In keeping with its mission, vision, core values, and code of business conduct, the Toronto Central CCAC is committed to respecting all clients’ rights to self-determination. By creating a policy outlining clients’ rights to make choices regarding how and where they live and which care or support services they receive, we are changing the model from risk aversion to managing risk in environments where everyone is aware that living with risk is a part of everyday life. In developing this policy and its implementation plan, we were keenly aware that many issues around patient care decisions can be attributable to conflict over treatment decisions among physicians, patients, and family members. They are also the result of issues around autonomy, the relationship between patients and family members in the same home, and the moral distress of health care staff who see their patients/clients living with increased risk in the community, or who they disagree with choices that patients/families make that may impact negatively on the patient’s quality of life, safety, and well-being. Our work has shown that many of these challenges arise out of healthcare workers’ inability and/or unwillingness to accept some of the choices that patients/clients make with respect to their own health, and a feeling that their role and the unstated direction of their agency is to opt for a risk-averse solution. Using an ethics-based decision-making framework, we address the dynamic between clients and healthcare professionals by supporting both parties in the development and implementation of acceptable service plans. They make it very clear as well that it is our responsibility to inform our clients about actual and/or potential risks and the consequences that may arise from their decisions and to identify appropriate mitigation strategies where possible The Toronto Central CCAC’s Supporting Clients’ Choices policy and practice standards: • Serves as an organizational policy on clients choosing to live at risk with relevant operational guidelines, including roles and responsibilities, for working with clients choosing to live at significant risk in the community. • Provides a definition of risk and examples of the types of risk that the Toronto Central CCAC will and will not support. • Supports clients, caregivers, and staff in making service decisions and increase the confidence of caregivers and staff in supporting clients in their choices, including the choice to live at risk. • Provides the foundation for the development of processes for “what to do and when,” to offer strategies to minimize risk (i.e., by putting in acceptable services or safety plans that support the client but allow for some agreed upon safety goals). • Situates the risk assessment process within a best practices ethical decision-making framework.

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