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Human rights in dementia. The only way is Kyoto.

It wasn’t that long ago that many people, after receiving a diagnosis of dementia, would be propelled head-first into an abyss of the health and social care systems, with no supportive ‘dementia friendly communities’.

As leading international campaigner Kate Swaffer provided in a talk in 2016, people beyond a diagnosis of dementia “are not provided with rehabilitation or other enabling post diagnostic support” and “are not provided with the same disAbility support as every other person with a disability”. It is widely recognised that people living with dementia are frequently denied their human rights both in the community and in care homes.

What I feel is the power in dementia is not as such the nebular notion of dementia, but that individuals with distinct lives of their own have rights. As Chris Roberts, also living beyond dementia, said this morning in Kyoto, “People with dementia have their rights trampled on – these are not just rights relating to their disability, but also their human rights”.

The back story is as follows.

The WHO International Classification of Functioning, Disability and Health (ICF) defined disability as ‘an umbrella term for impairments, activity limitations and participation restrictions’ (WHO, 2002, p. 2), referring to the negative aspects of the interaction between an individual with a health condition and that individual’s contextual factors (environmental and personal factors).

According to Article 1 of the UN Convention on Rights of Persons with Disabilities (UNCRPD):

“Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.”

In UK law, the Equality Act [2010] states that a person (P) has a disability if:
 (a) P has a physical or mental impairment, and
(b) the impairment has a substantial and long-term adverse effect on P’s ability to carry out normal day-to-day activities.

The term ‘disability’ is therefore not meant merely stigmatising label to be imposed upon individuals. Nor is the term ‘disability’ in this context intended to focus on what a person can’t do, but rather the wider societal context in which a person with a disability lives their life and what they can do. This is significant as the act of the diagnosis of dementia not in itself be profoundly disempowering.

National laws and policies (e.g. mental capacity legislation, health and social care services, dementia-friendly communities, etc.) must be compliant with human rights legislation – disability rights are therefore potentially powerful levers for change.

Dementia Alliance International (DAI) is an advocacy group, the peak body and global voice of people with dementia. Their mission particularly includes Human Rights based approaches that are applied to the pre and post-diagnostic experiences of people with a dementia, in every way. This unique group advocates for a more ethical pathway of support that includes their fundamental  human right to full rehabilitation and full inclusion in civil society; “nothing about us, without all of us.”

I’ve found their pamphlet ‘The Human Rights of People Living with Dementia – from Rhetoric to Reality’ very helpful.

There’s been a huge amount of work about why the label of dementia can bring with it negative stereotypes and pre-conceptions. The literature since the seminal work of Becker in the early 1960s is now substantial into the field of “stigma”Stigma can be a contributing factor for why people with dementia do not claim their rights.

Owen Miller wrote originally as part of the Scottish Council for Voluntary Organisations (SCVO) #RightApproach campaign, the following.

“But too often people with dementia find their rights restricted by the stigma which often surrounds their condition. Assumptions are made about a person’s capacity to make decisions. Risk-aversion becomes standard practice. Attention turns to what a person cannot do rather than what they can. Often this comes about as a result of circumstances in which well-meaning attempts are made to protect the person from harm or do what is perceived to be in their best interests. However, it is often the case that doing so fundamentally fails to respect the person as someone with unique experiences, interests and abilities, who can still actively and meaningfully engage with their community.”

Kate Swaffer, Chair and CEO of DAI, was the first to use the term “Prescribed Disengagement®” to characterise the advice that she received to “give up work, give up study, go home and live for the time you’ve got left”. Her husband was told he would soon have to give up work to care for her.

Many people with dementia report a common experience of loneliness and social isolation which they experience when friends and family members stop visiting, Older people are more fearful of developing dementia than they are of cancer, a poll recently suggested. Two thirds of people over the age of 50 fear that they will develop the condition, while just one in 10 said they were frightened about getting cancer.

The 161 countries that have ratified the CRPD are required to submit regular reports to the UN CRPD Committee. Non-Governmental Organisations (NGOs) and Disabled Persons Organisationshave the right to submit ‘parallel reports’ which are taken into consideration in the Committee’s Concluding Observations and Recommendations. All of the articles are significant, but it is especially noteworthy that a right to legal capacity on an equal basis was enumerated in the CRPD in Article 12 as a subsidiary to the right to equal recognition before the law.

An accessible Users Guide to the Convention is here.

In March 2015, Kate Swaffer made three demands at WHO’s First Ministerial Conference on Dementia:

  • Policy and practice for people living with dementia should be based on the CRPD
  • Research should focus as much on care and support as on cure
  • A more ethical pathway of care, including pre and post-diagnostic support from a wide range of rehabilitation professionals in the community

It was further reported that, at the Alzheimer’s Disease International conference’s international conference in April 2016, the leaders of 38 national Alzheimer Associations committed to a human rights based policy and full access to CRPD.

Prof Peter Mittler CBE in August 2016 noted:

“But people living with dementia are at great risk of being left behind in the sustainable development groups because there is a pervasive assumption that dementia is the sole responsibility of Health ministries, rather than the inter-sectoral responsibility of all Ministries, including Housing, Transport, Social Care and Protection. These would enable us to have access to the whole range of supports, services and amenities available to persons with disabilities recommended in CRPD.”

The human rights based approach (HRBA) is important.

HRBA is based on participation of people with lived experience, as with the disability rights movement’s motto ‘nothing about us without us’. Yet there is a shocking lack of consultation with people with dementia throughout much of dementia care. It was recently found the quality of dementia care in OECD countries is very poor.

Rights pop in various contexts.

For example:

  1. In many countries people living with dementia are often physically and chemically restrained, even when regulations are in place to uphold their rights. Furthermore, people living with dementia can also be victims of neglect and abuse.
  2. More recently the broader concept of advance care planning (ACP), a multi-stage process whereby a patient and their carers achieve a shared understanding of their goals and preferences for future care, has been introduced. Evidence shows that one to one discussions with a trained professional over a period of time are the most successful. ACP may thus provide an opportunity for more person-centred care, although such discussions should occur while the person still has capacity.
  3. Sexual self-determination is considered a fundamental human right by most of us living in Western societies. Conduct follows strict rules relating to consent and coercion, but for older people with dementia living in residential aged care facilities, however, the issue becomes more complex. But it is hard to deny a wish for people to form loving relationships, and this is bound to happen too in the context of residential care. We are at danger of treating all relationships which occur in residential care with suspicion until proven otherwise. This arguably offends inalienable, universal human rights and a right to democratic citizenship.
  4. Article 8 of the European Convention on Human Rights concerns the right to family and private life. This includes the right to respect for an individual’s home and correspondence. The right contained in Article 8 is known as a qualified right which means that there may be circumstances in which some interference with it is justifiable. This right means that an individual has the right to the level of personal privacy which is compatible with a democratic society, taking into account the equivalent rights and freedoms of others. Any interference with this right by a public authority, such as CCTV video surveillance, may be subject to a test of acceptability. This might also clash with the so-called “deprivation of liberty safeguards”, where somebody with dementia might have his liberty taken away by the State.

There’s no doubt that human rights are a big deal, and I have no doubt that the WHO/UN Sustainable development groups/human rights approach will become enshrined within the new vocabulary of dementia friendly societies or age friendly cities in time.

@dr_shibley

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