All patients deserve dignity in care

A range of different reports and inquiries, such as the one from the Healthcare Ombudsman earlier this year,1 have once again highlighted the need for improving dignity in care, particularly for the elderly. The Patients Association reports that older people often experience care that does not meet their needs, particularly with regards to dignity, and receive unjustified differential clinical treatment and access to services purely on the basis of their age.2 Most recently, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reported on elderly patients who died within 30 days of surgery. Only one third of patients had received good care, and major flaws in the care of the elderly were revealed. The report highlights that it is well understood that the elderly tend to be more vulnerable and to suffer more co-morbidities than younger patients. It is equally well known that they require a style of medicine that is correspondingly sensitive to many needs that may not be obvious when they enter hospital for surgical procedures. The trouble is that NCEPOD advisors found that far too many of this group were not getting that pattern of care.3 The NHS Constitution places the right of every patient to be treated with dignity and respect firmly at the centre of care. This right is powerfully established by the European Convention on Human Rights which essentially seeks to establish fundamental freedoms and the protection of human rights. The NHS Constitution outlines that the right to dignity includes a right “not to be subjected to inhuman or degrading treatment”. The constitution reminds healthcare professionals that they are subject to the standards set by their own regulatory bodies.4 Despite this, the NHS and independent Healthcare providers all over the UK regularly fail to meet the standards set. The Care Quality Commission (CQC) reported in August that one-fifth of Trusts were failing on dignity and nutrition standards and a further 35% were informed that they needed to do more to remain compliant.5 Perhaps dignity is too difficult to define. For more than a decade, researchers have struggled to pin down what is in essence an ethical concept that varies according to the cultural, historical and philosophical contexts in which it is discussed. But we are concerned here with the practical question of supporting dignity in care in the 21st Century. Research has identified – through observation, interview and analysis – a list of attributes of dignity or factors which indicate its presence in care provision. International comparative research has confirmed that it is possible to generalise across the EU and North America about many of these attributes. Everywhere, the literature reflects tensions and questions of balance: between preserving privacy on the one hand, and avoiding isolation on the other; between acknowledging autonomy and resilience, while offering close support; between actual frailty and dependence, and the need for continued usefulness; between setting clear service targets, and leaving room for flexible, holistic, personal responses.6

 Defining dignity

There are many and varied definitions available, but in a previous campaign in 2008, the Royal College of Nursing used the following definition, which the author feels covers almost every aspect pertinent to healthcare delivery. “Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals. In care situations, dignity may be promoted or diminished by the physical environment; organisation culture; by the attitudes and behaviour of the nursing team and others and by the way in which care activities are carried out. When dignity is present people feel in control, valued and confident, comfortable and able to make decisions for themselves. When dignity is absent people feel devalued, lacking control and comfort. They may lack confidence and be unable to make decisions for themselves. They may feel humiliated, embarrassed or ashamed. Dignity applies equally to those who have capacity and to those who lack it. Everyone has equal worth as human beings and must be treated as if they are able to feel, think and behave in relation to their own worth or value. The healthcare/nursing team should, therefore, treat all people in all settings and of any health status with dignity, and dignified care should continue after death.”7 In this series of articles, which focus on the issues surrounding dignity for patients, the author will use this definition; it may not be perfect, but it covers the importance of most aspects of human dignity which need to be realised when any human being has to rely on others to assist with their need to return to health or to experience a peaceful and dignified death.