Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
C
URRENT
O
PINION
A positive risk approach when clients choose to
live at risk: a palliative case discussion
Christopher E. De Bono
a,b,c
and Blair Henry
d,e
Purpose of review
The article discusses recent approaches in the literature about clients who chose to live at risk in their
homes. It argues for a positive risk-based approach and a tool to help manage risk in the home, and
applies these to a hypothetical end-of-life scenario.
Recent findings
Historically, safety plans to consider risk management involved a culture of risk aversion supported by
sometimes paternalistic motives intended to protect vulnerable clients. New findings in the literature engage
in a process that respects the ethical principles underlying harm reduction philosophies. The literature also
argues for a perspective that moves away from viewing risk as only harmful, to one that supports a positive
understanding of risk as part of a client’s informed choice.
Summary
A risk support management plan, based on a positive approach, can provide a way to both support a
client’s choice to live at risk, anticipate for expected complications, and inform the creation of a
contingency plan to address concerns as they may arise. The added value of a structured approach like the
one proposed here for risk support management plans is that it provides adequate due diligence and
informed decision-making when planning for risk-taking in complex situations.
Keywords
dying at home, end-of-life, ethics, home care, palliative care, positive risk, risk
INTRODUCTION
Home care is the most rapidly growing segment of
the Canadian healthcare system [1]. In 2011, Can-
ada had a population of just over 34 million [2]. In
that same period, 1.4 million Canadians received
home care, representing a 55% increase in clients
from 2008 [3]. Reasons for this increase in home care
usage have been attributed to an aging population,
overcrowding in acute care hospitals, shortages of
long-term care beds, and increased rates of disability
and chronic illness across the country [3].
The reality that people are living longer with
chronic life-threatening illnesses has meant an
accumulative increase in demand for care in the
home. In Canada, the underlying cause of most
deaths is attributed to advanced chronic illness
[4]. Individuals living with an advanced illness
choose to spend the majority of their last months
of life being cared for at home, regardless of the
ultimate location of death [5].
With homecare poised to continue to grow,
both in Canada and internationally [6], the mandate
to understand and effectively manage risk (safety) in
the home setting is receiving priority [7
&
]. A signifi-
cant gap in risk management is the absence of
‘structured mechanisms’ and tools to support safety
for clients and care providers in the home [7
&
]. In
society, individuals are generally free to make their
own decisions regarding the level of risks they are
willing to undertake for themselves. However, when
care is being negotiated in the home setting, it can
be expected that the healthcare teams and their
clients may not share the same priorities or even
assessment of risks. Clients will have differing values
a
Toronto Central Community Care Access Centre,
b
Joint Centre for
Bioethics,
c
Emmanuel College & St. Michael’s College, University of
Toronto,
d
Department of Family and Community Medicine, Division of
Palliative Care, University of Toronto and
e
Ethics Centre, Sunnybrook
Health Sciences Centre, Toronto, Ontario, Canada
Correspondence to Office of the Ethicist, Christopher E. De Bono, PhD,
Toronto Central Community Care Access Centre, 250 Dundas Street
West, Suite 305,Toronto, ON M5T 2Z5, Canada. Tel: +1 416 217 3820;
e-mail: c.debono@utoronto.ca
Curr Opin Support Palliat Care 2016, 10:214–220
DOI:10.1097/SPC.0000000000000223
www.supportiveandpalliativecare.com Volume 10 Number 3 September 2016
REVIEW