When Duty of Care and the Client's Wishes Collide
Ruth is a support worker visiting 79-year-old Alf, who lives alone. Alf has type 2 diabetes and a leg ulcer. He refuses to let the district nurse change his dressing, saying 'I've had enough of people poking at me.' He has missed two GP appointments and his pantry contains mostly biscuits and tinned soup. He is alert and oriented, manages his own medication, and tells Ruth, 'I'm not stupid, I know what I'm doing.' His daughter phones Ruth and demands to know his medical details and says she will 'make him' go to the clinic. Alf has not given consent for information to be shared with her. Ruth notices the ulcer smells strongly and the surrounding skin is red and warm.
1. Analyse the tension between duty of care, dignity of risk, and Alf's right to refuse. What should Ruth do?
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The tension: Duty of care requires Ruth to take reasonable steps to prevent foreseeable harm. Dignity of risk recognises that competent adults may make choices others consider unwise, and that overprotection can itself be harmful. Alf has decision-making capacity for this decision: he is alert, oriented, manages medication, and can explain his reasoning. Capacity is decision-specific, so his refusal of wound care should be respected unless there are signs he lacks capacity for that choice.
However, duty of care is not suspended. The red, warm, smelly wound suggests possible infection, which can become serious quickly. Ruth should:
- Assess and document the wound observations, his food intake, missed appointments, and his stated reasons.
- Have a calm conversation exploring his concerns - fear, pain, fatigue, distrust - and offer alternatives: a different nurse, a shorter visit, pain relief before dressing, a GP home visit.
- Provide information in plain language about the signs of worsening infection and when to call for help.
- Escalate appropriately - inform her supervisor and, with Alf's knowledge, contact the GP about the wound. If Alf refuses, document the refusal and the advice given.
- Recognise limits - if there is an immediate risk to life or he loses capacity, emergency action may be justified. Otherwise, supported decision-making and repeated offers are the correct response, not coercion.
Daughter: Ruth must not disclose medical details without consent. She can listen to the daughter's concerns, explain that she cannot confirm or deny details, and ask Alf whether he would like information shared. She can offer general guidance on supporting a parent and suggest the daughter talk with Alf directly.
2. Explain how Ruth should respond to the daughter and what she should record.
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Responding to the daughter: Acknowledge her worry genuinely - 'It sounds frightening to see him like this.' Then explain the limits clearly: 'I can't share his health information without his permission, but I can tell you what I'm doing to support him and what you can do.' Offer to ask Alf whether he consents to sharing specific information, and record his answer. Give general information about wound warning signs and how to contact the service. Do not confirm or deny diagnoses, medications, or appointments. If the daughter becomes aggressive, end the call politely and report it.
Recording: Ruth should document objectively: date and time of visit; Alf's statements in his own words; wound observations (odour, redness, warmth, size); his refusal and the alternatives offered; advice given about warning signs; his food supply; missed appointments; the supervisor notified; the GP contact and outcome; the daughter's call, what was requested, what was disclosed (nothing), and Alf's consent decision. Record facts, not judgements such as 'difficult' or 'non-compliant'.
Why this matters: Good records demonstrate that duty of care was exercised through assessment, information, and escalation, and that Alf's autonomy was respected. They also protect Ruth and the service if the situation deteriorates or a complaint is made.