Managing Risk in Advanced MS

Dr Barbara Chandler

NHS Highland

13th November 2017

Assessing Risk

• Travel to conference• What are the risks

• How did you manage those risks

• What would increase or decrease those risks

• Who else is affected by the risks you take

• Can you separate internal and external factors

Desired learning outcomes

Plan

Building Blocks and Ideas

• Definitions

• Risk Assessment

• Principles

• Tools

• Practical risk management

• Context

• Legal

• Practical

• Managing Outcome

• Case studies

Learning Outcomes

• Understand concept of risk in

the context of advanced MS

• Understand how to assess risk

and enable PwMS and/or

relatives and professionals to

assess risk

• Understand how to manage risk

to facilitate a positive outcome

Advanced MS

• Spastic Tetraparesis

• Neurogenic bladder

• Neurogenic bowel

• Dysphagia

• Dysarthria

• Fatigue

• Cognitive deficit

• Pressure area risk/pressure sore

• Epilepsy

• Frequent UTI

• Aspiration pneumonia

• PEG

• Family stress

• Care package

• Multiple professionals

• Coordination of care

Risk definition

• a situation involving exposure to danger.

• someone or something that creates or suggests a hazard

• the possibility of something bad happening

• the potential of gaining or losing something of value

Risk Assessment

“A risk assessment can only identify the probability of harm, assess the impact of it on key individuals, and pose intervention strategies which may diminish the risk or reduce the harm. Assessments cannot prevent risk”

Hope and Sparks, 2000

Risk management: probability and impact

• Large potential loss

• Low probability

• Low potential loss

• High probability

Risk

• Identify

• Assess

• Manage

What are the risks

How do you go about the risk assessment

CASE EXAMPLE

More information?

Risk

Mental Capacity

Legal Framework

Quality of Life

Goal engagementGoal dis-engagement

Managing riskAccountability

Documentation

Independence

Hope

Conflict

Choice Safety

Freedom

Multi-agency

CostAvailability of resourcesConcept vs realityRealistic Medicine

Principles of risk assessment

• Identify context

• Identify risks• Perceived by individual

• Perceived by professional

• Analyse risks• High probability; low impact

• Low probability; high impact

Compromise

Uncertainty

Principles of risk assessment

• Evaluate risk• Potential benefits of managing risk

• Potential adverse outcome of managing risk

• Potential risk of not intervening

• Management/Action taken or recommended

DOCUMENTATION

Activity or Context

Risk or Hazard

Contributing Factors

Impact and Probability

Action Impact and Probability

REVIEW DATE

Resources

• Mental capacity Act / Adults with Incapacity Act

Adults with Incapacity (Scotland) Act 2000

Incapacity means incapable of

Acting on decisions; or

Making decisions; or

Communicating decisions; or

Understanding decisions; or

Retaining memory of decisions

In relation to any particular matter due to mental disorder or physical inability to communicate because of physical disability

Adult Support and Protection (Scotland) Act 2007An adult at risk is

Unable to safeguard his/her own wellbeing, property, interests

At risk of harm

Because s/he is affected by disability, mental disorder, illness, mental or physical infirmity is more vulnerable to being harmed than an adult not so affected

• Recognise

• Respond, ensure safety

• Report

• Record

• Reflect

Risk of medication

• BNF

• Specific risks of disease modifying drugs

• Experienced colleagues

Driving

Assessing fitness to drive: a guide for medical professionals

Published:11 March 2016

• https://www.gov.uk/guidance/assessing-fitness-to-drive-a-guide-for-medical-professionals

Falls If you have had a fall in the last 12 months or answered Yes to two or more questions in the test then you are advised to discuss your risk of falls with your GP. If they feel that you are at risk of falling they may refer you to specialist falls services.

FALL RISK TEST

• Have you had a fall in the last 12 months? Yes / No

• Are you on four or more medications a day? Yes / No

• Do you have Parkinson's disease or have you had a stroke? Yes / No

• Do you feel unsteady or have problems with balance? Yes / No• Can you walk while talking? • Do you sway significantly while standing? • The 'Timed Up and Go' test:

• Do you struggle to get up from a chair? Yes / No

For more fall prevention tips download Get Up and Go: A Guide to Staying Steady (PDF, 2.65MB).

Marriage breakdownReduced strength in handsUrinary tract infection

PersonalityGeneticPsychiatricMale

Cognitive flexibilityMental health treatmentMeaningful relationships

Plan next 2 daysLiaise with other hcpNote informal supportSpecialist support –crisis teams

Build protective factorsEnsure access to help

RiskShort term + long

term factors –protective factors

= risk

Risks for patientRisks for carerRisk for family

Goals for patientGoals for familyGoals for professionals

Goal engagement and disengagementHope and hopelessness

CASE EXAMPLE

Risk

Documentation

Communication and consultation with Individual +/- family and professionals

Risk

Mental Capacity

Legal Framework

Quality of Life

Goal engagementGoal dis-engagement

Managing risk

Accountability

Managing conflictDocumentation

Independence

Hope

Conflict

Choice SafetyFreedom

Multi-agency

Activity or Context

Risk or Hazard

Contributing Factors

Impact and Probability

Action Impactand Prob

Living in own home

Choking MSFatigueSaliva

Impact – highProb - medium

PEGSwallowSaliva reductionCare package

Independent Decision Making

Unsafe,poorly understood decision

Mental capacityOther influence

same Mental capacityAdult support and protection

Independent Decision Making

Inappropriaterestriction of decision making

Mental capacityOther influence

same

REVIEW DATE

Activity or Context

Risk or Hazard

Contributing Factors

Impact and Probability

Action Impactand Prob

Living in own home, time alone

Night time

Calling for help

REVIEW DATE

Risk

Documentation

Communication and consultation with Individual +/- family and professionals

Implementation of agreed plan

Review

Cases

Resources

• Training, professionalism and experience

• Risk assessment tools• DMD’s, falls

assessment, suicide risk, fire risk, social, financial sexual exploitation risk

• Professional standards• GMC good medical

practice

• Legal framework• Adults with incapacity

(Scotland) Act 2000: a short guide

• ASP (Scotland) Act 2007

• Experienced colleagues in health and social care; local ethics committee