Dignity, Risk, and Choice

Education, resources and practice considerations in older adult care

Overview - Is the Patient Safe to Go Home?

The title was chosen because it is often the question health care providers ask when discussing discharge planning for older adults. This workshop provided opportunities to explore why health care providers ask this question, assumptions made when questioning an individual's risk potential, and the use of words like safe.

The goal of the workshop was to better understand how staff members feel and think about their work with older adults. The workshop was not presented in lecture format. Instead, adult participatory methods and interactive, thought-provoking questions were used to facilitate learning in small groups. Plenty of opportunities were provided for small groups to share and discuss their insights with the larger group.

During workshops delivered to date, six themes have consistently emerged when reflecting on interactions with older adult patients. Explore all six themes below.

Themes

Adopting a paternalistic approach when providing care can increase our sense of professional responsibility at the expense of the patient's right to autonomy.

Health care providers may often adopt a paternalistic approach in cases of risk and safety with older adults. This can either limit or remove the patients' decision-making ability without any reasonable grounds. Care providers sometimes do this without being aware of the negative outcomes. When they take control in this way, they can inadvertently take ownership and responsibility for the person’s outcomes upon leaving the hospital and beyond. 

Consider
  • At what point does our desire to be compassionate and caring become paternalistic?
  • How do we balance our “duty of care” with patients’ rights to risk?
  • What if we expressed those same desires for providing good patient care in a manner that is less about advising what we think they should do and more about engaging the patients in their own decisions and care planning, on the background of our expertise? Would the outcomes be different?

When we understand how common ageism is in our society, it is easier to recognize it in daily life. 

A 2012 Revera report focusing on ageism and gender states that despite an aging population, ageism is widespread. The same report highlights that half of Canadians say ageism is the most tolerated social prejudice when compared to gender or race-based discrimination.

A memory lapse can be written off as having a senior moment. Birthday cards for someone over 30 often include negative language associated with ageing such as being over the hill. Even the term senior can have negative associated connotations. Examples in our health care system and when speaking about older adult patients include:

  • Claire is 87. It's time she moved into a nursing home.
  • He’s just too old to cook for himself.
  • The grannies on the unit would love this.
  • Oh, she is just so cute!

Other examples of ageism include talking to an older adult in a high pitched or patronizing voice, or assuming that older adults are hard of hearing or cannot make decisions for themselves. A strength-based view of a person’s longevity reflects hardiness, resilience and wisdom; however, cultural and social messages about aging can cause older adults to be seen as frail, incompetent, less than, or even laughable.

Consider
  • What are other examples of ageism?
  • How does it affect our interactions with older adult patients in the hospital? In the community?
  • Older adults have a wealth of life experiences, have made countless decisions, and have somehow managed the resulting consequences. Some may view that this life experience has brought them to where they are in their advanced age.

When the focus is on the staff member as “expert”, they may feel more responsibility and adopt a more cautious route of care and/or default to the safest perceived care option(s). 

Each profession or discipline brings its own professional practices, code of ethics, and practice values to the interprofessional care team. Staff may have discomfort and/or disagreement about levels of risk based on these differences. These differences may lead to conflict within the team.

Personal values determine what people believe to be important about the way they live and work. Personal values can be influenced by family, culture, tradition, religion and exposure to media and the internet. Differences in personal values within a team or healthcare setting may also play a part in team members' recommendations and how they interact with older adults.

Consider
  • One team member has a personal experience of caring for a family member and feels this is an important role for family to take on for their elders. How might this influence the way the person interacts with a patient? The family?
  • A team member thinks the patient can't afford something so she or he decides not to give it as an option. How may value judgments affect practice or assumptions about people?
  • One team member feels a patient will not cope well at home, and another feels the patient is a natural risk-taker and should have the chance to try going home. How does this difference in opinion/approach manifest in the team's collaborative interactions, or individually with patient care?

Risk tolerance/aversion can be viewed as a continuum. All health care professionals come to the table with varying levels of risk tolerance based on personal experiences and values.

Consider
  • What happens in care planning when there are different tolerances for risk among the patient, health care professionals, and partners in care involved?
  • Do teams openly discuss conflicts arising from different perspectives of risk?
  • How might our approach to care planning and education change if we approached conversations around any given risk with language like “risk mitigation” and “risk management,” rather than, “are they safe?” or “they’re not safe”?
Part of a health care professional’s acceptance of risk may be related to the setting in which they work: a hospital, long-term care, or the community.

In the first wave of delivering the workshop, community staff shared experiences seeing older adults in the home and familiar settings, where the older adult is functioning well or able to use meaningful strategies to cope.  Despite increasing levels of frailty and functional disabilities, older adults were often more engaged, competent, and confident in taking small (or big) daily risks in order to experience a higher quality of life when in the home or other familiar settings. Health care providers in the community expressed a shift in their outlook towards risk when they saw older adults managing at home.

When older adults are admitted to hospital, it represents a small snapshot of their life and is often the result of a health crisis. It can be challenging for health care professionals to understand the bigger picture when the focus is on the acuity of the situation, within a culture of being taken care of.

The hospital is not home and can be overwhelming and confusing for patients, as the delivery of care is often designed for staff convenience and efficiency, rather than individual comfort, routine, or dignity.

When health care staff are involved in an older person's care planning for an extended period of time, more emphasis can be placed on forming a therapeutic relationship with the older person. This relationship informs recommendations for care planning.

Consider
  • How may a health care professional approach an older adult in their home in the community compared to in a hospital setting? 
    • ​How may patient choices, dignity, and autonomy be different between settings?
    • How are the risks different between hospital, community, and long-term care settings?
  • Imagine an older adult looking very unsteady on their feet when walking in hospital, relying on holding room furniture for support.
    • How might the reaction and care planning differ between health care professionals working in hospital and community? Long-term care?
    • What risks tend to have the most focus in care planning?
    • Do we have a wide view of risks that extend beyond the physical?

Over-emphasizing safety can create barriers for older adults to take meaningful risks.

This theme emerged when discussing risk in relation to working with older adults in both hospital and community care. Health care professionals recognized that a constant focus on safety, incident reports and falls prevention strategies can make them hyper vigilant on physical risk/falls. This can cause staff to give other forms of risk for patients (e.g. skin sores, de-conditioning, psychological well-being/sense of autonomy, choice, and risk taking) less priority.

Participants also acknowledged that hospitals are often designed for the health care professionals to complete their jobs in the most efficient way possible with the least potential physical risk to staff and/or patients. Staff members did not necessarily feel they had the support and resources to challenge this safety-oriented culture within their daily practice.

Consider
  • What are some tangible examples within our settings that may encourage a more safety-oriented approach to avoid physical harm, perhaps at the expense of respecting older adults’ rights to risk taking?
  • When referring to a patient’s mobility, how may the terms “independent at risk” and “stand by assist” be the same or different in terms of approach to care, enabling dignity of risk, and potential outcomes?

Perceived risk of liability can result in limiting or removing an older adult's autonomy and right to make decisions regarding their care.

Workshop participants were often fearful of doing the wrong thing and of their professional liability in relation to patients. They also discussed the difficulty of being the sole voice in a service culture that was either less or more risk tolerant than they were.

The original delivery of the workshop highlighted the need for staff to have ethics and legal education regarding liability. Access to this education on a regular basis would help to dispel perceived myths that can often result in limiting or removing an older adult’s autonomy and rights to make decisions in their care.

A legal consultant and a representative from Ethics NSHA spoke to staff on the issue of professional liability at Geriatric Academic Rounds in 2013, delivering the following take-home messages:

  • Negative outcomes do not equal negligence, unless there is a failure to meet the reasonable standard of care that caused the outcome. Patient complaints do not always lead to liability.
  • Rather than ask, “Could I be held liable if (they fall, they come back to the emergency, they break their hip)?”, we should be considering, “Have I met my obligations as a healthcare provider in assisting the patient and their supports in implementing an appropriate care plan that reflects the person’s informed choices and respects their autonomy?”
  • Encourage and support each other with a focus on quality of care related to patients’ goals and values rather than a heightened fear of liability.
  • Legal would be more concerned if staff did not respect a person’s right to choose, even in instances of negative outcome.
Consider
  • What do we need to feel supported in preserving the autonomy and right to risk-taking of older adults?
  • What language can we use to enable meaningful choice for older adults?
  • How do we educate ourselves, our colleagues and family members about the potential negative impact that a fear of liability has on an older adult's autonomy and right to dignity of risk?