enhancing coordination and reducing the risk of caregiver burnout. In dementia care, traditional reactive, costly, institution-focused approaches contrast with SDM-driven, proactive, home-centric strategies that use lifestyle and behavioral therapies and the implementation of supportive technology to prevent cognitive decline, prioritizing physical, psychological, and emotional support in the least institutional setting possible.  For seniors, this means retaining dignity and independence, allowing them to age in place with confidence. For families, it fosters collaborative roles, reducing the emotional burden of sole decision-making and preventing conflicts. 

Legal Frameworks: State Variations and RecognitionSDM is rooted in human rights principles, such as the UN Convention on the Rights of Persons with Disabilities, and is legally recognized in states like Colorado, where agreements are presumed valid unless made under guardianship. In Colorado, SDM can complement powers of attorney or conservatorships, with agreements requiring notarization or the presence of witnesses to ensure voluntariness. Other states, such as Delaware and Texas, have similar statutes. At the same time, Missouri and Ohio may honor SDM informally through limited guardianships and less intrusive/restrictive alternatives. Nationally, the Administration for Community Living (ACL) promotes SDM as a rights-based model. When incorporating into directives, ensure compliance: agreements can't imply incapacity and must include provisions for mistreatment reporting.Creating an SDM with Integrated Advanced DirectiveTo build this, start with a standard directive and add SDM elements:

• Select Supporters: Choose trusted individuals based on strengths (e.g., one for health, another for finances.  Consider supporters based on strategic or task-oriented involvement.

• Define Roles and Scope: Specify assistance areas, like evaluating treatment risks or communicating with doctors, without decision-making power.

• Holistic Integration: Include preferences, goals, objectives, and specific directions or guidelines in making or implementing decisions (e.g., for experimental treatments, authorizing trials if benefits outweigh risks or for psychosocial care, prioritizing non-pharmaceutical drug interventions, but only for hallucinations or ideations that create a threat of harm to yourself or others).

• Legalize and Review: Notarize, align with POAs, and update annually.

• Periodic Review and Revision:  Review your directions ansd dupporters to ensure that your wishes are clear, correct, and supported by the appropriate people. 

Review the standard and specific advanced directives we have offered as models, revising them as necessary or appropriate.  Consult with an elder lawyer to ensure integration with your estate planning documents, and with a financial advisor to ensure availability of funds to implement decisions.  Finally, discuss your planning goals, objectives, conditions, and needs with a Medicare Specialist to ensure you are maximizing your supporters' ability to fulfill your wishes.  

 

Challenges and Safeguards
Challenges include limited state recognition, risks of undue influence, and access barriers for isolated seniors. Safeguard with multiple supporters, revocation clauses, and attorney oversight.
While this article has provided a general examination of SDM and its integration into advanced directives, it is by no means comprehensive. The landscape of decision-making tools evolves rapidly, influenced by legal reforms, state policies, and individual circumstances, and no single resource can fully capture it. Therefore, remain vigilant and continuously educate yourself through reliable sources such as the ACL, AARP, and local elder law attorneys, while regularly evaluating your personal situation to identify potential risks. By combining awareness with tools, seniors and their families can better safeguard independence and thrive as they age in place. For ongoing support, consult professionals and stay informed.  Your security depends on proactive engagement.

CCRC Contract Pitfalls: Tennessee Court Ruling Highlights Risks for Seniors and the Power of Proactive Planning

Imagine signing a life care contract with a continuing care retirement community (CCRC), paying a hefty "lifetime use fee" for the promise of seamless care from independent living to nursing home, all under one roof, without escalating costs. Now picture this: Your spouse passes away early, your health declines, and despite available beds, you're stuck in your apartment, shelling out $137,000 for private nurses because your conservator honors your wish to stay put until a "better" facility opens. When you sue for reimbursement, the court sides with the CCRC, citing the contract's fine print—no refund, no breach. This isn't a nightmare scenario; it's the reality for Susan Anderson in the recent Tennessee Court of Appeals case Susan Anderson v. Ascension Health-IS, Inc., decided September 11, 2025. 
For seniors and families navigating aging in place or CCRC options, this ruling is a wake-up call: Contracts can lock you into obligations that prioritize facility benefits over your autonomy, potentially draining savings and sparking costly disputes.  This article unpacks the case, its consumer consequences, and strategies beyond aging in place to mitigate risks, emphasizing prevention over litigation.The Case: A 'Lifetime' Promise That Didn't Deliver
In 2011, Susan and Ralph Anderson signed a Lifecare Plan with Alexian Village of Tennessee, a CCRC owned by Ascension Health-IS, paying $237,200 upfront for unlimited access to independent living, assisted living, and nursing care, plus monthly fees for amenities. The contract promised no additional charges for escalating needs, with a refund schedule if terminated, but only if all residents occupying the apartment ended the agreement. Ralph died in 2013, just 18 months in. Susan's health soon deteriorated, requiring constant care. From April to October 2014, she stayed in her apartment, incurring over $137,000 in private nursing costs (including from Alexian staff) because no nursing bed was "ideal" despite available rooms communicated to her conservator.
The conservator was appointed in April 2014, but the 2011 contract nonetheless governed. Susan sued in 2018, claiming breach (no refund after Ralph's death, overcharges, and failure to transfer), financial exploitation of the elderly, negligence (i.e., personal injury or malpractice), and improper fees. Alexian countered by filing a motion for partial summary judgment, arguing that the contract's plain language barred refunds and transfers, which were optional. The trial court agreed and certified the ruling as final. On appeal, the Tennessee Court of Appeals affirmed, emphasizing unambiguous contract interpretation: No refund without complete termination (no written notice given); transfers were "permissive," not mandatory; and the conservator's choice to delay amid available beds negated breach. Financial exploitation failed as derivative of the contract claims. Health liability claims proceed, but the ruling protects the CCRC.Consequences for Consumers: Financial Traps and Autonomy Erosion
For seniors eyeing CCRCs, this case exposes harsh realities: "Lifetime" fees aren't refunds on death, and "seamless care" isn't guaranteed.  Delays can bankrupt you or worse. 
Consequences include:

• Unexpected Costs: No partial refund after a spouse's death leaves survivors paying full monthly fees for unused space, plus private care bills ($137K here). With CCRCs averaging $300K+ entry fees, this can wipe out savings meant for home care or heirs.
• Exploitation Risks: The ruling dismisses financial exploitation tied to contract breaches, but it signals how facilities can exploit ambiguity, e.g., permissive transfers shifting the burdens of risk and loss to residents. Amid a 2024 OIG report showing 24% of facilities failing staffing standards, delays exacerbate neglect risks.
• Autonomy Loss: Conservators or courts interpret "best interests" narrowly, often overriding wishes without directives. Here, Susan's preference to wait for a more suitable room cost dearly; without planning, families face similar dilemmas amid caregiver burnout.
• Litigation Toll: Even partial wins for providers drag cases, with costs exceeding $50K, eroding estates and delaying care.

The problem is widespread: A 2023 GAO report notes inconsistent CCRC regulations, with 20% of contracts lacking clear refund terms, leading to $500M+ in disputes annually. Financially strained facilities (80% operating at 90% capacity per 2025 Argentum data) prioritize revenue, delaying transfers amid $159K/year nursing home costs.

How Delays Exacerbate Neglect RisksDelays refer to situations when care isn’t provided promptly, whether it’s waiting for a transfer to a higher care level (like from independent living to nursing care), a staff response to a fall, or medical attention for a worsening condition. In the context of the Anderson case, Susan Anderson’s delay in moving to an available nursing bed, given her declining health, led to $137,000 in private care costs and her eventual vulnerability. Here’s how and why these delays amplify neglect when staffing is inadequate:

• Slower Response Times

• Why: With only 76% of the required staff, nurses and aides are stretched thin, juggling multiple residents. A call for help might wait 20 minutes rather than 5.
• How it Hurts: A senior who falls and lies unattended risks physical injuries, pressure sores, as well as psychological or emotional trauma. In Susan’s case, delayed nursing care likely worsened her frailty, mirroring the statistical findings of more fall-related injuries in understaffed facilities.

• Unaddressed Health Decline

• Why: Fewer staff means less time for regular checks, blood pressure, hydration, or wound care might be skipped.
• How it Hurts: Conditions like infections or malnutrition (as in the Kansas neglect case) fester. Susan’s risk of emaciation could have escalated without timely intervention, a pattern also associated with staffing shortages.

• Overwhelmed Care Coordination

• Why: Delays in transferring to higher care (e.g., waiting for a “better” facility) strain existing staff, who can’t adapt to escalating needs.
• How it Hurts: In Susan’s situation, the conservator’s choice to delay despite an available bed left her dependent on costly private care, while understaffing at Alexian might have delayed basic support, heightening neglect risks like untreated pneumonia.

• Emotional and Physical Isolation
  • Why: Staff shortages limit social interaction or assistance with mobility, leaving residents isolated longer.
  • How it Hurts: Isolation worsens mental health, reducing a senior’s ability to signal distress. Higher depression rates are often linked to understaffed homes, a neglect precursor.

The Connection: Why Delays Amplify the ProblemDelays don’t just slow care; they compound the effects of understaffing. With only 80% staffing, a facility might manage routine days, but delays (e.g., waiting for a transfer or a staff shift) create bottlenecks. Residents with urgent needs like falls, infections, or dementia episodes wait longer, and the already thin staff can’t catch up. This creates a vicious cycle: neglect (e.g., missed meals) leads to worse health (e.g., weakness), which demands more care that the facility can’t provide, deepening the neglect. In Susan’s case, the delay in transfer, even if voluntary, amid a potentially understaffed environment, likely contributed to her vulnerability, aligning with findings that staffing failures directly correlate with higher neglect incidents.Takeaway for SeniorsThis interplay means delays aren’t just inconveniences.  They’re neglect amplifiers in understaffed settings. For aging in place, it’s a reminder to avoid facilities where staffing risks lurk by carefully evaluating institutions.  Use our toolkit, "Choosing a Nursing Home or Skilled Nursing Facility: Navigating the Long-Term Care Crisis." Of course, aging in place is still a superior plan to avoid the risks altogether, starting with legal tools such as advance directives regarding aging in place, dementia care, guardianship, and health/end-of-life care incorporating supported decision-making (SDM), and trusts and powers of attorneys for asset and property management and preservation. 

Strategies to Avoid CCRC Risks: Beyond Aging in PlaceWhile aging in place is ideal, not all can; here are strategies to sidestep CCRC traps:

• Scrutinize Contracts Pre-Signing: Demand clear refund/termination clauses (e.g., partial on death); use attorneys to negotiate "permissive" language into mandatory. Review with elder law attorneys before signing.

• Build in Conservatorship/Guardianship Safeguards: Nominate a trusted agent in a durable power of attorney; include "veto rights" for transfers, and fund private care via trusts.  Draft trusts to eliminate a guardian exercising your rights to, among other things, amend your trust or remove assets from the trust.

• Use Trusts for Financial Firewalls: Create trusts with preferences and incentives for non-institutional care clauses, earmarking funds for home or alternative care; irrevocable trusts shield assets from penalties.  Permit and encourage private care plans, empowering your agents with guidelines and authority to negotiate and execute them. 

• Leverage SDM Agreements: Formalize family input via SDM, ensuring decisions reflect wishes without court; nominate supporters for care disputes.

• Explore Alternatives: Consider life care at home via Medicaid HCBS waivers.  Explore hybrid models like "pocket neighborhoods" that blend community without full CCRC commitment.

• Financial Exploitation Shields: Include penalties in trusts for family/facility actions violating wishes; report suspicions via state APS.

• Leverage Medicare Advantage Plans: Explore and select MA plans that fund hospital at home, Smart Home Health Care, home health, disability, and in-home exercise.

• Protect your Cognitive Health:  Make lifestyle changes, and embrace technology!

These steps empower consumers, turning "lifetime" contracts and decisions into true lifelines. Implement a plan today!