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Self-neglect and a duty to intervene ethically
I’m taking a break from the series of blogs on European social care this week (although I’ll be looking at best practice examples from Europe over the next couple of weeks), in order to focus on a topic which seems to be gaining focus in Wales: that of self-neglect.
Self-neglect is increasingly being recognised by the NHS and Welsh local authorities as a source or indication of personal distress and a barrier to well-being. It is a problem requiring attention by professional care agencies within their operational policies and staff training.
Self-neglect is a broad concept and a difficult one to pin down. It is multi-factoral and may originate for widely different reasons and manifest in different ways (hoarding, not attending to basic hygiene, domestic squalor, anorexia or malnourishment).
One widely cited definition by Gibbons (2006), defined self-neglect as:
"The inability (intentional or non-intentional) to maintain a socially and culturally accepted standard of self-care with the potential for serious consequences to the health and well-being of the self-neglecters, and perhaps even to their community."
People can neglect themselves for a host of reasons such as depression, personality disorder, schizophrenia, cognitive impairment, physical inability to manage household tasks, dementia or other progressive and disabling conditions.
However there may also be some level of choice or lifestyle preference being exercised by the client. For example, when does keeping a lot of animals indoors become problematic? Decisions about care and support packages therefore need to weigh up all the relevant factors and balance these against the individual’s right of self-determination. This right normally requires that services and support must be consensual.
The ‘consent’ perspective
Informed consent is based upon the principle that competent individuals have a right to choose freely whether to receive services. Informed consent protects individual choice and respects autonomy. This respect for choice and autonomy extends to tolerance of different lifestyles and eccentricities which is where decisions about self-neglect become difficult. Where does a lifestyle choice to live outside conventional norms and standards become injurious to the individual? If services and client agree that an intervention, such as assistance with washing or de-cluttering and domestic deep-cleaning are required, then that is ideal. But what if consent is not forthcoming even to the degree of refusing to accept that there is a problem?
Challenges to services
It is clear that the multi-factoral nature of self-neglect poses challenges to outlining a clear and unambiguous rationale for intervention. Services and care professionals must ensure that interventions are consensual where possible or manifestly in the client’s best interests and legally justified where consent is not forthcoming.
Of course much of this is down to judgement calls made by experienced and knowledgeable practitioners. These same practitioners will be skilful and imaginative in attempting to build rapport and confidence with the client in order to come alongside them consensually. Judgements also need to reflect the levels of distress, infirmity, disability, mental state and degree of support and choice which the client has available to them.
Simply dismissing self-neglect as a lifestyle choice is not a supportable position in a caring and regulated society. The reality is that sometimes individuals will not consent to necessary services and intervention. So what available measures and courses of compulsion are available? For tenants there may be regulations attached to their tenancy agreement which give leverage over their behavior and its effect on others. The same is true to a more diluted effect with a private householder under civil law. Depending upon the exact circumstances surrounding the self-neglect measures may be available under the following legislation:
1. Safeguarding measures under the Social Services and Well-being (Wales) Act, 2014
2. Measures available for assessment and treatment under the 1983/2007 Mental Health Act
3. Best Interest measures under the Mental Capacity Act, 2005
Self-neglect is a complex practice domain calling for well thought out policies, procedures, training and skilled practice.
Reference: Gibbons, S., Lauder, W. (2006) Self-neglect: a proposed new NANDA diagnosis, International Journal of Nursing Terminologies and Classifications, Jan-Mar, 17, 1