Safety versus dignity: A balancing act

In the hospital, privacy is a scarce commodity often sacrificed in return for patient safety or our own convenience. Recently, we admitted a patient with multiple medical problems who required maintenance IV fluids. Not only was she a fall risk because she was cognitively impaired, she was also attached to an IV pole and oxygen tubing. She also had a balance disorder and was on several high-risk medications.

She would not cooperate with the interview before using the restroom, and would not use a bedpan. The nurse brought out a bedside commode. The patient gave it a puzzled look, stood up with our assistance and bolted for the restroom on the other side of the hospital room. Just before she nearly self-discontinued her peripheral IV and garroted herself with the oxygen tubing, we were able to stop her.

We sat her on the bedside commode. She would not go on this “throne” with us standing there. It felt like we were coaxing a two-year-old to use the potty. She finally asked, “How can I use the restroom if you won't let me go?” We assured her that she was free to “go” at that moment since she was sitting on the commode. The nurse showed her the removable “bucket” as she began to call it, and she candidly asked, “Do you keep yours as a souvenir?” We replied that we generally did not, and she asked, “Well then why do you want to keep mine? I need my privacy.”

After all, she was right. Anybody about to use the commode deserves privacy, but what if she fell? Falls are always a concern when treating the elderly population, particularly when an additional risk factor exists, such as dementia in this example.

In a study published in the Journal of General Internal Medicine in 2004, risk factors for falling were identified as weakness, poor cognitive status and medications. Another source identifies “binders” such as IV tubing and poles, fall history and inadequate amounts of staff as additional risk factors. Patients who fall usually have a longer length of stay, and on average, a fall adds $33,894 to the cost of a hospital stay. Over the course of a year, in-hospital falls add an additional $6.6 billion to medical costs.

Because this is such a large problem, many hospitals have instituted protocols to prevent inpatient falls, usually based on identifying patients with risk factors. Preventive strategies include identification using wrist bands, remaining with the patient while using the bedside commode or toilet, more frequent rounding, use of toileting schedules and use of bedside lights.

But that doesn't solve the problem of choosing safety over privacy and, some would argue, over dignity as well.

Even more worrisome is the number of falls that occur while trying to use the restroom. The study published in the Journal of General Internal Medicine found that the most common activity performed at the time of the fall was ambulation. Of those who fell while walking, the most frequent destinations were bed to bathroom, bedside commode to bed and bed to bedside commode. A large number of falls occurred when patients were attempting to perform activities unassisted, especially toileting-related.

Even with those statistics, there is an ongoing effort to find a solution to the issue of safety versus privacy. Is there a way to provide both?

A campaign called “Behind Closed Doors: Using the toilet in private” launched by the British Geriatrics Society in August 2006 aims to “rais[e] awareness that people, whatever their age and physical ability, should be able to choose to use the toilet in private in all care settings.” The recommendation is to assess patients using their level of mobility and level of safety to determine the best method of transporting a patient to the restroom or transferring a patient to a bedside commode. Even this very ambitious campaign recognizes that in high-fall-risk patients, supervision with adequate screening is required to ensure safety.

So, where do we draw the line? Or do we? Most medical personnel would agree that we are willing to compromise patient privacy to make certain that patients are safe. Maybe it would be worth asking patients what they would prefer, but then we might encounter issues of beneficence and paternalism versus autonomy.

This issue presents quite the dilemma, without a clear answer. For this patient we had the staff to get extra-long oxygen tubing and a modicum of privacy. However, that night we pondered, what would we want? And would anybody care? Maybe an advance directive should include something like this: “Do not maintain life-sustaining treatments if my chance for recovery is dismal. Please protect my privacy, but keep me safe. And please, do not keep any souvenirs.”