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.

The carer has put herself in a very difficult position if she did change the dressing, was she trained to do it. The discolouring could be bruising, we cant say but the carer should really speak with her manager for advice, the nurse may notice that the dressing was done by someone else and it puts her in a difficult position too. He will be angry. No idea how you approach this really, it sounds more like he just didnt want the nurse there as it wasnt a planned visit.

We agreed that I'd say I changed the dressing. I can understand why he's angry, too. He agreed a care plan and then they just showed up off-schedule. He still wants his independence, and I've watched him shoot himself in the foot time and again over the years and not interfered. This is just a step too far, though.

The wound sounds necrotic and likely needs more urgent attention.
As an ex district nurse I would be escalating my concerns to the GP/safeguarding lead/social services. As it stands she certainly can't do his dressing against his will.
Very difficult. Many elderly people live like this, living in unsuitable homes, refusing care and then end up in A&E with a crisis that could have been avoided.

Did the nurse just show up off schedule or was it because you called them? It sounds a very difficult situation but I would probably tell the nurse that the dressing has been changed and it doesnt look healthy.

Interesting that he allowed the carer to change it but not the DN.
Suggests that maybe with the right person working with him he will accept the input around the wound.
If the DN, you or the carer are concerned that he is putting himself at serious risk though refusing health input then a referral to the local adult social care team or adult safeguarding team would be appropriate.

Would he agree to you photographing the wound to show DN/GP so they can assess the risk?
Is there a nurse at the GP practice that he likes who he might accept support from? Or would he show a GP that he likes?

Sometimes when people are losing independence/control they need to control what they can.

She came because on my advice, another person (not a relative or professional, she just cares about him) called and asked her to. She explained the condition of the wound, so the nurse has been told.
It's impossible to let grandad know you're going to call round though. He refuses to have a phone.

As long as he is mentally competent enough to understand the consequences of his decision, he can choose to do what he wants - even if he dies as a result.
If you can't get him to accept treatment why do you expect the nurse to get him too? It sounds as though she is doing her best.
People can determine their own fate. This is not the nurses fault.

sharkyfan he only seems to like this carer, nobody else. She came to give him a bath while I was there, and afterwards she put his hearing aid back in for him. I couldn't believe he let her. You know when a cat picks up a kitten and the kitten goes all limp and docile? He went limp like that. Despite everything, I know he's soft in the middle, but there's no way in.
I can't photograph it, I'm 250 miles away. He won't let anyone else photograph it, and the nice carer's not allowed to take the dressing off so she can't.
The nurse is going back for the scheduled visit tomorrow. I hope he'll be more amenable and she'll see it's infected. If not, I'm going to raise a safeguarding alert with ASC.

He may have just thought the nurse turned up, that might have upset him and that's why he told her to eff off. Does he know you called them? I dont think the nurse has done anything wrong, she called round after you expressed concern and was told to go away. You can call her again and ask what they can do but it would probably be better if he agreed. What a dilemma.

Can the carer be there for the visit?
Sometimes they do just click with one person, I spent ages trying to persuade a woman to shower. Turns out she didn't like the cold and was worried about me seeing her naked. I did a lot of covering my eyes with a flannel and towels on radiators to keep warm and we got a routine - but she would never let anyone else shower her!

It doesn't sound great, I had a dressing in my armpit and the wound was fine but the dressing stunk but that's more because of where it was

I don't think she's done anything wrong either. He's not allowing her to do her job. Any consequences from this will be his own fault. I just can't bear to watch this play out. He's so weak. He's 94. I don't want him to go painfully or have to have an amputation or something. It's horrible.

I’m on the social care side rather than clinical, but in terms of pain is it not true that once a wound is a certain depth it doesn’t hurt because the nerve endings are damaged? I know that’s true for pressure sores. So it may genuinely not be feeling that bad for him.

Not saying obviously that you wouldn’t want to try everything to get it sorted!

@SpruceTree I am not blaming the nurse at all, unless she made a mistake when she initially examined the wound and set the course of treatment. He was compliant then. Everything else he's bringing upon himself.
I think it hadn't had a chance to go bad when she saw it though.

I am surprised the nurse doesn't think there could be consequences, it's standard wound care knowledge. I am a bit outdated in my dressings but can't think of any that smell like rotting wound ! I think you need to start asking questions about capacity assessment being documented. The other possibility is that the district nurse goes when the career he likes is there and the nurse agrees to the carer removing the dressing so she can look at it.

@ClientQueen it will just be luck if she's there, I think. She's not at liberty to switch her schedule.

It's definitely not a body odour smell. When his friend went in she said 'it smells like death in there'

As a carer we couldn't change dressings but if it "fell off" ahem we could put a new one on

Recently left district nursing for another post but.... this type of situation happens alot. The nurse will not be leaving your grandad 'to rot' and will have made an assessment of his capacity to make a decision to refuse care/only agree to once weekly visits. All I can suggest from experience is that without being party to the full conversation between your grandad and clinical staff that have visited it is impossible to know what they have discussed fully. It may be that visiting on a weekly basis was all your grandad would allow and that is the compromise they have come to - otherwise he may have refused to see the DN's at all.

Assessing and treating wounds is a complex skill and you need to know what your looking at. Sometimes, in certain stages of healing wounds can become wetter, they can have thick yellow coverings and they can have a slight odour depending on what products/dressings have been used on the wound - but this may be normal for the stage of healing/wound care used.

I would hope that the DN team have explored the options of different team members visiting, explaining risks etc but it sounds like your grandad just doesn't wan them to visit, and like pp have said they can't force themselves into someone's home. Even with concerns re mental capacity there are processes to go through to safeguard your grandad against anything being forced upon him and it's a multi professional decision/approach. I think the fact your grandad has told them to f off and this is not an unusual thing for him to do speaks volumes.

I think you have to let him at it. Tough as it is.

The consequences of worry are on you, not him. I know that sounds incredibly bad, but honestly some people just refuse to be cared for by others and that is their choice.

The unfortunate thing is that those who care for them constantly worry about them. Kind of selfish of the ill person if you ask me, but we cannot change anyone.

I'd back off, having done everything I could really. Nothing good will come of you insisting he should do this and that if he still has capacity.

Legally a person must be assumed to have mental capacity unless there is 'impairment of, or disturbance, in the functioning of mind or brain '
Thankfully soley being elderly and stubborn isn't legally considered enough grounds to start assessing someone's capacity ...if there is indeed such an 'impairment' that makes a MCA appropriate and the individual was found to lack capacity then a best interests decision would still need to be made which incidentally has to take into account the individuals wishes and what they would have chosen before they lacked capacity.....
There are plenty of people that chose to name unwise decisions in regard to their health ....should every smoker have their mental capacity scrutinised just because they are likely to die a painful death if they dont take medical advice ..

Rejectthetossers,

That is fine, but what about those family members who care for these stubborn people. I know from experience who comes out best, and it is usually the stubborn person to the detriment of those who wish the best for these people. Veteran here and have the scars to prove it, literally.

As 'self neglect' it could come under the remit of Adult Safeguarding but ultimately they have no more power than you do to make him do something he doesn't want to do. Plus they will in the first instance refer it back to the district nurses to deal with as its a health issue.

I'm not trying to put you off ringing them as its worth having it recorded, but don't pin any hope on them actually being able to do anything about it.

What might be more constructive is actually being honest with the district nurses about how much more likely he is to comply with the dressing regime if the carer he likes is involved. It's very unlikely that she will get into trouble from the district nurses (especially if she uses the 'it fell off' defence). He might not have a phone but the care worker will and the DNs could liaise with her/ her company to let him know when they will visit and can arrange to visit at the same time as her.

That's what I would be suggesting if I was the safeguarding social worker who's desk it landed on anyway....

Thanks all for your responses. Your experience is helping me make a more informed decision.

@SIB09 Your response is based entirely on your faith that the district nurse is doing her job properly, but that's where my doubt lies. If I had faith in her, there's no way I'd be intefering in a person's treatment from a medical professional. What would I know? But it's considerably more than a 'slight smell',, and I don't even think she would have been aware of it, having only seem him when the wound was fresh. That's why I called her back.

@SpecLosers It's not the consequences of worry that are concerning me, it's the consequences of his hand poisoning him to death and nobody doing anything about it. I know it's not up to him to take care of my concerns, although I wish he'd show some signs of giving a shit. It's always very frustrating going to see him because he only ever talks about himself and his woes. He could be quite happy if he chose to, and he's fully got the capacity to be able to involve himself in other people's happiness to cheer him up. He just doesn't bother. He moved twice in 2 years, by choice, a few years back. All very worrying and technically complicated (buying/selling properties, trying to pack all his stuff to his specifications etc) Both times I did exactly what I asked at every turn, and both times afterwards he's looked at me with disgust and told me 'Moving here was the worst decision you could have made for me, it's like living in hell.'
He's never asked me how I am, although I drive several hours to see him. Never offers me a cup of tea when I arrive, or says 'Help yourself if you want a drink.' He's got no idea about my life, doesn't know what I do for a living, whether I have a partner, whether my own health is good.
I really just wish I could switch off my emotions towards him...