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.

Rising Malpractice Claims in Assisted Living: A Stark Incentive for Robust Aging-in-Place Planning

A recent report from the Nurses Services Organization and CNA Financial Corp. reveals a troubling 32% increase in malpractice claims against assisted living nurses from 2018 to 2023, with claims frequency rising to 0.71 per 100 beds and average severity reaching $284,000. Common allegations include falls (28%), pressure injuries (17%), and wrongful death (15%).  A majority of nurse professional liability claims involved treatment/care allegations (56.2%). The second most frequent category of allegations involved patients’ rights/abuse/professional conduct claims (18.2%). These trends, highlighted in McKnight's Senior Living article on October 2, 2025, underscore systemic vulnerabilities in institutional care settings, where understaffing and complex health needs heighten the risk of neglect and errors. Among the drivers of these claims is "increasing resident acuity," specifically  "acuity mismatches." 
Acuity and Acuity Mismatch
In healthcare, acuity refers to the severity or complexity of a resident's health needs, encompassing physical, cognitive, and emotional conditions. An acuity mismatch occurs when a resident's care needs exceed the capabilities, resources, or staffing levels of the assisted living facility in which they reside. In the context of the CNA report, acuity mismatches arise when facilities accept or retain residents with complex conditions, such as advanced dementia, severe mobility limitations, or chronic illnesses requiring intensive medical oversight, without adequate staff training, numbers, or infrastructure to provide appropriate care. 
A resident with significant cognitive impairment, for example, might require one-on-one supervision to prevent falls or wandering.  An understaffed assisted living facility, however, may lack the personnel or specialized training to meet these needs. This mismatch can lead to neglect, errors, or inadequate monitoring, resulting in incidents like falls,  pressure injuries, or even wrongful death.  These outcomes comprised the vast majority of claims in the study. 
How Acuity Mismatches Drive Malpractice Claims
Acuity mismatches contribute significantly to malpractice claims because they create conditions where care failures are more likely:

• Inadequate Staffing: Facilities often operate with low staff-to-resident ratios, unable to meet high-acuity needs. For instance, a resident requiring frequent repositioning to prevent pressure sores may be neglected if staff are stretched thin, leading to costly claims averaging $284,000.

• Lack of Specialized Training: Nurses may lack expertise in managing advanced dementia or complex medical conditions, increasing risks of errors like improper medication administration or failure to recognize warning signs.

• Facility Misalignment: Assisted living communities are designed for residents needing moderate support, not intensive medical care. Unfortunately, care needs change.  Accepting or retaining high-acuity residents without transferring them to better-oriented assisted living facilities or skilled nursing facilities can result in injury and claims.

• Regulatory Gaps: While states like Missouri have tightened oversight with 2025 laws mandating better staffing and reporting, enforcement varies, and many facilities struggle to comply.  Facilities failing to comply with standards and regulations may leave residents with less capable staff that might be necessary to meet individual and collective needs, heightening malpractice risks.

These mismatches directly fuel claims, as families pursue legal action when loved ones suffer harm due to preventable oversights. The 32% rise in claims frequency reflects how acuity mismatches, combined with other institutional challenges, like staffing or training deficits, create a perfect storm of liability in assisted living settings.
For readers of the Aging-in-Place Planning and Elder Law Blog, this surge serves as a powerful incentive to prioritize home-based strategies that minimize exposure to such hazards inherent in institutional care. As discussed in our "Rethinking Elder Abuse Strategies: How Prophylactic Planning Can Safeguard Autonomy and Aging in Place," proactive tools such as trusts and powers of attorney can help avoid institutional pitfalls altogether. This article examines the report's findings and offers practical guidance for leveraging aging-in-place planning to mitigate these risks.The CNA Report: Escalating Risks in Assisted LivingThe study, analyzing claims data from its Aging Services program, attributes the rise to chronic staffing shortages, exacerbated by post-pandemic turnover, and to residents with higher care needs, such as those with dementia or mobility issues. Falls remain the top claim, often linked to inadequate supervision, while pressure injuries highlight gaps in routine care. Wrongful death claims, though less frequent, carry the highest severity, resulting in significant payouts due to allegations of negligence. Industry leaders like Argentum note that these trends reflect broader challenges, including regulatory pressures and workforce deficits, which could lead to higher insurance premiums and operational costs for facilities.
For consumers, this means that assisted living, once viewed as a safe middle ground between independent living and nursing homes, now carries growing liabilities and risks. The report recommends enhanced training, improved risk assessment, and technology integration (e.g., fall-detection systems) to curb claims.  Still, these fixes don't eliminate the inherent risks and uncertainties of institutional environments.Why the Findings Incentivize Aging-in-Place PlanningThe rising number of malpractice claims is a wake-up call: institutional care, despite regulations, remains prone to human error and systemic flaws that can result in harm and legal battles. These risks are not unique to nursing homes. Aging in place offers a compelling alternative, allowing seniors to control their environment and care, reducing risks like those highlighted in the CNA report. By planning ahead, you can avoid the emotional, physical, psychological,  legal, and financial toll of facility-based mishaps, preserving autonomy.
Key incentives from the report:

• Reduced Exposure to Neglect: Home settings minimize risks through targeted modifications like grab bars or smart sensors, unlike understaffed facilities.
• Customized Care: Family or vetted caregivers can provide personalized attention without the acuity mismatches driving claims.
• Financial Savings: Avoiding high-severity incidents cuts potential medical and legal costs, redirecting funds to home supports.

Practical Strategies: Building a Resilient Aging-in-Place PlanTo harness this incentive, integrate elder law tools into your planning strategy. Establish trusts, advance directives with supported decision making  (SDM), dementia, aging in place, and guardianship directives.  Consider powers of attorney with safeguards. Include health care powers of attorney to outline home-based preferences and prevent forced institutionalization.
Invest in aging-in-place planning technology, medical devices, and security devices and monitors to secure home caregiving. These steps not only mitigate malpractice risk and dangers but also align with the CNA's call for better preparation in senior care.
While this article has provided a thoughtful examination of the rising malpractice claims in assisted living and their role as an incentive for aging-in-place planning, it is by no means comprehensive. The landscape of care risks evolves rapidly, influenced by staffing trends, regulatory changes, and individual circumstances that no single resource can fully capture. Readers, therefore, must remain vigilant, continuously educating themselves through reliable sources like CNA reports, AARP, local elder law attorneys, and this Blog, while regularly evaluating their personal situations to identify potential risks. By combining awareness with tools such as legal safeguards, caregiver screening, and home modifications, seniors and their families can better safeguard independence and thrive as they age in place. For ongoing support, consult a professional and stay informed.  Your security depends on proactive engagement.