The family is a complex unit comprised of individuals with varied cognitive, emotional, and behavioral characteristics and abilities that can greatly affect family decision-making across an individual’s life-span. “Decision-making” describes the process by which families make choices, judgments, and ultimately come to conclusions that guide behaviors. Family decision-making implies that more than one member’s input and agreement is involved (Scanzoni & Polonko 1980). The decision-making process is centered on core communication processes involved in creating shared meaning. In the decision-making process, families can acknowledge the differences among members and negotiate their needs for closeness and independence (Baxter & Montgomery 1996).
Nature of Family Decisions
Aspects of verbal (e.g., words, syntax) and nonverbal communication (e.g., eye contact, tone, vocalics, gestures, expressions, etc.), listening (e.g., passive or active), and conflict (e.g., collaborative, competitive, or avoidance) negotiation skills play important roles in the myriad of family decision-making across the life-span. Such elements range from everyday decisions such as where to live, to rent or buy a home, and which schools or universities to attend, to increasingly life-altering decisions such as whom to marry or whether or not to have children and how many. Difficult family decisions are made when faced with more multifaceted family issues ranging from “should mom move into our household because she can no longer independently take care of herself” to excruciatingly difficult chronic health and end-of-life decisions such as treatments for a cancer diagnosis or a “do not resuscitate” (DNR) decision. Such decisions are made either within the family unit or in consultation with extended family from birth to end-of-life.
Decisions within families can be classified into types such as: instrumental, affective, social, economic, and technical. Instrumental decisions are those that focus on issues of money, health, shelter, and food for the family members (Epstein et al. 1982). Affective decisions deal with choices related to feelings and emotions such as deciding about getting married. Social decisions typically consist of decisions related to the values, roles, and goals of the family (see, e.g., Noller & Fitzpatrick 1993). Such decisions may include whether the children will be raised going to one church or another or whether one parent will stay at home while the children are preschool age. Economic decisions focus on choices about using and gathering family resources, such as whether an adolescent should get a job and contribute to the family income or buy his or her own car. Technical decisions consist of the smaller decisions that must be made to carry out a larger decision. For instance, if a family decides that one member must stop working in order to go back to school for an advanced degree, then a series of technical decisions must be made so the larger decision will materialize (Noller & Fitzpatrick 1993). Families use a variety of decision-making processes ranging from using familiar approaches over and over to more varied methods depending on the type of decision, their emotional state, and most often their stage of development across the life-span, from when the children are babies to when they are in school to midlife and later-life issues.
Decision-Making in Earlier Family Life
The temperament and disposition of each child can greatly vary within the same family. Consequently, the relationship between parents and different siblings is dynamic and unique, with each individual responding to and modifying the behavior of the other (e.g., Pecchioni et al. 2005). Family decision-making processes are a two-way street with parents influencing communicative patterns of their children and vice versa. Joint decision-making and autonomy are best achieved through collaborative problem-solving, parental modeling, negotiation, and compromise (e.g., allowing the child to decide when to set the table or when to walk the dogs; Crockenberg et al. 1996).
When children are given opportunities for decision-making in areas that matter less, they are more likely to conform to parental expectations that matter more. Conflict resolution in collaborative decision-making between parents and children has been found to play out in later childhood in the resolution of peer-group interpersonal issues (e.g., Kochanska 1992). Developmental stages and child dispositions are important factors to consider in family decision-making in the early years of family life. As children grow older and more mature, they can be granted more autonomy and play a larger role in individual and family decision-making (Baumrind 1996).
Decision-Making in Later Family Life
Research has consistently shown that serious illness impacts the lives of patients, their families and loved ones, with a number of scholars making the argument that serious illness is indeed a family issue (e.g., Sparks & Pecchioni 2007). Serious illnesses such as a cancer diagnosis add demands, strains, and hardships to families who must deal with numerous changes and decisions that impact the entire family. Families are often uniquely qualified in terms of understanding patient attitudes and decision-making strategies and can therefore assist as an important resource in helping the patient to make better decisions about their care (Blustein 1998).
In a review of variables affecting family decision-making and family dynamics in later life, Rothchild (1994) found that there are a range of factors confronting families as they decide about terminal care of a family member. Many families react to their sense of guilt and hopelessness by pushing for maximal medical intervention until the end of life. This often results in patient failure to resist such pressure and persuasion, consequently accepting treatments that they very likely would not have chosen on their own. Rothchild claims that family decision-making is impacted according to the following variables: (1) patient’s role in the family (boss, scapegoat, caregiver), (2) ages of patient and family members, (3) family continuity and cohesion, (4) who is considered to be “family,” (5) how information and decisions are shared within the family, (6) presence of denial, guilt, and anger, (7) communication of treatment wishes to proxies, (8) comfort with sophisticated technology, (9) ethnicity and religion, and (10) economic pressures.
Family decisions are negotiated every day from family decisions in the childhood and adolescent years to middleand later-life family decisions, many of which occur in healthcare environments. Family decision processes in the health-care environment are particularly difficult and complex because of the uncertainties, emotions, technical language, and subsequent health outcomes (e.g., Sparks 2003). Conflicting information from various sources can be difficult to navigate and process to make the most informed health-care decisions. Families make decisions about health issues using information from a variety of sources, including insurance provider lists, internet research, recommendations from primary care physicians and specialists, interpersonal communication with friends and family members, and mediated messages (see Pecchioni & Sparks 2007).
Individuals and their family members process the uncertainties involved in health-care decision-making in different ways due to individual differences in message processing and the history of family member dynamics. For example, developing the most effective communication to encourage detection and prevention of a health concern assumes that the patient will engage in message-relevant thinking (see, e.g., Sparks & Turner, in press). Early research on persuasive message processing focused on issues such as the time and attention allocated to the message, the comprehension of the message content, and the acceptance of the message conclusions (Todorov et al. 2002). Even though people can carefully process messages they do not always do so. Individuals who process messages systematically will think carefully about the message and engage in thoughts and judgments that are relevant to the message content. Individuals are economical and will only invest in the cognitive effort required to complete the current task. In order to engage in systematic processing people must be suitably motivated, and have adequate cognitive resources.
If messages are perceived to have features that are high in quality or very appealing, the message receiver should generate positive ideas and opinions. If the message is reviewed to have features low in quality the thoughts generated by the message will be negative, leading to less influence or a different outcome. Thus, systematic processing is the highest pursuit of cognitive processing. Systematic processing of messages occurs in various ways. Cognitive processes refer to such information processing activities such as perceiving, abstracting, judging, elaborating, rehearsing, and recalling from memory. If one can motivate careful processing, message receivers will engage in message elaboration and engage in the recommended actions, which will result in more effective decision-making and long-term change. For family decision-making related to an emerging or chronic health issue, this could mean the difference between (1) early detection of alcohol abuse and living, or failing to detect alcohol abuse and dying; (2) early detection of heart disease and living, or failing to detect heart disease and having a heart attack; or (3) early detection of cancer and living, or failing to detect cancer and dying. In addition, the role of the family in the decision-making process in the initial stages that surround the end of life can be particularly important as the care-giving team is often comprised of the patient’s family, loved ones, and interdisciplinary health-care teams (Connor et al. 2002).
Family Decision-Making Solutions to Consider
Family decision-making has become increasingly complex as family life has dramatically changed over the last several decades. Changing roles of women, increasing integration of women in the labor force, increases in divorce rates, increased mobility, increased longevity, and complex health-care environments are just some of the crucial changes that are impacting families and thus, arguably, impacting family decision-making across the life-span. Where does this leave family decision-making in the twenty-first century?
A few final thoughts that families should consider when implementing decision-making processes: (1) identify the issue, (2) understand all possible alternative strategies and options, (3) achieve satisfaction in choosing the best strategy for the family, (4) enact an action plan for implementing the decision, (5) evaluate the decision and refine as needed. These are a few simple steps to get families started in decision-making processes. However, more evidence from empirically based studies is needed to substantiate ways in which family decision-making processes are impacted by and impact individuals and their family units in our increasingly complex multicultural society.
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