Falls aren’t right, but is there a right to fall?

Of the 87 critical incidents detailed in a recent Manitoba Heath report from Oct. 1 to Dec. 31, 2013, more than half (44) were related to falls by patients, with most being described as having occurred in personal care home settings.

As a group, geriatric patients are a population uniquely vulnerable to medical error. This is for a wide variety of reasons, not the least of which being simply the number and frequency of medical procedures they undergo as well as the complexity inherent in treating numerous underlying conditions in multiple domains.

Numerous international studies have confirmed that the elderly are disproportionately involved in adverse events in the health care system. In fact, the rate of adverse events increases significantly with age, a 65-year-old being twice as likely to experience harm related to medical error as someone 16- to 44-years-old.

One recent U.S. study found that the highest rate of harm from adverse events in the entire patient population was in patients between the ages of 65 and 74.

Unintentional injuries related to falls are among the leading causes of mortality in the elderly population. Complications related to a variety of underlying issues, notably delirium, dementia and frailty, when added to the cumulative effect of other impairments, increase patients vulnerability and exacerbate the consequences of injury.

Effective fall management

There are a wide variety of measures to be applied in a comprehensive falls management strategy, and their effectiveness is proven.

Programs for strengthening and rehabilitation are one method. The use of devices like mobility aids, visual aids and hearing aids are another. Padding and positioning devises are used, too.

The safe design of the physical environment is crucial. The removal of obstacles and the placement of objects in a safe manner in familiar positions for the patient will help. Well-lit spaces increase safety, as do considerations like lowered beds.

There needs to be particular attention to the patient’s physical and personal needs. Toileting routines are vital. One of the most human, personal, dignifying activities of daily living is self-toileting. Yet, after a great deal of cognitive function has been lost, this human need has launched patients on many unsafe journeys unassisted.

There are also the other basic needs, like hunger and thirst, to be attended to. Socialization and activities, especially those geared to an individual’s current abilities and past interests, will not only enhance quality of life, but will ultimately aid in fall prevention as well.

Facilities also need to be designed to accommodate the close observation of patients by staff. Isolated television rooms are an invitation to problems and falls.

Continuity of care

Continuity of care in terms of staffing will reap many benefits and will increase the potential for improved patient function and decrease behaviours that might otherwise require the application of restraints. Spaces that are soothing and comfortable with minimal noise and visual and aural simulations — like a pleasant view or music — will ease the propensity for wandering.

Bed and chair alarms are often essential measures to alert staff about unsupervised movements of patients when they can’t be in sight. Roam alerts worn by the patient and door alarms are good measures as well.

Knowing that optimal falls prevention measures are successful places the occurrence of nearly every fall in the category of medical error — specifically, being the preventable adverse outcome of care.

Unfortunately, at the extreme end of the range, concerning patients with significant cognitive impairment, the proven safety measures present a number of ethical issues related to patient safety for discussion.

After all, the best falls management practices have been applied to patients suffering from various types of cognitive impairment there remains, for an ever-growing group, only two ways to keep these patients safe — either restraint or continuous one-on-one care.

Issues around restraints

The issues around restraints, either physical or chemical, are huge. Concerns related to the fundamental human rights of personal movement, quality of life and the individuals’ sense of dignity, create a moral minefield around the application of restraints. Most facilities providing care to the elderly in Canada have adopted a policy of absolute minimal or no restraints in response to these concerns.

Most institutions will employ every measure to ensure that the application of restraints takes place only as a measure of last resort in emergent situations, with ever stricter guidelines for their ongoing use. The restraint used will be ensured to be the minimal amount possible, and to be used for the shortest possible time.

Often the only safe alternative to restraint will be the provision of individualized care with a constant monitoring by a one-on-one personal attendant. In the context of our aging population, the needs within the demographic have produced huge demands on facilities already overtaxed for human resources. The difficulties in staffing 24/7 constant care for high-risk patients are manifold.

The demanding nature of the work requires a very specific skill set and a suitable personal disposition by attendants for the work. And of course, the financial costs are huge. Sometimes the patient’s family can be included as part of such a care plan, but this may prove only a partial solution and in many instances, simply impossible.

Many patient families will be unable or unwilling to bear the costs associated with privately provided attendant care, when the facilities themselves are unable to bear the burden either.

Moral anathema

So, we return again to the increasing scenario where restraints are the only measure for patient safety possible. And because restraints present so many challenges to safely apply, there are inherent risks in their application.

So if restraints are a moral anathema, what do we do? Does the patient simply have the right to fall if restraint is refused and constant care is not possible?

The decisions made about such extreme interventions should be perhaps considered in the same context as many other measures necessary for the preservation of life. As decisions concerning measures such as resuscitation, intubation and other such invasive or heroic measures are part of an advanced care planning process, could we not consider as well the question if, in the circumstance of deteriorating cognitive capacity, it is only possible to keep a patient safe by means of restraint, if and how will such restraints be applied and will the consequence of a fall be accepted should those restraints not be applied?

Does the patient simply have the same right to fall as they may have to place a DNR order on their chart?

Like any other decision in health-care directives and advanced care planning, these decisions should be made well in advance, ideally when the patient’s participation is still possible and their wishes known. Many individuals will have an answer to the question “If the only way to keep me safe one day is to restrain me, will I accept the potential consequences of a fall?”

The quality of life in a restrained environment and potential alternatives like the costs of attendant care can be weighed and measured in the same light as many other decisions made regarding care in the difficult circumstances of any other degenerative condition.

It’s been estimated that each fall and fracture can have direct costs to the health care system of up to $30,000. An ounce of prevention, as they say, is worth a pound of cure.

The question remains: are resources being allocated that could pre-emptively protect patients and ameliorate post-fall costs and human suffering? If you pay to install non-slip flooring, you will never know how many people didn’t fall because of it. But that’s how a safety culture behaves. And some would say, it’s a moral imperative.

Darrell Horn is a health-care system safety and accountability expert.

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