What is Dignity of Risk?

What if my choices are deemed unsafe?

Dignity of Risk is the term used to acknowledge that people have the right to choose how they want to live their life, even if their choices might involve some risk. Dignity of Risk accepts a person's right to self-determination.

In the aged care industry, providers of in-home care might struggle with this concept.

In these instances, a provider may default to their 'duty of care' position to safeguard their organisation from possible liability, should the older person be harmed by the outcome of their decision.

Dignity of Risk aligns with the Consumer Directed Care approach of our aged care system and is included in the Aged Care Quality Standards.

Our guest contributor for this post, Donna Reis, is a former Registered Nurse and educator who has a special interest in this topic, and who has provided us with 'real life' examples of Dignity of Risk.

Donna's first example relates to the incidence of falls and providers' concerns about clients and residents sustaining injury from falling.

Data from the Australian Institute of Health and Welfare reports falls as being the leading cause of hospitalised injuries and injury related death among older Australians.

One in two falls that resulted in hospitalisation occurred in the person's home and one in five occurred in a residential aged care facility.

"We must accept the chance that a person will fall, in exchange for the freedom to move freely. And while they are not sitting in a chair against their will, people are experiencing reduced anxiety and greater engagement in life."

"A man in a facility I visited recently put it in a way that explained what self-determination really means. Asking a staff member to bring him back his missing walking frame, he was told, “No, we’re worried about you falling on your hip!” His simple response: “Well, it’s MY hip, not yours."

"Dignity of Risk is about much more than just the freedom to walk, of course, it’s about making all sorts of life choices, big and small. And sometimes, within reason, making mistakes. It can be as much about the person’s right to eat what they want, make their own coffee when they want or stay up late if they want."

What about our duty of care? ...

Our obligation in our work role to protect a person from harm, that seems to contradict the very idea of dignity of risk. Can duty of care and dignity of risk both exist happily together? They can, and they do, if support workers remember three things:

• If you allow a person to make a choice that carries an element of risk, you must first explain to them fully, in a way that they can understand, the consequences of their decision.

• You must feel confident that the person has understood the consequences to an adequate degree.

• The person does not have the right to dignity of risk where their choices could cause physical or emotional harm to others. 

Donna explains how two different residential aged care facilities responded to residents who wanted to have a greater say in their diet, which placed the staff in a challenging situation.

‘Facility A’ is the home of a resident who is overweight. The managers know that choice and self-determination is important. They understand that forcing a person to diet against their will is as absurd as hearing the teenager at the MacDonald’s drive-through suggest that it might be better if you have a salad, because of your weight.

So the directive is given at Facility A that this resident has the right to eat what she wants. This presents a quandary for the staff, however, since the managers also allow the resident to choose whether or not she is transferred using a hoist. She hates the lifting machine. She insists the staff transfer her manually, putting themselves at risk while doing so because of her weight. The support staff find themselves forcing a furtive unsanctioned diet to save their backs, and so the problem continues in a circular conflict between choice and harm.

‘Facility B’ faced the same quandary relating to the increasing weight of a resident but they understood their responsibilities differently in balancing dignity of risk with duty of care.

Their approach took the complexities of self-determination into account, and ticked off the three important things that must be considered when a resident prefers to do something that might present risk. Unlike Facility A, they understood that the third point on the list, ‘…the person does not have the right to dignity of risk where their choices could cause physical or emotional harm to others’, includes potential harm to staff.

Here is where Facility B changed course. The resident has the right to choose, but staff have the right to be safe. So, the lady's choice to eat in a way that will continue to increase her weight, resulted in staff letting her know that one of the consequences is the requirement to use the hoist.

The key to providing the freedom of choice is to remember the three points of consideration, and to document the conversations you have surrounding a person’s riskier requests or their refusal to accept recommended treatment. In some services, a waiver that outlines what the person has been told can help to protect staff.

Donna was our guest presenter for September's Aged Care Masterclass, presenting on this topic, Dignity of Risk.

Donna initially trained as a Registered Nurse and worked in some of Melbourne’s largest acute hospital settings, before moving into aged care and disability settings in leadership roles. She has been involved for many years in the development and teaching of diplomas and certificates in Community Services, with a speciality in aged care.

Donna has had multiple articles published in mainstream media, and writes for the Vocational Training and Education sector, improving the quality of national qualifications with her unpassable skill of breaking down complex research into easy to understand, real world examples that are easily understood by frontline workers and managers.