The Dignity of Risk Dilemma

Written by Simon Kerrigan, September 27, 2018.

Here’s something you may have missed.

Part 2 of the ABC’s four corners investigative program into aged care was difficult viewing from start to finish. But as a physiotherapist, something stood out to me which may have been overlooked due to the gross depravity of the footage.

Dignity of risk is a concept which is often misunderstood and poorly adhered to in aged care. It is specifically defined in the new aged care quality standards but will more than likely continue to be a point of conjecture. The dignity of risk dilemma is usually driven by a provider’s obligation to resident safety. Both are necessary elements of effective care but together, they form a paradox which can be hard to overcome. When facing this dilemma, usually safety takes precedence. But at what cost?

The opening footage of Part 2 of ABC’s “who care’s” showed footage of an elderly lady with a diagnosis of dementia struggling to stand from her bed. The bed had been lowered to the floor, with a “crash mat” placed beside. Her son stated that his mum was continually falling out of bed. But as he effectively pointed out, his mum wasn’t falling out of bed. She was merely trying to stand up but couldn’t.

Unfortunately, the current trend in aged care is that when a resident begins to experience falls at night, the default response is to lower the bed to the floor and put a crash mat in place. This process may lower the risk of injury, but it also dramatically increases the risk of falls. Furthermore, it raises serious questions about whether the resident is in-fact being restrained.

I was recently informed that the AACQA agency was a firm advocate of this practice, promoting a blanket approach to residents at high risk of falls within at least one home. It’s very rare that a “one size fits all” approach actually works, and in this instance, it certainly doesn’t.

As I watched the elderly resident drag her rollator-frame across the floor, suggesting that she still had some capacity to ambulate, I couldn’t help but think that this practice wasn’t in her best interest.

There’s no doubt that care has to be individualised. But if a resident has the ability to ambulate and will try to get themselves out of bed independently, my priority is always to support their ability to stand whilst controlling factors which can lead to falls.

Accepting that “falls happen” is a key part of overcoming the dignity of risk dilemma. At times, the perceived risk of recognising and accepting that falls can occur as a result of promoting independence, dignity and choice can be too high. So, is it time that we took this risk away?

Is it possible to introduce a form of advanced care directives which begin to address the dignity of risk dilemma? Should we be promoting the opportunity for people to make decisions about their future care needs prior to entering aged care? Do we need to go beyond “not for resuscitation” and include things like “accepting falls risk” and “public wandering”, for lack of a better term?

This topic obviously needs much greater exploration and thought. However, it would seem that introducing such a system would ensure the consumer directed care approach that we are promoting. It would also eliminate the predicament which providers are faced with when promoting independence in the face of risk. I wonder what decisions the elderly resident on the four corners program would have made, if she had been given the choice prior to entering care?