Healthcare organizations, and providers who work within them, put significant effort in striving to achieve a culture of patient safety. The concept of “safety” is somewhat of an umbrella term insofar as different types of safety exist: physical safety, psychological safety, and cultural safety are just three examples. When thinking about physical safety in particular, there are countless ways in which this is prioritized and practiced. For instance, many, if not most, healthcare organizations strive to achieve “zero falls” within their spaces. To this end, healthcare providers adhere to calculated protocols to decrease medication errors and evidence-based strategies are followed so that pressure injuries are prevented.
The prioritization of patient safety goes part and parcel with the bioethical principle of non-maleficence, which is the idea that we (healthcare providers) ought to prevent patients from experiencing harm. In other words, if we ought to prevent people from experiencing harm, then it seems essential to promote patient safety.
Patient safety is important, preventing harm is important, and dignity is important, and it may be the case that we define and/or prioritize these concepts differently than our patients.
Healthcare providers’ and organizations’ dedication to patient safety is necessary so that we can provide patients with the best care possible. With that being said, an ethical dilemma sometimes occurs in circumstances wherein patients may not want their safety to be prioritized. In order to describe this kind of scenario, let’s consider the following:
Mr. D, a 78-year-old male, lives by himself in a 3-storey home. A few weeks ago, as Mr. D was walking to the washroom in the middle of the night, he fell down the stairs, resulting in a hip fracture. Subsequently, Mr. D was admitted to an acute care hospital and surgery was offered. After receiving surgery, Mr. D was given an opportunity to be transferred to a post-acute care rehabilitation centre. While in rehab, Mr. D participated in all therapeutic interventions and expressed an eagerness to return to his previous home.
The rehab team (comprising of occupational therapy and physiotherapy) recommended that in order to facilitate a safe discharge home and prevent future falls, Mr. D should: (a) install grab bars in his washroom and (b) use a rollator walker in both indoor and outdoor environments.
In response to these recommendations, Mr. D stated that he would not be making alterations to his home, nor did he intend on using a walker upon leaving the hospital. Although Mr. D was using a walker and grab bars while in-hospital, he stated that he would not live “this way” when he leaves. The clinical team stressed that he is at an extremely high risk of experiencing another fall without implementing these strategies, but he could not be swayed.
The importance of patient safety, coupled with healthcare providers’ obligation to prevent harm, makes Mr. D’s response is difficult to accept. In fact, Mr. D’s response may influence providers to experience quite a bit of distress. Providers may reasonably ask why a person would want to be discharged to an environment that is not safe?
Ethicists are sometimes consulted in these complex circumstances to facilitate decision-making processes and support all parties in determining next steps, particularly if there is uncertainty on the “right” way to proceed. In the case of Mr. D, we may explore whether Mr. D is providing a fully capable, informed refusal of recommendations. We may unpack his decision-making rationale. We may ensure he is aware of what to do if he changes his mind about installing grab bars and/or using a walker. We may also explore alternative options in terms of patient recommendations. In short, we may take various actions and explore multiple options as an interdisciplinary team to ensure that next steps are ethically defensible.
I understand why clinicians may experience distress when patients make autonomous, informed, and capable risky decisions. With that being said, when it comes to cases like Mr. D’s, it can sometimes help to reflect upon and grapple with the concept of the dignity of risk.
The dignity of risk is a concept that was introduced in 1972 by Robert Perske. Although the concept was initially used in relation to people with mental illness and cognitive impairment, it is frequently applied to other populations in which “risk-taking” may be prevented. In his work, Perske describes the importance of offering and allowing people “to assume a fair and prudent share of risk” in relation to their capabilities, and he notes that some risk-taking may be an important part of human dignity. In other words, the concept suggests that living a dignified life may, in fact, require some degree of risk-taking.
The dignity of risk can, at times, be a useful concept for us to consider as healthcare providers. If, for instance, Mr. D’s idea of what it means to lead a dignified life involves risk-taking, then his decision to take some risks and not to prioritize safety makes sense. Now, it is still important to ensure that we – as healthcare teams – promote safety. However, it may also be important to promote dignity and consider the possibility that this concept may mean different things to different people; a dignified life may look different depending on the person.
Balancing the many competing priorities and responsibilities that healthcare providers owe to patients can be complex. Patient safety is important, preventing harm is important, and dignity is important, and it may be the case that we define and/or prioritize these concepts differently than our patients. The concept of the dignity of risk can sometimes help us work through circumstances where patients make capable and informed decisions to take risks and not prioritize our conception of safety.
By Andria Bianchi
Andria Bianchi, PhD, is a Clinical Ethicist at Unity Health Toronto – Centre for Clinical Ethics, where she offers ethics support to post-acute care settings. She is also an Assistant Professor (status-only) at the Dalla Lana School of Public Health – University of Toronto.