LEGAL
Guarding against discriminatory treatment decisions Richard Griffith
Richard Griffith is Lecturer in Health Law, School of Health Science, Swansea University Email: [email protected]
T
he challenge of how to respond to an incapable adult’s refusal to comply with treatment is one that district nurses are frequently asked to meet. Drug non-compliance is such a problem that the World Health Organization has identified it as worldwide problem of striking magnitude that has consequences for the individual and wider society (McGraw and Drennan, 2004). Factors that contribute to poor compliance include: w Unwanted side effects w Concerns about the value or appropriateness of taking medicines w Complex regimes involving multiple doses and several medicines. However, where the person who has been prescribed the medicine is an adult who lacks decision-making capacity, practical difficulties or confusion associated with taking medicines are generally the main cause of noncompliance (Brown and Bussell, 2011). Responding to the problem of non-compliance appropriately is essential so that district nurses can demonstrate that they have discharged their legal duty of care and have done all they can to preserve the therapeutic benefit of the treatment. In the case study in this article, the district nurse is right to consider the legal obligations she owes the patient before making any decision about his continued treatment. As an accountable practitioner, the district nurse would face sanctions ranging from a criminal prosecution to disciplinary action by her employer and statutory regulator if she failed to meet those obligations.
© 2013 MA Healthcare Ltd
Case study synopsis Paul, 52, has early onset dementia, Down’s syndrome and an associated heart condition, for which he is prescribed warfarin and digoxin. A district nurse, who is an independent prescriber, monitors and adjusts his medication and takes the required blood sample. The staff at the care home where he lives report that Paul is now spitting out his medication and they have not been able to persuade him to swallow his tablets for a week. Despite Paul being assessed as lacking capacity to decide treatment decisions, the care home staff argue that his refusal to take medication should be respected and the medication discontinued. Although withdrawing the medication would make caring for Paul less challenging, the district nurse must
British Journal of Community Nursing Vol 18, No 10
make an assessment of the legal obligations that must be considered before this decision can be considered lawful.
Duty of care Where a district nurse undertakes the care of a patient, it gives rise to a duty of care (Kent vs Griffiths [2001]). The scope of the duty was defined by Lord Diplock as:
‘A single comprehensive duty that covers all the ways you are called on to exercise clinical judgement to improve the physical and mental condition of the patient.’ (Sidaway vs Bethlem Royal Hospital [1985]) This duty cannot be abdicated or abandoned and continues until the patient is discharged or the care of the patient is transferred to another health professional (R (On The Application Of Oliver Leslie Burke) (Respondent) vs General Medical Council (Appellant) & The Disability Rights Commission & 8 Others (Interveners) [2005]). This comprehensive duty demands that district nurses ensure that their acts or omission do not harm the patients in their care (Bolam vs Friern HMC [1957])
Abstract
This article studies a case in which a 52-year-old male patient has early onset dementia, Down’s syndrome and an associated heart condition, for which he is prescribed warfarin and digoxin. A district nurse, who is an independent prescriber, monitors and adjusts his medication and takes the required blood sample. The staff at the care home where the patient lives report that the patient is spitting out his medication and they have not been able to persuade him to swallow his tablets for a week. Despite the patient being assessed as lacking capacity to decide treatment decisions, the care home staff argue that his refusal to take medication should be respected and the medication discontinued. Although withdrawing the medication would make caring for the patient less challenging, the district nurse assesses the legal obligations that must be considered before this decision can be considered lawful.
KEY WORDS
w Discrimination w Equality w Wilful neglect w Gross negligence w Amelioration
513
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 12, 2015. For personal use only. No other uses without permission. . All rights re
LEGAL
Patient dignity underpins the district nurse’s duty of care to their patient. The Royal College of Nursing consider dignity to lie at the heart of all that nurses do and define it as concerning:
‘How people feel, think and behave in relation to the worth or value of themselves and other.To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals’. (Royal College of Nursing, 2008) The legal basis for the concept of dignity is derived from the Universal Declaration of Human Rights, article 1, which proclaims:
‘All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.’ (United Nations 1948) This fundamental right is reinforced by the Charter Of Fundamental Rights Of The European Union (European Union, 2000) and the Council of Europe (1950), which consider dignity to be an inviolable right. In practice, respect for dignity places a duty on the district nurse in our case study to treat Paul as an individual who requires care and treatment that is underpinned by understanding, empathy and compassion (Munby, 2012). This duty is all the more important where that patient, as in our case study, has a disability that makes them vulnerable and at risk of having their dignity ignored (Hale, 2004).
Amelioration and compensation To ensure that the dignity of vulnerable and incapable patients is maintained, district nurses have a duty to ensure that their care and treatment decisions do not discriminate against those patients because of their disability. The Equality Act 2010, section 13 makes it unlawful not only to treat a person less favourably because of their disability, but requires that district nurses take measures to ameliorate and compensate for that disability. This legal obligation means that, in our case study, the district nurse cannot take the decision to simply agree with the care home staff and withdraw the medicine until she has considered and weighed the consequences of stopping the treatment and the merits of alternative methods of administering the medicine, such as a liquid formulation or patch. As Paul lacks the capacity to make decisions about his treatment, the district nurse is obliged to determine what care and treatment is in his best interests under the provisions of the Mental Capacity Act 2005 and its Code of Practice (Department for Constitutional Affairs, 2007). The requirements for determining best interests under the 2005 Act make it clear that any care or treatment decision concerning a person who lacks decision-making capacity must be made in their best interests (Department
514
Box 1. Mental Capacity Act 2005, section 4: best interests checklist of factors. The person making the determination must consider all the relevant circumstances and, in particular, take the following steps. He must consider: ➢ Whether it is likely that the person will at some time have capacity in relation to the matter in question, and ➢ If it appears likely that he will, when that is likely to be. He must, so far as reasonably practicable, permit and encourage the person to participate, or to improve his ability to participate, as fully as possible in any act done for him and any decision affecting him. Where the determination relates to life-sustaining treatment he must not, in considering whether the treatment is in the best interests of the person concerned, be motivated by a desire to bring about his death. He must consider, so far as is reasonably ascertainable: ➢ The person’s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity) ➢ The beliefs and values that would be likely to influence his decision if he had capacity ➢ The other factors that he would be likely to consider if he were able to do so. He must take into account, if it is practicable and appropriate to consult them, the views of: ➢ Anyone named by the person as someone to be consulted on the matter in question or on matters of that kind ➢ Anyone engaged in caring for the person or interested in his welfare ➢ Any donee of a lasting power of attorney granted by the person ➢ Any deputy appointed for the person by the court ➢ As to what would be in the person’s best interests Source: Department for Constitutional Affairs (2007)
for Constitutional Affairs, 2007). The Act also forbids discriminatory treatment decisions. A best-interest determination must not be made merely on the basis of: w The person’s age or appearance w A condition of theirs, or an aspect of their behaviour, which might lead others to make unjustified assumptions about what might be in the person’s best interests (Department for Constitutional Affairs, 2007). Section 4 of the 2005 Act sets out a list of factors (Box 1) that must be considered when deciding what care and treatment would be in the best interest of a person who lacks capacity to make a particular decision. These fac-
© 2013 MA Healthcare Ltd
Dignity
British Journal of Community Nursing Vol 18, No 10
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 12, 2015. For personal use only. No other uses without permission. . All rights re
LEGAL tors offer district nurses guidance on the determination of best interests. District nurses must identify all relevant issues, including the benefits and risks of continuing or withdrawing treatment, and must give due consideration to the past and present wishes of the individual who lacks capacity. A multidisciplinary guideline is available to assist district nurses with the determination of best interests of patients with learning disabilities who have problems swallowing tablets (Wright et al, 2012).
Wilful neglect Should the district nurse in our case study fail to properly work through the checklist of factors or ignore the consequences of withdrawing treatment from Paul, then she would be liable to face prosecution for wilful neglect. Section 44 of the Mental Capacity Act 2005 makes it an offence to ill-treat or wilfully neglect a person who lacks decision-making capacity. The Court of Appeal has recently clarified the definition of wilful neglect in a health context and the offence is made out in the following way. In R vs Patel [2013], the Court of Appeal held that neglect occurs where a nurse does not do that which should be done in the treatment of the patient.The neglect is wilful if the nurse knows the treatment is necessary and deliberately decides not to carry it out. The Court of Appeal also reminds nurses that, where such neglect caused the death of the patient, a more serious charge of gross negligence manslaughter could be brought.
Futile treatment The decision of the court of appeal in R vs Patel [2013] does allow for the withdrawal of treatment, but only where it is reasonably considered to be futile to continue. Futile treatment has also been redefined recently by the Court of Appeal. In Aintree University Hospitals NHS Foundation Trust vs David James [2013], a narrower definition was adopted by the court that found treatment to be futile if it did not secure a therapeutic benefit for the patient. That is, the treatment, standing alone or with other medical care, has the real prospect of curing, or at least palliating, the disease or illness from which the patient is suffering. In our case study it is likely that the district nurse will consider that continued administration of warfarin and digoxin is necessary to secure a therapeutic benefit for Paul.
© 2013 MA Healthcare Ltd
Conclusion Discontinuing the administration of medication from incapable adults who are unable or refuse to swallow their tablets is a common response to patients who present such challenging behaviour. The district nurse in our case study is right to be cautious in acceding to the request of the care home to stop Paul’s tablets. A district nurse’s duty of care requires that treatment decisions are made on therapeutic grounds and promote the dignity and equality of the patients in their care. It is unlawful for district nurses to
British Journal of Community Nursing Vol 18, No 10
withdraw treatment merely for the convenience of carers. Treatment that will reasonably secure a therapeutic benefit for a patient must continue and the district nurse must carefully assess the causes of Paul’s reluctance to take medication and act on the findings of that assessment. In this way the district nurse will discharge her duty of care and ensure that Paul is treated in a non-discriminatory way that promotes his health and his dignity. If you are interested in finding out more about the legal cases noted in this feature, please email the editor at [email protected] Aintree University Hospitals NHS Foundation Trust vs David James [2013] EWCA Civ 65 Bolam vs Friern HMC [1957] 1 WLR 582 Kent vs Griffiths [2001] QB 36 (CA) R (On The Application Of Oliver Leslie Burke) (Respondent) vs General Medical Council (Appellant) & The Disability Rights Commission & 8 Others (Interveners) [2005] EWCA Civ 1003 R vs Patel [2013] EWCA Crim 965 Sidaway vs Bethlem Royal Hospital [1985] AC 871
Brown MT, Bussell JK (2011) Medication adherence: WHO cares? Mayo Clinic Proc 86(4): 304–14 Council of Europe (1950) European Convention on Fundamental Human Rights and Freedoms Council of Europe, Rome Department for Constitutional Affairs (2007) Mental Capacity Act 2005 Code of Practice. TSO, London European Union (2000) Charter Of Fundamental Rights Of The European Union (OJ C 364/01). http://tinyurl.com/nol6v5a (accessed 19 September 2013) Hale B (2004) Paul Sieghart Memorial Lecture,What can the Human Rights Act do for my Mental Health? British Institute of Human Rights, London McGraw C, Drennan V (2004) Older people and medication management: from compliance to concordance. Rev Clin Geront 14(2): 145–53 Munby J (2012) Safeguarding and dignity: protecting liberties—when is safeguarding abuse? Brunswick Mental Health Care Rev 7(16): 32 Royal College of Nursing (2008) The RCN’s definition of dignity. http://tinyurl.com/qeuklav (accessed 19 September) United Nations (1948) Universal Declaration of Human Rights: Adopted by General Assembly Resolution 217 A(III). United Nations General Assembly, New York Wright D, Beavon N, Branford D et al (2012) Guideline for the identification and management of swallowing difficulties in adults with learning disability. http://tinyurl.com/nnpmy6k (accessed 19 September 2013)
Learning points
w Where a district nurse undertakes the care of a patient it gives rise to a duty of care w This duty cannot be abdicated or abandoned, and continues until the patient is discharged or the care of the patient is transferred w Patient dignity underpins the district nurse’s duty of care to patients w District nurses have a duty to ensure their care and treatment decisions do not discriminate against those patients because of their disability w Neglect occurs where a nurse does not do that which should be done in the treatment of the patient w A multidisciplinary guideline is available to assist district nurses with the determination of best interests of patients with learning disabilities who have problems swallowing
515
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 12, 2015. For personal use only. No other uses without permission. . All rights re
Guarding against discriminatory treatment decisions Richard Griffith
Richard Griffith is Lecturer in Health Law, School of Health Science, Swansea University Email: [email protected]
T
he challenge of how to respond to an incapable adult’s refusal to comply with treatment is one that district nurses are frequently asked to meet. Drug non-compliance is such a problem that the World Health Organization has identified it as worldwide problem of striking magnitude that has consequences for the individual and wider society (McGraw and Drennan, 2004). Factors that contribute to poor compliance include: w Unwanted side effects w Concerns about the value or appropriateness of taking medicines w Complex regimes involving multiple doses and several medicines. However, where the person who has been prescribed the medicine is an adult who lacks decision-making capacity, practical difficulties or confusion associated with taking medicines are generally the main cause of noncompliance (Brown and Bussell, 2011). Responding to the problem of non-compliance appropriately is essential so that district nurses can demonstrate that they have discharged their legal duty of care and have done all they can to preserve the therapeutic benefit of the treatment. In the case study in this article, the district nurse is right to consider the legal obligations she owes the patient before making any decision about his continued treatment. As an accountable practitioner, the district nurse would face sanctions ranging from a criminal prosecution to disciplinary action by her employer and statutory regulator if she failed to meet those obligations.
© 2013 MA Healthcare Ltd
Case study synopsis Paul, 52, has early onset dementia, Down’s syndrome and an associated heart condition, for which he is prescribed warfarin and digoxin. A district nurse, who is an independent prescriber, monitors and adjusts his medication and takes the required blood sample. The staff at the care home where he lives report that Paul is now spitting out his medication and they have not been able to persuade him to swallow his tablets for a week. Despite Paul being assessed as lacking capacity to decide treatment decisions, the care home staff argue that his refusal to take medication should be respected and the medication discontinued. Although withdrawing the medication would make caring for Paul less challenging, the district nurse must
British Journal of Community Nursing Vol 18, No 10
make an assessment of the legal obligations that must be considered before this decision can be considered lawful.
Duty of care Where a district nurse undertakes the care of a patient, it gives rise to a duty of care (Kent vs Griffiths [2001]). The scope of the duty was defined by Lord Diplock as:
‘A single comprehensive duty that covers all the ways you are called on to exercise clinical judgement to improve the physical and mental condition of the patient.’ (Sidaway vs Bethlem Royal Hospital [1985]) This duty cannot be abdicated or abandoned and continues until the patient is discharged or the care of the patient is transferred to another health professional (R (On The Application Of Oliver Leslie Burke) (Respondent) vs General Medical Council (Appellant) & The Disability Rights Commission & 8 Others (Interveners) [2005]). This comprehensive duty demands that district nurses ensure that their acts or omission do not harm the patients in their care (Bolam vs Friern HMC [1957])
Abstract
This article studies a case in which a 52-year-old male patient has early onset dementia, Down’s syndrome and an associated heart condition, for which he is prescribed warfarin and digoxin. A district nurse, who is an independent prescriber, monitors and adjusts his medication and takes the required blood sample. The staff at the care home where the patient lives report that the patient is spitting out his medication and they have not been able to persuade him to swallow his tablets for a week. Despite the patient being assessed as lacking capacity to decide treatment decisions, the care home staff argue that his refusal to take medication should be respected and the medication discontinued. Although withdrawing the medication would make caring for the patient less challenging, the district nurse assesses the legal obligations that must be considered before this decision can be considered lawful.
KEY WORDS
w Discrimination w Equality w Wilful neglect w Gross negligence w Amelioration
513
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 12, 2015. For personal use only. No other uses without permission. . All rights re
LEGAL
Patient dignity underpins the district nurse’s duty of care to their patient. The Royal College of Nursing consider dignity to lie at the heart of all that nurses do and define it as concerning:
‘How people feel, think and behave in relation to the worth or value of themselves and other.To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals’. (Royal College of Nursing, 2008) The legal basis for the concept of dignity is derived from the Universal Declaration of Human Rights, article 1, which proclaims:
‘All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.’ (United Nations 1948) This fundamental right is reinforced by the Charter Of Fundamental Rights Of The European Union (European Union, 2000) and the Council of Europe (1950), which consider dignity to be an inviolable right. In practice, respect for dignity places a duty on the district nurse in our case study to treat Paul as an individual who requires care and treatment that is underpinned by understanding, empathy and compassion (Munby, 2012). This duty is all the more important where that patient, as in our case study, has a disability that makes them vulnerable and at risk of having their dignity ignored (Hale, 2004).
Amelioration and compensation To ensure that the dignity of vulnerable and incapable patients is maintained, district nurses have a duty to ensure that their care and treatment decisions do not discriminate against those patients because of their disability. The Equality Act 2010, section 13 makes it unlawful not only to treat a person less favourably because of their disability, but requires that district nurses take measures to ameliorate and compensate for that disability. This legal obligation means that, in our case study, the district nurse cannot take the decision to simply agree with the care home staff and withdraw the medicine until she has considered and weighed the consequences of stopping the treatment and the merits of alternative methods of administering the medicine, such as a liquid formulation or patch. As Paul lacks the capacity to make decisions about his treatment, the district nurse is obliged to determine what care and treatment is in his best interests under the provisions of the Mental Capacity Act 2005 and its Code of Practice (Department for Constitutional Affairs, 2007). The requirements for determining best interests under the 2005 Act make it clear that any care or treatment decision concerning a person who lacks decision-making capacity must be made in their best interests (Department
514
Box 1. Mental Capacity Act 2005, section 4: best interests checklist of factors. The person making the determination must consider all the relevant circumstances and, in particular, take the following steps. He must consider: ➢ Whether it is likely that the person will at some time have capacity in relation to the matter in question, and ➢ If it appears likely that he will, when that is likely to be. He must, so far as reasonably practicable, permit and encourage the person to participate, or to improve his ability to participate, as fully as possible in any act done for him and any decision affecting him. Where the determination relates to life-sustaining treatment he must not, in considering whether the treatment is in the best interests of the person concerned, be motivated by a desire to bring about his death. He must consider, so far as is reasonably ascertainable: ➢ The person’s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity) ➢ The beliefs and values that would be likely to influence his decision if he had capacity ➢ The other factors that he would be likely to consider if he were able to do so. He must take into account, if it is practicable and appropriate to consult them, the views of: ➢ Anyone named by the person as someone to be consulted on the matter in question or on matters of that kind ➢ Anyone engaged in caring for the person or interested in his welfare ➢ Any donee of a lasting power of attorney granted by the person ➢ Any deputy appointed for the person by the court ➢ As to what would be in the person’s best interests Source: Department for Constitutional Affairs (2007)
for Constitutional Affairs, 2007). The Act also forbids discriminatory treatment decisions. A best-interest determination must not be made merely on the basis of: w The person’s age or appearance w A condition of theirs, or an aspect of their behaviour, which might lead others to make unjustified assumptions about what might be in the person’s best interests (Department for Constitutional Affairs, 2007). Section 4 of the 2005 Act sets out a list of factors (Box 1) that must be considered when deciding what care and treatment would be in the best interest of a person who lacks capacity to make a particular decision. These fac-
© 2013 MA Healthcare Ltd
Dignity
British Journal of Community Nursing Vol 18, No 10
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 12, 2015. For personal use only. No other uses without permission. . All rights re
LEGAL tors offer district nurses guidance on the determination of best interests. District nurses must identify all relevant issues, including the benefits and risks of continuing or withdrawing treatment, and must give due consideration to the past and present wishes of the individual who lacks capacity. A multidisciplinary guideline is available to assist district nurses with the determination of best interests of patients with learning disabilities who have problems swallowing tablets (Wright et al, 2012).
Wilful neglect Should the district nurse in our case study fail to properly work through the checklist of factors or ignore the consequences of withdrawing treatment from Paul, then she would be liable to face prosecution for wilful neglect. Section 44 of the Mental Capacity Act 2005 makes it an offence to ill-treat or wilfully neglect a person who lacks decision-making capacity. The Court of Appeal has recently clarified the definition of wilful neglect in a health context and the offence is made out in the following way. In R vs Patel [2013], the Court of Appeal held that neglect occurs where a nurse does not do that which should be done in the treatment of the patient.The neglect is wilful if the nurse knows the treatment is necessary and deliberately decides not to carry it out. The Court of Appeal also reminds nurses that, where such neglect caused the death of the patient, a more serious charge of gross negligence manslaughter could be brought.
Futile treatment The decision of the court of appeal in R vs Patel [2013] does allow for the withdrawal of treatment, but only where it is reasonably considered to be futile to continue. Futile treatment has also been redefined recently by the Court of Appeal. In Aintree University Hospitals NHS Foundation Trust vs David James [2013], a narrower definition was adopted by the court that found treatment to be futile if it did not secure a therapeutic benefit for the patient. That is, the treatment, standing alone or with other medical care, has the real prospect of curing, or at least palliating, the disease or illness from which the patient is suffering. In our case study it is likely that the district nurse will consider that continued administration of warfarin and digoxin is necessary to secure a therapeutic benefit for Paul.
© 2013 MA Healthcare Ltd
Conclusion Discontinuing the administration of medication from incapable adults who are unable or refuse to swallow their tablets is a common response to patients who present such challenging behaviour. The district nurse in our case study is right to be cautious in acceding to the request of the care home to stop Paul’s tablets. A district nurse’s duty of care requires that treatment decisions are made on therapeutic grounds and promote the dignity and equality of the patients in their care. It is unlawful for district nurses to
British Journal of Community Nursing Vol 18, No 10
withdraw treatment merely for the convenience of carers. Treatment that will reasonably secure a therapeutic benefit for a patient must continue and the district nurse must carefully assess the causes of Paul’s reluctance to take medication and act on the findings of that assessment. In this way the district nurse will discharge her duty of care and ensure that Paul is treated in a non-discriminatory way that promotes his health and his dignity. If you are interested in finding out more about the legal cases noted in this feature, please email the editor at [email protected] Aintree University Hospitals NHS Foundation Trust vs David James [2013] EWCA Civ 65 Bolam vs Friern HMC [1957] 1 WLR 582 Kent vs Griffiths [2001] QB 36 (CA) R (On The Application Of Oliver Leslie Burke) (Respondent) vs General Medical Council (Appellant) & The Disability Rights Commission & 8 Others (Interveners) [2005] EWCA Civ 1003 R vs Patel [2013] EWCA Crim 965 Sidaway vs Bethlem Royal Hospital [1985] AC 871
Brown MT, Bussell JK (2011) Medication adherence: WHO cares? Mayo Clinic Proc 86(4): 304–14 Council of Europe (1950) European Convention on Fundamental Human Rights and Freedoms Council of Europe, Rome Department for Constitutional Affairs (2007) Mental Capacity Act 2005 Code of Practice. TSO, London European Union (2000) Charter Of Fundamental Rights Of The European Union (OJ C 364/01). http://tinyurl.com/nol6v5a (accessed 19 September 2013) Hale B (2004) Paul Sieghart Memorial Lecture,What can the Human Rights Act do for my Mental Health? British Institute of Human Rights, London McGraw C, Drennan V (2004) Older people and medication management: from compliance to concordance. Rev Clin Geront 14(2): 145–53 Munby J (2012) Safeguarding and dignity: protecting liberties—when is safeguarding abuse? Brunswick Mental Health Care Rev 7(16): 32 Royal College of Nursing (2008) The RCN’s definition of dignity. http://tinyurl.com/qeuklav (accessed 19 September) United Nations (1948) Universal Declaration of Human Rights: Adopted by General Assembly Resolution 217 A(III). United Nations General Assembly, New York Wright D, Beavon N, Branford D et al (2012) Guideline for the identification and management of swallowing difficulties in adults with learning disability. http://tinyurl.com/nnpmy6k (accessed 19 September 2013)
Learning points
w Where a district nurse undertakes the care of a patient it gives rise to a duty of care w This duty cannot be abdicated or abandoned, and continues until the patient is discharged or the care of the patient is transferred w Patient dignity underpins the district nurse’s duty of care to patients w District nurses have a duty to ensure their care and treatment decisions do not discriminate against those patients because of their disability w Neglect occurs where a nurse does not do that which should be done in the treatment of the patient w A multidisciplinary guideline is available to assist district nurses with the determination of best interests of patients with learning disabilities who have problems swallowing
515
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 12, 2015. For personal use only. No other uses without permission. . All rights re
