title: Sense of Control in End-of-Life Decision-Making.
abstract: OBJECTIVE
  To explore how older adults in the community with a limited life expectancy make healthcare decisions and the processes used when they are not in an acute crisis.
  
  
  METHODS
  Grounded theory.
  
  
  METHODS
  Medical programs and geriatrics clinics at the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center.
  
  
  METHODS
  Community-dwelling adults aged 67 to 98 with a life expectancy of less than 1 year (N = 20).
  
  
  METHODS
  In-depth semistructured interviews in participants' homes. Constant comparative analysis was used to develop codes and identify themes.
  
  
  RESULTS
  Participants generally delegated decisions to others, expressing their wishes by describing desired end-of-life outcomes and highlighting meaningful aspects of their lives. They did this in the belief that the delegate would make appropriate decisions on their behalf. In this way, participants were able to achieve a sense of control without being in control of decisions. Four themes emerged from the analysis that reflect the various approaches participants used to articulate their goals and maintain a sense of control: direct communication, third-party analogies, adaptive denial, and engaged avoidance.
  
  
  CONCLUSIONS
  These findings challenge the prevailing view of personal autonomy. These older adults suggest a path to decision-making that focuses on priorities and goals, allowing them to take a more-passive approach to decision-making while still maintaining a sense of control.
authors.affiliation: Department of Physiological Nursing, School of Nursing, University of California San Francisco, San Francisco, California.|Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California.
authors.forename: Rafael D
authors.initials: RD
authors.lastname: Romo
authors.affiliation: Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California.|Department of Family and Community Medicine, University of California San Francisco, San Francisco, California.
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Allison
authors.affiliation: Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California.|Geriatrics, Palliative and Extended Care, San Francisco Veterans Affair Medical Center, San Francisco, California.
authors.forename: Alexander K
authors.initials: AK
authors.lastname: Smith
authors.affiliation: Department of Physiological Nursing, School of Nursing, University of California San Francisco, San Francisco, California.
authors.forename: Margaret I
authors.initials: MI
authors.lastname: Wallhagen
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D000369:Aged, 80 and over; D001293:Attitude to Death; D003657:Decision Making; D005260:Female; D066296:Grounded Theory; D006801:Humans; D008297:Male; D026684:Personal Autonomy; D013727:Terminal Care; D019452:Terminally Ill / Q000523:psychology*
keywords: decision-making; end-of-life care; qualitative research; sense of control