All aspects of a district nurse’s working day require the ability to anticipate what lies ahead and to do as best they can to prepare for it. Such abilities come with training and, even more so, with professional judgement founded on experience. Past mistakes or misjudgements are of value, if only to forewarn of learned errors and to provide solutions towards them. Wisdom before the event is often a prerequisite to avoid the occurrence of an untoward outcome.
To say that legal responsibility encompasses learning from past mistakes is no threat to the legal responsibilities of district nurses for at least two reasons. First, the law never expects a guaranteed outcome in any arena of treatment or care. Second, no two cases are exactly the same in each and every detail and there is no guarantee that the avoidance of such-and-such an outcome will guarantee a perfect, or even desired result in any particular case.
The building blocks of legal responsibilities, as they affect district nursing practice, have been identified in earlier issues of the BJCN (Finch, 2019a;2019b;2019c;2020;2022) and needs only the briefest restatement here. The law never requires a clinician to do their best, let alone to do their best at all times. Such may be one’s professional aspiration but it is never a legal duty.
The requirement to respect patient confidentiality remains a cornerstone of advance planning. It remains as important as consent in any other arena of clinical care but it, too, raises special questions on account of the involvement of family and other carers and presents special responsibilities. Genuine consent by the patient to proposed treatment and future care remains as important as with any other arena of clinical care; but it, too, is apt to raise special questions in advance planning when the patient is getting older-heralding in potential changes in the patient’s desires and thought processes. Interagency working raises some of the most delicate questions in advance planning and the gift of predicting future relations between professionals is to be treasured.
What are patients consenting to?
As in all other aspects of clinical treatment and care, the genuine consent of the patient is essential, both now and in the future. The reliable prediction of consent at some future time may be problematic for many reasons. These include the prospects for major domiciliary change, in which, the patient’s future circumstances are predictably, or at least possibly, subject to variation in the current scheme of care. Factors influencing advance planning include the patient’s age, the particular stage at which the treatment has reached, the prospects for continued improvement or deterioration of the patient’s physical or mental condition, the possibility of a major change in living arrangements such as a move to a residential or nursing home, and the age and personal circumstances of family and immediate carers themselves.
Patient’s wishes may change over time according to age, mental and physical condition and personal circumstances. These and any other factors bearing on their personal circumstances should be carefully noted and taken into account in advance planning relating to genuine consent. A change of domicile-planned or anticipated-should always be considered a major influence on consent.
In cases of mental incapacity-actual or anticipated-recourse may be indicated to the Court of Protection pursuant to the provisions of the Mental Capacity Act 2005 (UK Goverment, 2005). The Act and its accompanying Code of Practice have been discussed at length elsewhere (Finch, 2019).
Differential diagnosis and advance planning
Many cases of patient care and treatment are straightforward and the question of differential diagnosis of physical or mental condition does not need to be considered. There are some cases, however, where a differential approach may be vital to proper care.
Differential diagnosis and its influence on advance care planning should be distinguished from cases where a patient suffers from more than one (although, perhaps, related) condition. The latter is not so much a case of differential diagnosis as one in which the conditions are treated in tandem. It may be that such a combination or overlay of conditions could, in time, lead to a further state of affairs, in which case, advance planning comes into play.
A true instance of differential diagnosis affecting advance planning is one where future choices are indicated for treatment and care. Each indicator should be carefully noted, and it can be helpful to adopt a method of recording, which draws particular attention to such indicators to other team members and to clinicians who may assume responsibility at some later date, whether precisely known or broadly anticipated.
Differential diagnosis may have been initially based on the expert opinion of a single clinician or on the opinion of more than one. Whichever is the case, it is always important to flag up the origins of the diagnosis in the patient’s notes, in order for clinicians currently treating the patient to fully understand the parameters offered for ongoing treatment and to facilitate proper advance planning.
Policies and advanced planning
As one who is normally averse to policies, the author would like to offer a note of caution when it comes to advance planning in the practice of a district nurse. Policies can be good or bad, depending on a variety of factors, let alone, the reason why they may exist at all. They could make life easier for managers, not all of whom are sufficiently familiar with the clinical niceties of a particular case. However, they also have the capacity to obscure clinical details, which may be essential to proper treatment and care. Toeing the party line may get brownie points if it makes life easier for a manager who is less than sufficiently clinically informed, but it can store up trouble for the future and may well not be in the best interests of the patient in either the shorter or the longer term. The law recognises that clinicians practise an inexact science, no matter how hard the clinicians in question try; and a court of law would be likely to look askance at a clinical decision made on the basis of a blanket policy, were sight to be lost of the wellbeing of the particular patient.
While it is true that policies may be legitimately called for in some circumstances, such as staff shortages, they should be kept constantly under review to ensure that they continue to have a valid reason to continue. While it is well beyond the scope of the present article to embark on the major ongoing problem of the shortage of nurses on a national scale, it is the legal, as well as the moral and professional responsibility of service provision managers, to ensure that the policies operating in their service do not fall out of step with times and conditions.
Handover
The handover of clinical responsibility for a patient’s treatment and care is a vital stage for a number of reasons. First, the information passed to the nurse taking over requires a delicate balance between economy of expression and the responsibility to ensure accuracy and attention to detail to fully implement the treatment plan. The balance is delicate because, while some observations made and written down are so mundane, that reading them would be like reinventing the wheel for the clinician taking over, others may not be so susceptible. Every case is different. Factors which may be relevant to the information given on handover could include: the knowledge, if any, on the part of the handover nurse; the responsibility of the nurse taking over; or their overall experience in practice. The legal responsibility is to exercise good sense-common and professional.
The role of notes on handover
Patient notes play an important, sometimes pivotal, part in the impression made on the clinician who takes over responsibility. This can have a particularly profound effect when the patient moves to another clinical setting where the notes are the only link between the new carers and the patient’s past history.
An anecdotal aside on handovers and notes, comes from an experience the author had during the early days of the Mental Health Act Commission. The remit of the Mental Health Act 1983 was that the Commission should keep under review the powers conferred and duties imposed by the Act. This principally meant that, to make sure during scheduled and occasionally unscheduled visits to ‘psychiatric and mental handicap’ (the term then used) that the requirements of the Act relating to involuntary detention and treatment were met. In reality, many members of the Commission took this to give them free rein to tell experienced practitioners in those hospitals how to do their job, sometimes with disastrous results.
There was, however, one salutary by-product of the legislation, this time from the hospitals themselves, which represented a major step forward in the human rights of detained patients.
A colleague on the Mental Health Act Commission who was the Medical Director of Rampton Hospital, previously one of the several ‘special hospitals’, used to say that probably only half the patients detained needed to be there. The trick was knowing which half.
Be that as it may, the managers at Rampton decided that one of their patients, a Mr C, could more suitably be cared for at a less secure provincial hospital and together, they formulated a detailed and careful plan. When news of his anticipated transfer reached the Press via some well-wisher, the popular press created an outrage and based it on a remarkably simple and narrow reason. The gentleman in question was profoundly mentally handicapped and had been so since birth. He may have been in a ‘special hospital’ on account of outmoded diagnostic methods dating back to the Mental Treatment Act 1930 (the funny farm) approach and he presented a clear case for review.
In his youth, Mr C took his pleasures from simple things, one of which was his toy cat. He was particular about the sanitary condition of the cat and washed it regularly, hanging it out on the washing line to dry. Mr C also had contact with chickens and had visited the local market where he had witnessed live chickens being processed. One day Mr C was spotted by a neighbouring curtain-twitcher in the act of biting his toy cat’s ear to see whether it was dry enough to take off the line. This was inscribed in his notes as ‘bit ear off [of] cat’.These events reached the Press in a wholly concatenated way. Amalgamating the two stories, and ever eager to put the wind up their readers, some newspapers reported that the neighbour had seen Mr C biting the head off a live chicken. You could not make it up, though the Press wasted no time in doing so. Had more pressing matters not arisen for report they would have had him breakfasting on live bats. Though there were other elements to the story, the misinformation started with someone who could not tell the difference between of and off or was in too much of a hurry to check what they has written. Believe it or not, the investigation of the outcry and it being laid to rest took two Commission members, a psychiatrist and a lawyer, 2 years, on and off. So far, as is known, Mr C is continuing to benefit from his care in less secure accommodation.
A little pedantry
Some readers might be disappointed if this article were not to end on a pedantic note, so here it is. Mr C and his alleged dietary proclivities were no doubt a one-off in miscommunication, but it is not alone. Non-words such as ‘reckonise’ (recognise) and ‘fuffill’ (fulfil), are both apt to appear in advance planning. So is ‘mitigate’ to denote the objective of reducing a risk. What one does not do is to ‘mitigate against’ something (a favourite of the current Health Secretary).
The worst offender by far, though, is one that might crop up in a reference to a patient’s reaction to a proposal for future treatment. It is the misuse of the verb, and the noun, ‘protest’. An outcry against a wrongful conviction is a protest, and people are protesting against a perceived injustice. These days, this is commonly expressed as people ‘protesting’ the perceived injustice whereby they ‘protest’ the guilt of the person concerned. They are, in fact, doing precisely the opposite; namely protesting their innocence. Were nurses to set out their reports under the influence of the sloppy linguistic habits of news reports, they might be sowing the seeds of confusion.