Caregiver Decision Fatigue

Caring for aging parents brings with it a new kind of exhaustion called decision fatigue. While its cause has a number of contributing factors, two in particular stand out as primary sources:

• Sustained engagement with dilemmas
• Decision volatility in family systems

Although demanding and stressful, the problems of aging can be contained or eliminated. Lost prescriptions can be refilled. Unsafe staircases can be modified. Transportation for an unscheduled medical testing can be arranged. Solving problems means eliminating uncertainty and most caregivers are well versed in how to do this.

In sharp contrast, the dilemmas of aging defy containment or elimination. They demand sustained engagements with uncertainty, a challenge most caregivers are ill equipped to handle. Consider the following example:

An 84-year-old woman is scheduled to seen by her doctor at her family’s request over her unwillingness to use a walker. She has an unsteady gait, a history of falls and significant bone loss. She lives alone with the assistance of home care services. Her family has tried a number of approaches to get her to use the walker, but she has rejected all of them because she feels it makes her look old and frail.

This situation typifies the nature of the dilemmas, which present as:

• Complex and messy
• Threatening
• Unsolvable
• No-win options
• Decisions must be made

As the family of the 84-year-old woman scrambles to head off a disastrous fall, their challenge goes beyond engaging a dilemma. They must also address how decisions regarding the walker will play out in the family system.

By definition, families are complex systems whose behavior impacts the receptivity and response to intra-family decisions. These behaviors include:

• Non-linear reactions—Seemingly minor decisions can carry major consequences. The decision to have the family’s matriarch see the doctor was made by her two daughters without consulting their brother. The daughters were certain their brother would agree with their plan. He and his wife didn’t, and it provoked a heated argument between the sibling’s families about who has the authority to make these kinds of decisions as well as who has the authority to override their mother’s wishes.

• Resistance to dictates—Solutions in family systems cannot be dictated. Rather, they must emerge through an idiosyncratic consensus ritual. The flair up over the doctor’s appointment is emblematic of how seemingly benign dictates can rain havoc in the system.

• Structural instability—Even the most promising solutions fall apart without warning. Collective consensus in family systems is fragile with emotional crosscurrents and unsettled agendas poised to collapse even the most adventitious decisions. Push back from family members about the lack of communication and consensus regarding the need for the doctor’s appointment resulted in bitter recriminations and the appointment’s cancelation.

Given the stress and complexity of dilemma management within family systems, what are some strategies caregivers can adopt to reduce decision fatigue?

• Reorient the big picture—Caring for aging parents involves sustained engagement with uncertainty on an unstable playing field. The rules and expectations of stable, problem dominated environments do not apply. This means success needs to be redefined to allow for messy outcomes and wobbly consensus.

• More dancing, less wrestling—The metaphor for engaging dilemmas in family systems is dancing instead of wrestling. Attempts to impose solutions or outthink the structure are doomed and only accelerate and intensify decision fatigue. Honoring the nature of dilemmas by acknowledging that imperfect choices have to be made reduces the endless recrimination over outcomes that are beyond anyone’s control. Honoring the nature of family systems by acknowledging that all caregiving decisions are vulnerable to emotional crosscurrents reduces exhaustive attempts to craft perfect and lasting consensus.

• Shrinking the horizon—In the non-linear world of dilemmas and family
systems, recalibrating the horizon can reset expectations that may have become distorted and emotionally punitive. The reality is that caring for aging parents occurs one day at a time. Recasting the horizon to a daily dance based on “doing the best I can do with what I’ve got” honors our best intentions while restoring a sane estimation of our capacity and limits.

• Reorient self-care—Sustained engagement with dilemmas in family systems is not possible without a recovery ritual. Without one, caregiver morbidity and mortality rapidly and tragically declines. While recovery rituals vary in style and content, they all share a common theme. Rest, nurturing relationships, and enjoyable activities. The noble call to do the right thing for aging parents should always include the preservation of the physical health and sanity of the caregiver.

• Partner Up—Sustained engagement with dilemmas in family systems is always better with the non-judgmental support of those who have walked the same path. Caring for aging parents is a long game full of dark vignettes, dramatic reversals and thankless service. It is not designed for solo heroics or the faint of heart. Partnering up one on one or in a small group setting is a personal breakthrough for both caregivers and aging parents.