For those living in residential aged care, the benefits of living in a safe and comfortable environment, where you receive the care you need, must be weighed against the loss of independence that can also occur at this stage of life.
Aged care providers have a duty of care to keep residents safe, healthy and happy, and the tension between that duty and what we call ‘dignity of risk’, allowing residents to take risks as a way of preserving their wellbeing, is one of the key challenges.
Locking doors in aged care homes is a key issue that highlights this tension.
While some say residents have the right to move freely around an aged care home and open doors are a way to preserve dignity for the residents, others say safety is the priority, and we must find ways to make locked doors acceptable for the resident.
But locked doors can upset residents who may not understand why they can’t pass through it, making them feel “trapped” and “upset”.
Kate Swaffer is the co-founder, chair and CEO of Dementia Alliance International, and is globally recognised for her advocacy of people living with dementia. She told HelloCare that when her father-in-law was living in residential aged care, he couldn’t understand why the front door was locked.
“You promised me this was my home,” he would say.
Locked doors can cause anxiety
Lee-Fay Low, Associate Professor, Ageing and Health at the Faculty of Health Sciences, The University of Sydney, told HelloCare that some people living with dementia “don’t like” locked doors.
They attempt to “escape” homes with locked doors by following visitors or staff out the front door, or they try door handles repeatedly, “knocking and pushing”. They also sometimes try leaving by other means, such as by climbing the fence, Low said.
Just as Swaffer’s father-in-law was upset he no longer had the autonomy to walk out the front door whenever he wished, Low said locked doors can make residents “feel trapped”, making them become “upset”.
But open doors mean residents can leave the home without supervision, and may do so without staff noticing, putting themselves in danger, Low said.
A barrier to walking
Locked doors can also be a barrier to residents living with dementia who like to walk. The “challenge”, Low said, is that “residents who walk sometimes go into the rooms of others, and it upsets those other residents”.
“Residents need a safe place to walk, for example, a garden with a flat path, and perhaps with places to sit, and things to do along that path,” Low said.
A dementia expert who asked that their name be withheld told HelloCare that aged care providers have to find a balance between the rights of the person living with dementia and the rights of the other residents.
There are “pros and cons” to locking doors, the expert said.
Though Swaffer now advocates for an end to institutional care for older people, she understands “in the short term” this need for aged care homes to keep residents safe by locking some doors.
Leave the right doors open
Residents must have access to outside areas 24/7, Swaffer said. Even if the front door is locked, the back doors can remain open, she suggested.
Swaffer said Group Homes Australia uses this practice successfully in its homes.
Low says, “Residents need a safe place to walk, for example, a garden with a flat path, and perhaps with places to sit, and things to do along that path.”
“People who were active through their lives would not want to sit for most of the day, their body rhythms are telling them they need to move and do things.” It’s essential that those living with dementia in residential aged care can satisfy this urge to move, and so some doors must remain unlocked to allow this to happen.
The dignity of risk
“People with dementia need to have some autonomy and choice to be who they are, this ‘freedom’ is important to their psychological wellbeing,” Low said.
“This can involve taking some risks”, such as being able to move freely about their home and not being ‘locked’ in.
When the person doesn’t have the cognitive skills to judge the level of risk “hopefully their family and paid staff would be able to balance the physical risk with the psychological/wellbeing benefits to that person to still be able to do that ‘risky’ activity,” she said.
Finding a better way
The Interim Report of the Royal Commission into Aged Care Quality and Safety notes the “countless” stories it heard about residents losing their “basic rights to take risks, to choose what to do in their day.”
“There is no joy in this,” the report states.
Being able to move freely around a home and not ‘locked’ inside is one of the most basic of rights, but it must be carefully balanced against safety. It’s not always an easy call.
Swaffer said that almost every time they visited her father-in-law he would ask, “Why have you put me in jail?”
“It was gut wrenching,” she said. “We have to find a better way.”