Eastern Case study 4 - Dignity and Respect - a case study from an acute medical ward

Dignity and Respect

Dignity and respect for another person are at their most vulnerable when that person is unable to afford you the same courtesy. This is common when people suffer form dementia and is exacerbated when there is a superimposed delirium. Delirium can and does make people behave in very strange ways. The complex care team funded by SWIFT monies was set up to meet this challenge and improve the experience for service users and carers. Our team of nurses and support workers spend their day working in the district general hospital with people who have both dementia and delirium. They constantly work in a world of misinterpretation and misunderstanding.

Mrs. M was admitted to the district general hospital with a suspected UTI. Already known to the complex care team from a previous admission they met her when she arrived in A&E. She recognised the staff and was pleased to see them. Over the next week her behaviour became increasingly bizarre. She became grossly thought disordered, she was switching between topics and her conversation and flow of ideas became illogical. She had taken to drawing her thoughts on the bedding, the tables and just about anything else to hand. She became verbally aggressive and very demanding of staff. On one occasion kicking a nurse from the team.

Mrs M was 84 years old, her language would have made Gordon Ramsey cringe and by the end of the week she was becoming sexually inappropriate. Some of the ward staff found her behaviour amusing and in some of her more lucid moments would make jokes with her about what she had done or said. In her less lucid moments they would chastise. Their approach was less than consistent. There was no doubt Mrs. M presented an enormous challenge. Our team were asked to model appropriate behaviour. They would not respond frivolously to sexually inappropriate comments, and would not criticize bad language. They would whenever possible inform and explain to ward staff, other patients and visitors what was happening to Mrs M and why. If her behaviour became too bad they would spend time with her away from the ward areas.

At the same time they would spend time with Mrs M and allow her to talk about her concerns, take actions to respond to them these were things that were important to Mrs. M at the time. She was included in all conversations about her care; they insisted the consultant physician explained her treatment to her directly even though they were unsure how much she could understand. Personal comments were not to be taken personally and throughout they spent time educating ward staff about the causes of her illness. Mrs M's family were kept informed at all stages and when she moved to a new ward the team's support and understanding went with her. There was a great deal of effort to have Mrs. M moved to a psychiatric ward, but the team persisted with the need to exhaust medical options. Eventually some 10 days after her admission she began to stabilise. A few days latter she was displaying none of the bizarre behaviour evident during those first days. The first thing she did was apologise to staff for her actions, she apologised to the nurse she kicked and those she had been rude to. She could recall most of what had happened during her admission. The team would accept no apologies they explained to her why she had acted and behaved they way she did. She had nothing to apologise for.

For more information contact David Jarrold David.Jarrold@smhp.nhs.uk