Balancing Dignity and Safety: Introducing Dignity of Risk

One of the great balancing acts in delivering person-centered care is honoring both a client’s freedom of choice and their need for personal safety. Having control over how one spends each day is a key principle of person-centered care, while client safety is a primary responsibility for caregivers. 

There can be times when these goals can seem to be at cross purposes, however. For example, if a client is advised by a speech pathologist to eat pureed food because he has swallowing issues, but he wants to eat solid food, what do you do? What if a client in the early stages of dementia wishes to continue cooking for herself and performing household chores but her children object? 

For the provider and the provider’s caregivers, deciding what to do in such situations can pose potential liability as well as anguish. Freedom of choice is essential to human dignity and can enhance a client’s quality of life, but “do no harm” is also an important ethic when caring for others. 

These situations can also raise thorny questions: Who is responsible for the potential risks that may arise from a client’s choices? How do you train staff to feel empowered to enact client choices in the presence of real or perceived risk? How do you honor a client’s wishes when their family opposes those wishes out of concern for their loved one’s safety? 

One aid in sorting through these questions is to apply the principles of a concept called dignity of risk.

Dignity of risk is a concept which recognizes that living a dignified life may require some degree of risk-taking. It holds that self-determination and the right to take reasonable risks are essential for dignity and self-esteem.¹ Conversely, the concept also suggests that overprotectiveness can diminish an individual’s sense of dignity.

The dignity of risk concept was introduced in 1972² by Robert Perske, an author, minister, and disability rights activist. Today, there are no official standards for dignity of risk and definitions vary. One state department of health and human services defines dignity of risk as: "the right of every person …  to make informed choices and take reasonable risks to learn, grow, and have better quality of life."³

Originally developed in relation to people with mental illness and cognitive impairment, dignity of risk has since been applied in other areas of health care, including person-centered care planning for older adults with long-term service and support needs.⁴ 

Keeping dignity of risk in mind can help caregivers guide clients and their families through a thought process that can help balance the need for safety with the need for dignity. Achieving this balance can be a key element of person-centered care.  

Honoring both a client’s need for dignity and their need for safety don’t have to be in conflict. Here are four often cited person-centered principles to keep in mind when seeking to balance a client’s personal autonomy with their personal safety:

• Know the whole person 

• Identify and document choices and risks 

• Develop individualized strategies to manage risk 

• Revisit, revise, and relay 

Helping staff understand each of these principles can help them incorporate dignity of risk in person-centered care planning, and in specific situations as they arise. Here’s an overview: 

Developing a deep understanding of who a person is along with their needs and preferences is at the heart of person-centered care. Knowing a client holistically is also a key to balancing freedom of choice and safety.

Every client is different. What living a dignified life looks like for one person can look very different from someone else’s idea. People’s tolerance for risk can vary widely. Knowing a client well – factors such as their life history, culture, attitudes, personality, ability to heed recommendations, and family and social connections– can inform any decisions regarding manageable levels of risk-taking in their care.

A deep, holistic understanding of who the client is can also help in evaluating their capacity to make decisions and understand the implications of any risk involved, as well as their ability to continue to exercise caution. It may be helpful to remember this advice from the National Center on Advancing Person-Centered Practices and Systems (NCAPPS) regarding dignity of risk: “Understand that everyone is the expert of their own life.”⁵

Discuss any potentially risky choices the client wishes to make regarding activities of daily living, making sure to understand each decision and why the client is making it. Review any past choices that posed risk and what their consequences were. Establish that the client understands any potential harm(s) to themselves and to others posed by the risks they feel willing to take.

In the case of the man with swallowing issues above, for example, he may understand full well that the risks of eating solid food include choking and asphyxiation, but he absolutely hates the idea of eating pureed food. For this client, eating solid food is essential to his quality of life and he’s willing to take the risk. Letting him know you understand his preference and the reasoning behind his choice honors his dignity.

Let other members of the care circle know that you welcome their input as well. Remind them that their loved one’s dignity and safety are priorities and that you will work with the client and them to come up with strategies that can potentially honor both.

Keep a written record of all discussions and any agreements. Be sure to note both the benefits and risks of any changes to the care plan. 

Knowing that the client understands any risk involved, collaborate with them to plan for any steps deemed helpful to accommodate and minimize those risks. These measures may include increased monitoring or additional personal assistance where needed. As the NCAPPS suggests, consider how to give a “soft yes” and provide the least restrictive support to help the client maintain their dignity.  

It's also a good idea to discuss the benefits and possible risks of accommodating the client’s preferences with other members of the care circle to help get everyone on board and enlist their support. 

For example, in the cases of the man who wants to eat solid food and the woman with dementia, their care coordinators might get each client to agree to a slight increase in staff supervision at mealtimes. The care team would then communicate to the clients’ care circles how important continuing these activities is for their loved ones, that their loved ones understand the risks involved, that supervision will be provided, and that either situation will continue to be monitored day-to-day. 

Think of the risk vs. choice discussion as an ongoing conversation with both the client and other members of the care circle, including family.

• Revisit. Plan to review the client’s choices and any consequences on a regular basis with the client as well as with any members of the care circle the client wishes to be part of the conversation. Note any recorded incidents and other pertinent data. Gauge the client’s levels of satisfaction and anxiety. 

• Revise. If and when needed, adjust the plan of care to bring dignity and safety back into balance. As before, note the benefits and potential risks of any changes. 

• Relay. Keep the care circle informed about the client’s wishes and any changes to the care plan. Continue to welcome everyone’s input and let them know their views are respected. 

Honoring dignity and safety while preventing harm can be a complex task. Keeping dignity of risk in mind when planning and delivering care can help sort through the complexity by keeping the client’s wishes uppermost. Deep respect and understanding for who the client is, helping them make informed choices, finding the least restrictive strategies to accommodate those choices, and keeping the choice vs. risk conversation ongoing can all help caregivers achieve the best possible balance of dignity and safety, and ultimately provide quality, person-centered care.