Duty of Care – Different Interpretations!

Members article

By Jane Verity © Dementia Care International

The following question was asked at a presentation on how to deal constructively with challenging behaviour:

What should we do when one of our residents – a lady in her 8o’s, who has dementia – wants to go out for a walk? She cannot go on her own because she can’t find her way back. We try to divert her attention or, if that doesn’t work, we tell her that she can no longer walk on her own in case she gets lost. She then becomes agitated and very angry to the point of being aggressive!’

On further questioning, it was revealed that the lady in question, Alice, was physically capable of walking and that she had always gone for a walk each day because she believed it kept her healthy and fit.

Knowing that going for a walk had been such an important part of Alice’s life and that she was physically able to walk, it was important to support her in continuing to take her walks on a daily basis.

Three ways were suggested how this could happen practically:

  1. As part of the care plan, a staff member could provide the support needed to enable Alice to go for her walk each day. (Avoid expressions such as: a staff member could take her for a walk. This is the type of language we use when speaking about what we do with our pets!)
  2. This could be an ideal role for a volunteer to come in and, as a friend, go for walks with Alice.
  3. A rejected Seeing Eye dog could become an integral part of the care team and could accompany Alice on her walks. The dog would be trained to get both back to the hostel. (This solution is already being used successfully in facilities within Australia.)

The staff member who posed the above question responded in strong terms that she did not see how staff could find the time to implement the above strategies, nor would she ever allow this resident to walk outside because she saw it as her duty of care to ensure the resident was safe.

This is a real life story, which represents a very unfortunate and growing trend – one that indicates that the term duty of care is now being used by some carers as a reason to justify the use of power and control, enforcing restrictions on those they are meant to care for; instead of providing support and encouragement to enable the person to live life to his or her fullest potential.

Let’s explore this new trend. Imagine the following. When you arrive at work tomorrow you are greeted with a memo about duty of care.

Dear Jane Citizen

Management is concerned that we may face future litigation if we allow you to maintain an unhealthy lifestyle while you remain an employee of this organisation. Since you have demonstrated that you are not able to look after your own health, because you indulge in one or more of the below mentioned bad habits, we deem it necessary to take the following precautions as, clearly, we know better what’s best and how to care for you?

From this day forward, while on duty, no staff member will be allowed to smoke either indoors or outdoors; no staff member will be allowed to drink coffee or tea; eat biscuits, cakes, chocolates (except dark chocolates) and all other sweet foods and snacks are banned for all staff, including bad carbohydrates such as white bread, hot chips etc. These rules will be strictly enforced and cannot be negotiated nor appealed.

Now, honestly… Do you feel cared for? Hardly! How do you really feel? A little peeved? Perhaps even angry that your rights have been taken away? Or maybe you are fired up to fight for your freedom of choice? Thoughts such as: How dare they! – might come to mind too.

This is simply an example of applying the same trend of interpretation of duty of care to your life as used in the story about the lady wanting to go for a walk. Both are restrictive and result in taking away a person’s rights.

While duty of care is about ensuring that a person is kept safe and secure, duty of care is also about ensuring that the person’s needs are fulfilled too.

So back to the real life story about the lady wanting to go for a walk: Step into her shoes and think, if this was me, how would I feel? What would your reaction be if you wanted to go on a walk, which you had always done in the belief that it was good for you, but were now prevented from doing so?

What would your feelings be if, instead, you were invited to go for a walk with a friend? Pleasure, excitement, perhaps even relief!

Another aspect to the carer not wanting to support the woman above in going for a walk could be a fear of the risk that she might fall.

In the book The Tao of Pooh an incident in the life of Chuang-tse is quoted. This tale is something to think about in regard to the fear of risk.

While sitting on the banks of the P’u River, Chuang-tse was approached by two representatives of the Prince of Ch’u who offered him a position at court. Chuan-tse watched the water flowing by as if he had not heard. Finally, he remarked, ‘I am told that the Prince has a sacred tortoise, over two thousand years old, which is kept in a box wrapped in silk and brocade.’ ‘That is true,’ the officials replied. ‘If the tortoise had been given a choice,’ Chuang-tse continued, ‘which do you think he would have liked better – to have been alive in the mud, or dead within the palace?’ ‘ To have been alive in the mud, of course,’ the men answered. ‘I, too, prefer the mud,’ said Chuang-tse. ‘Good-bye.’

Have we come to a point where, ideally, we would like to keep our residents immobile ‘wrapped in silk and brocade’ in pretty surroundings because that way they can’t harm themselves; where they are completely safe and everything looks good on the surface?

For more food for thought on the fear of risk, here is a quote from the poem called Now our Roles are Reversed by Nellie Renoux.

They are right when they say there are risks,
I might fall,
I might leave the stove on!
But there is no challenge, no possibility of triumph,
no real aliveness – without risk.

When they were young and climbed trees and rode bicycles and went away to camp,
I was terrified
but let them go,
because to hold them
would hurt them.

Now our roles are reversed,
help them to see.

Keep me from being grim or stubborn about it.
But don’t let them smother me.

Successful duty of care in the above example is about ensuring that the lady who wants to walk is safe, while, at the same time, having her need fulfilled.

There are so many other opportunities for a positive interpretation of duty of care. Here are some to consider:

What about making it duty of care:

  • whenever a person with dementia goes to hospital that a staff member accompany the person so that they may help with the myriad of factual questions the person will be bombarded with.
  • when a person with dementia needs to go to the toilet and needs assistance that they get that assistance at the time they need it. It is no good being able to sit in a beautiful bedroom with its own en-suite if you can’t get to the toilet when you need it.
  • when a person with dementia needs comfort that they receive warmth and love from a trusted carer instead of an entry in the progress notes that they have been attention-seeking.

When duty of care is interpreted as justification for restriction and control then the focus is only on the action of duty of care not on the possible consequences of the action. Whenever we take control over another person and exercise this by using restrictions, we are bound to create strong negative reactions, such as anger and aggression, resulting in most unfortunate negative consequences.

Further reading – Click topic

  • Checklist for Choosing the Right Aged Care Home – Members article – (Advice on different types of accommodation and home care support for people with dementia; plus comprehensive checklist & guide for comparing facilities & the services they offer; plus contact details for where to get help & advice about aged care, including further helpful links.)
  • Concerns and Complaints in Residential Care – Members article – (Advice on concerns or complaints regarding your rights as a resident or those of a family member in care, including contact details for the Aged Care Information Line & further helpful links in Australia.)
  • Hugs not Drugs – Members  article – Jane Verity (Discover 3 factors behind attention-seeking behaviour, the 5 secrets to ‘great’ hugs & 5 hints to check if a hug is creating discomfort in another person; plus a wonderful non-threatening excuse for exchanging a big hug.)