Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: Balancing patient safety and autonomy

BMJ 2019; 366 doi: (Published 20 August 2019) Cite this as: BMJ 2019;366:l4948
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

If a 90 year old is climbing ladders, should your first instinct be to congratulate her or to warn her of the dangers? I discussed this recently with a friend, whose elderly patient kept chickens that had taken to roosting in the trees. On balance, we agreed that the benefit of tending her allotment and chickens probably outweighed the risks of ladder climbing, even though her balance wasn’t what it used to be.

Nearly five years after the publication of Atul Gawande’s Being Mortal, with its urgent call to reconsider how our society treats older people, we still tend to err on the side of safety rather than autonomy.

I’ve watched as patients variously submit to, or battle against, the restrictions that family or services seek to impose on their activities for safety’s sake. When they’re falling at home and calling on emergency services more frequently, there comes a point when those around them agree that it’s no longer safe for them to remain independent. The safety involved here is physical, avoiding the risk of broken hips and head injuries. Perhaps we’re also considering the psychological wellbeing of the people who feel responsible: family, social workers, and a GP who would otherwise be worrying about what might happen to the frail elderly person left unattended. There are resources to consider too, and after the umpteenth call-out to paramedics in a month, the costs mount up.

But what about the psychological wellbeing of the patient? Unless there’s enough money and space to support live-in carers, a care home beckons. Moving to an institution usually means multiple losses: only a small space now counts as yours, and you may have little control over who enters it. Food, not of your choosing, is served at times that fit in with the smooth running of the home but not necessarily when you’re hungry.

Although they worry me (and I have huge sympathy for their families), I have a secret admiration for my patients who steadfastly hold on to their independence, refusing to do the sensible thing and let others care for them. As long as they have capacity these patients choose autonomy, and a daily struggle against faltering abilities, rather than graceful acceptance of their decline. I remember one patient from years ago, who lived in chaos but was completely preoccupied with the academic paper he was writing. I suspect that the conference he was preparing for existed only in his imagination, but it gave him purpose and a reason to get up each day.

Perhaps, instead of focusing solely on safety—which appears near the bottom of Maslow’s hierarchy of human needs—we should also set our sights higher and understand the necessity of freedom and purpose.