Embracing the DIGNITY of Resident Relationships: A Case Study of the Decision-Making in Aging and Dementia for Autonomy (DIGNITY) Protocol

Abstract

Public policies governing U.S. nursing homes emphasize resident rights, autonomy, and person-centered care, yet translating these principles into everyday practice remains challenging – particularly for residents living with dementia whose preferences involve perceived risk. Regulatory requirements, liability concerns, and inconsistent interpretations of decision-making capacity often constrain staff ability to honor resident choice. This case study examines the application of the Decision-making in Aging and Dementia for Autonomy (DIGNITY) protocol, a structured, evidence-based framework designed to support shared decision-making within regulated long-term care environments. Using a resident-to-resident relationship preference as an illustrative case, the study demonstrates how the DIGNITY protocol guides interdisciplinary decision-making through systematic preference assessment, decision-specific capacity evaluation, risk-benefit analysis, documentation, family engagement, and collaboration with organizational leadership and regulators. The case highlights policy-relevant challenges, including the inappropriate reliance on cognitive screening tools such as the Brief Interview for Mental Status (BIMS) as proxies for decision-making capacity. Findings underscore the importance of clear organizational policies, staff training, and leadership engagement to align person-centered care with regulatory expectations. This case study illustrates how structured decision-making protocols can operationalize resident rights, support autonomy, and mitigate risk, offering a practical model for policy implementation in nursing home dementia care.