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Objectives 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. Design Grounded theory. Setting Medical programs and geriatrics clinics at the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center. Participants Community-dwelling adults aged 67 to 98 with a life expectancy of less than 1 year (N = 20). Measurements 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. Conclusion 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. [ABSTRACT FROM AUTHOR]

Objective. We tested the Analytical Hierarchy Process tool for its use in public health to identify potential gaps in emergency preparedness by local health departments (LHDs) in California and Hawaii during a radiological emergency. Methods. We developed a dedicated tool called All-Hazards Preparedness Squared (AHP2) that can be used by those who are responsible for all-hazards preparedness planning and response to guide them while making strategic decisions both in preparing for and responding to a slow-moving incident while it is unfolding. The tool is an Internet-based survey that can be distributed among teams responsible for emergency preparedness and response. Twenty-eight participants from 16 LHDs in California and Hawaii responsible for coordinating preparedness and response in a radiological emergency participated in using the tool in 2013. We used the data to compare the perceived importance of different elements of preparedness among participants and identify gaps in preparedness of their organizations for meeting the challenges presented by a radiological incident. Results. Clarity of information and transfer of information (to and from agency to public, state, and federal partners) were public health officials’ dominant concerns while responding to an emergency. Participants also found that there were gaps in the adequacy of training and awareness of the chain of command during a radiological emergency. Conclusion. This preliminary study indicates that the AHP2 tool could be used for decision making in all-hazards preparedness planning and response. [ABSTRACT FROM AUTHOR]