District nurse/elderly relative

[Eckhart]

My grandad fell, and has an open wound. It has been dressed by the district nurse, who was going to come back twice a week to re-dress it. I visited him on day 2 after it was dressed and it stank to high heaven. He said he'd told the nurse not to re-dress it for a week and she'd agreed.
We contacted the district nurse today to tell her about the smell. She went to see him and he told her in no uncertain terms to go away.
I fear that he will be gangrenous or get septicemia if it's left a week.
Does the district nurse have a duty of care, or is it ok for the NHS to just let a vulnerable old person rot alive because they say they don't want a dressing changing? He has full mental capacity. I have no idea why he's refusing. I've never known anyone so stubborn. I'm very worried about him.

If he has full mental capacity like you say and understands the (unwise) choice he is making, then there is nothing anybody can do. He has a right to make this choice.

He needs admitting to hospital for his own good. Contact the GP and insist that he is admitted. There comes a point where others have to act in his best interests.

Would he allow you to do it?

He has the right to refuse. What do you want the nurse to do. Assault him against his will? Would you feel happier uf you spoke to the nurses and suggest you be there when they can visit and see if that helps.

It's infected, that's why it smells. He needs antibiotics urgently.

Yes unfortunately he has the right to refuse treatment, they won't force him. Can you reason with him as your concerns are very real if he continues like this.

is it ok for the NHS to just let a vulnerable old person rot alive because they say they don't want a dressing changing?

What would you propose they do?

Do it against his will while he has his back turned? (Common Assault)

Restrain him whilst they did it (Common Assault, Possibly ABH and definitely a breach of his Article 5 Human Right to liberty)?

Admit him to hospital against his will? (Article 5 again and would also be an unlawful deprivation of liberty under the Mental Capacity Act).

People with mental capacity have the right to make unwise decisions. What the NHS need to make sure is that he definitely has mental capacity, that means talking to him about why he doesn't want the dressing changing and what might happen if he doesn't let them treat him.

He can only refuse if he's making an informed choice. My MIL was admitted recently, even though she didn't want to be. The DN admitted her, so she could be assessed and the professionals could talk to her and explain everything. She also had an infected leg.

Have you asked him why he is refusing to have a dressing changed and told him how worried you are and that you would like him to see the nurse or doctor.

If the nurse has visited and he's told her to leave and he has full mental capacity then of course she can't force him to recieve treatment against his will.

If you're worried about him then you will have to look into getting him sectioned, but if he has full capacity then that will be hard to achieve.

Why do you think he has full capacity. It sounds more like he has onset dementia.

Your family will need to sort out what to do next. Find out what options there are. You will either need to care for him full time as a family as I doubt he will accept carers or find a suitable home for him.

It will be hard for you and your family and I wish you all luck.

Call your GP who will advise you what to do next.

No such thing as full capacity. Capacity is specific to a) the decision to be made and b) the time of making the decision. Nurse needs to be assessing his capacity to make a decision to decline to adhere to the recommended care plan at the time of the refusal (which includes being relatively certain that he understands consequences of making this choice i.e. infection, more treatment, hospital admission etc). It would be sensible of the nurse to record their assessment thoroughly, as this situation might not end well. Also need to remember infection can lead to delirium, which can impact on capacity.

Btw: Even if a person has capacity to make an unwise decision, it doesn't mean professionals shrug their shoulders and walk away, citing "it's their choice". If it appears the person is neglecting their basic needs, this is a Safeguarding concern and there is a process to be followed,.

Also, a professional would usually attempt to work with the person to find out why they're not keen on the care plan being followed. For example, is the dressing change painful? Does pain relief need to be given before the nurse visit etc. Also, as PP suggests, could a friendly face (i.e. you) be available to help and support during the visit if that might help.

HTH

Does the district nurse have a duty of care, or is it ok for the NHS to just let a vulnerable old person rot alive because they say they don't want a dressing changing?

He's your grandad so his care falls ultimately into yours and your family's hands if he's refusing help from the DN / NHS.

In response to a PP - you can't 'section' (i.e. detain under the Mental Health Act) a person for treatment of a physical health problem...

Just call the district nurse again and say you're worried about infection, can she please see him again and you will also be there to help. Pp suggestion that it might be painful is very valid. There must be a reason he doesnt want it done and I imagine the nurse has documentary evidence, she may well have spoken to her colleagues or g.p about what to do next. He cannot just be sectioned and even if he continues to refuse to see her for a few days and understands the risks involved you are not ultimately responsible for him or his care. I hope he gets the treatment he needs and recovers soon.

Thanks all for your responses. I don't think it's dementia. He's always been this way, and I truly believe he'd be willing to die rather than admit being wrong. He's an immensely difficult man. I've told him he could die from septicaemia if this doesn't get treated, and, if he cares about nothing else, I'll have that on my conscience for the rest of my life. He said 'I don't care - I won't be here, will I.' It is hard to care for somebody when they will deliberately stand in your way.
It's very difficult for me to be there when he sees doctors/nurses as I live 250 miles away. It would make no difference anyway. He is still entitled to his decision whether I'm there or not.
The district nurse has been told of the smell but doesn't seem to think it's a problem. She says it's the dressing, not the wound. But surely a rotten dressing can't be left on a wound? This is really the crux of the problem. I feel like I'm trying, unqualified, to tell a trained nurse what an infection is.
Part of me is saying 'Leave the daft bugger to his decision' (he's been wanting to be dead for about 20 years), and the other part of me is outraged and horrified.
I appreciate your input, MN gang.

@HappyHammy We did call the nurse back, and she went to his flat. He told her to f*ck off.

Maybe the nurse is right. Have you seen the wound or the dressing. Was it wet or discoloured. The nurse must of assessed the wound and decided how often it needed changing.

Oh dear seen your update. Is he normally that rude to people.

It's not about it being painful. I've seen him poking at the dressing himself whilst talking to (at) me about something else, and also seen him pull a jumper and a t shirt right over it. He's not wary of it at all. Why it doesn't hurt him is beyond me. The wound is like horror film make up.
I think it's more that he's decided he wants the dressing changed once a week because that gives it time to heal, and he's too stubborn to back down. He also says he can't smell it. Even though it hits you the second you open his front door.

Just telling the nurse to fuck off is not a demonstration of capacity, he needs to be able to hold a conversation with a HCP about his decision and demonstrate understanding of the consequences. I would ask the GP to do a home visit or contact the community Matron in his area, they are usually helpful. He needs a formal capacity assessment around refusing treatment.

Yes Hammy, he's horrible. He expects care and then treats people like this. Then he complains that they don't do exactly what he tells them to.
One of his carers changed the dressing while I was there, graphic description warning which he allowed. She's not allowed to do that but she agreed something was very off and changed it on the condition that we didn't tell anyone. The dressing was wet, dirty, and you can see the bones (it's on his hand) Some of the flesh is very dark/black. Sorry to be graphic.

@dottycat123 But the nurse doesn't seem to think there'll be consequences. Do you think that can be the case, given my previous post re the state of the wound?
He did talk initially to the nurse and they agreed once a week was ok. He told her to F off because she came again, unscheduled.

He does sound very depressed and this will affect his judgement. It sounds hard for you to have a calm discussion with him as you love him and it upsets you. If the GP or nurse could have a more dispassionate conversation about the risks he is running, and exploring how far his feelings run towards not wanting to live, it might get to why he’s so reluctant to be treated. It’s very distressing watching someone self neglect like this and you have my sympathy.

Maybe I'm just wrong, and there's no risk. I can't quite believe that, though.

@Craftycorvid Thank you. He won't talk to doctors about his mood or mental state. He's determined to be miserable and finds the negative in everything. He's been like this a long time. I've told him he's probably got depression and he could get help to feel better, but he just refuses. He won't even talk about options.