How do we respect the dignity of older persons in receipt of long-term care with limited staff and resources?

In January 2017, we finalised ENNHRI’s report on the human rights situation of older persons in LTC in Europe, based on monitoring work carried out by our members in Belgium, Croatia, Germany, Hungary, Lithuania and Romania.

One of the key issues highlighted in the report was the struggle that care providers face in respecting the dignity of their care recipients. Some staff may not fully understand what dignity is, others may understand it but not know how to protect residents’ dignity at all times and others may not have the time to do so. Here, we demystify dignity and offer useful examples to help care providers meet their obligations.

What is dignity?

Many of us find it hard to define dignity, but yet we hold the concept dear to our hearts. Struggling to understand what it means in practice, particularly in the context of human rights, is not that surprising, given that the European Court of Human Rights itself treats it differently in different contexts. We often find it easier to identify situations in which dignity is lacking than when it is present. Scholars believe that one of the reasons it is so hard to define is because it is a subjective concept – dignity refers to the fulfilment of the human need for self-worth and respect for the physical and psychological integrity of each individual.

Is dignity a human right?

Dignity is rarely listed as a stand-alone human right, though it is often understood as the basis of fundamental rights in international law, including:

• the European Convention on Human Rights
• the UN’s Convention on the Rights of Persons with Disabilities and
• the UN’s International Covenant of Economic and Social Rights.

In other words, the dignity of the human person can be regarded as a goal of human rights legislation. This means that it is linked with lots of human rights, including privacy, autonomy and choice, participation and equality.

Different human rights monitoring bodies focus on different aspects of dignity. For example, the UN Committee responsible for monitoring implementation of the Convention on the Rights of Persons with Disabilities (CRPD) tends to focus on dignity in relation to autonomy, and the right of persons with disabilities (including older persons in need of care) to participate in decisions affecting their everyday lives and their care.

The European Court of Human Rights (ECtHR) also prioritises the right to dignity – it has clarified the scope of Article 8 of the European Convention on Human Rights (ECHR) to include the right to respect for personal dignity and personal autonomy.

Case law of the ECtHR suggests that the Court tends to link dignity (in the context of care) with the availability of adequate resources to ensure that the physical and psychological integrity of all individuals is respected.

For example, in one case (McDonald v UK, Appl. 4241/12, 20/5/2014), it found that staff reduction in the care home, resulting in the applicant having to wear incontinence pads at night although she was not incontinent, constituted “an intolerable affront to her dignity”.

What are the obligations of governments and care providers to (older) service users?

Traditionally, the ECtHR has set standards of care to protect dignity at a minimal level – requiring states to provide basic medical care or a minimum level of subsistence. However, new developments at the UN (recent Convention on the Rights of Persons with Disabilities and steps to develop a new convention on the rights of older persons) are being taken into account by human rights monitoring bodies internationally, including the ECtHR. This means that states are required to meet higher standards of care.

Recent “soft law” from the Council of Europe (Recommendation CM/Rec(2014)2) offers a good starting place to delineate the obligations of governments (on behalf of the state) in relation to care for older persons.

With regard to residential care, the Recommendation emphasises the following points:

• Older persons should only be placed in residential care with their free and informed consent;
• Older persons should be free to make decisions about their daily lives and care – any limitations should be proportionate;
• Older persons in care should not be unnecessarily restrained – any restriction should be lawful, necessary and proportionate;
• Older persons should have the possibility to interact with others and participate in social and public life;
• Older persons have the right to respect for their private life;
• Governments should put in place an independent monitoring body to inspect residential care settings;
• Older persons should have access to sufficient information about their rights, to an effective remedy and adequate redress;
• Older persons should receive appropriate resources to have an adequate standard of living.

What are the key challenges faced by care providers in protecting and promoting the dignity of their care users?

The findings from ENNHRI’s human rights monitoring work in residential care suggests that most older persons were happy with the standard of care they received. Most care providers made every effort to offer their residents the best quality of care possible. However, we found several causes for concern, including:

• Staff being rude to residents or treating them in a patronising manner
• Neglect of personal care (refusals to change incontinence pads and empty urine bags when requested, residents left in unwashed bedlinen)
• Insufficient attention to privacy (doors left open when personal tasks were being carried out, or residents transported in a state of undress)
• Insufficient support at mealtimes
• Limited opportunities to participate in family and community life
• Limited opportunities to participate in decisions and make choices

How can care providers meet their obligations?

Our research indicated that the biggest causes of these human rights concerns were:

• a lack of knowledge by staff of what human rights were and what their obligations to their residents were;
• a lack of resources (staffing shortages; limited funding for the long-term care sector overall and shortcomings in the health system).

The most important steps governments and care providers can take are to:

• Provide training on human rights to care workers, managers and students (future workers);
• Invest in the care home and the long-term care sector to allow for higher staff ratios and a better physical environment to facilitate privacy and protect residents’ safety.

A human rights-based approach (HRBA) can be used to help care staff and managers understand how to think in a way that meets their obligations. Click here for more information on a HRBA within care homes.

Photo: Feed the Birds by Sheree Ziekle is licensed under CC by 2.0.