The ever-increasing awareness of climate change and its harmful effects usually focusses on geophysical harm. TV programmes are devoted to the issue and are rarely without images of a melting iceberg or a parched river bed. However, climate change has adversely affected people's health across the globe, with extreme temperature events seeming to increase in frequency, duration and magnitude (WHO, 2023).
In the UK, there is a total unpredictability in climate—a regular occurence every year. While, all populations are affected by extreme heat, some are more vulnerable than others—such as the elderly, infants and children, pregnant women, outdoor and manual workers and the poor (WHO, 2018). In such populations, exposure to extreme heat can amplify already-existing conditions and result in premature death/disability (WHO, 2018). Older people, in particular, are at risk of developing hyperthermia (National Institute of Health, 2018).
Heat in the UK
Community nurses are likely to find among their clientele, patients ranging from very young to very old, with vulnerabilities associated with those respective stages in life, as well as those with an ongoing or chronic condition exacerbated by heat.
Media reports of excessively hot weather are seldom without the effects of heat on the most vulnerable in the community, such as older people. Factors that put older people at a greater risk of heat-related illness include: pre-existing medical conditions; medications that prolong the body's ability to cool itself; being obese, overweight or underweight; drinking alcoholic beverages; or becoming dehydrated (National Institute of Aging, 2023). The adverse effects on physical and, in some people, mental health, are widespread. Those effects are more often indirect or consequential rather than causative of a specific condition, though seasonal affective disorder (ironically referred to as SAD with more than a grain of truth) can have a profound effect on both motor and mental functions.
Those with fewer resources are likely to have correspondingly fewer technological means to offset the effects of heat, such as air-conditioning or even an efficient ventilation system. Therefore, in such instances, community nurses are best placed to guide their older clientele in to making appropriate health-related choices.
Heat and the ability to make sound decisions
During my five years' living in a southeast Asian country, the combination of heat and humidity occasionally caused me not to be able to think, not just straight, but at all. It was most unpleasant.
Community nurses should be alert to the fact that some patients' abilities to make a sound decision, which genuinely reflects their state of mind, can be affected by hotter weather than they are used to. Perhaps they feel under added pressure or are simply unable to think things through like they normally do. Consent is a matter for the particular individual and in that individual's circumstances at that particular moment.
The very fact that such-and-such a person is a patient is enough to indicate some vulnerability as well as their need for support. Consent to clinical treatment of any sort is a matter for the particular individual and for that individual alone. It is a matter conditioned by the particular circumstances in which a treatment proposal is offered. Giving consent to a proposed treatment is transactional. In reality the process simply represents part of the overall duty of care owed by practitioner to patient.
Heat and law
Legal issues relating to the adverse effects of heat range from the strai ghtforward duty of advising patients against exposure to its harmful effects, to issues of duty of care and consent to treatment, and confidentiality and privacy. Respect for patient privacy is integral to a community nurse's legal responsbilities to their patients, though even this essential principle has its limits.
Let us take, by way of example, the case of an older person living alone in a small house without air conditioning or insufficient ventilation during hot weather. It may be nice to go out into the garden for a while and get a bit of sun. The combined effects of heat-induced dehydration and the normal physiological changes, which occur during sleep can be harmful. A community nurse familiar with their patient's preferences would do well to warn them. How to do so could be tricky because the paying of personal respect is also a clinical responsibility and the receipt of it a legitimate expectation of the patient. Would these two aspects in our example be shattered if the nurse went straight to the patient's relatives and told them of a concern for the patient? As in so many other matters in clinical treatment, there are ways of doing things, some of them good and others clay-footed.
Contrary to widespread belief across the clinical professions, there is no such legal wrong as breach of confidence, save in the illicit sharing of strict commercial confidences, which is not our present concern, and which forms part of the law of contract. Though, as a non-clinician, I would never presume to give clinical advice, my view about the maintenance of confidentiality in professional clinical situations would be to err on the safe side in order to remove or at least reduce the risk of harm to the patient. Standing on one's rights to confidentiality is no more attractive a prospect than ‘They Died with Their Rights’ is as a western. Of greater practical import is the prevention of patient exposure to the harmful effects of heat.
The law does not, as a general rule, impose a positive duty to act to another person's benefit. Even the Hippocratic Oath stops short, requiring the more anodyne ‘First do no harm’. General texts on the duty of care aspect of the tort ‘civil wrong actionable in damages’ stop short at asserting the absence of a positive duty to act to another's benefit without going into what for present purposes is vital to the issue, namely the precise content of a duty to act to the benefit of the patient. Books on clinical law are, for the most part, not much better because they are written either by lawyers with a thin grasp of medicine or by clinicians with a sparse knowledge of law. There is little to choose in the current state of clinical publishing in the UK.
As a general rule, if ever there was one, it is better to err on the side of positive interference when it comes to preventing harm. Being (literally) a positive nuisance can redound to the patient's benefit. No court in the land will try to tell the community nurse that they made an unwarranted and therefore, unlawful interference, not least because it is not unlawful in the first place. By way of linguistic correction, there isn't actually any general rule at all. Courts in the UK are the first to recognise and respect flexibility in clinical judgment resulting from practical professional experience. In a notable case heard by the Court of Appeal, Lord Donaldson told the defendant obstetric consultant that ‘It ill becomes anyone to assume an air of superiority’. It is inconceivable that a court of lawyers would ever do that in the direction of a practising clinician.
A matter that clearly does attract the legal duty of care is the effect of heat on patient medication. It is elementary that medicines and medications such as creams should be stored in appropriate condition and the community nurse should take steps to ensure that they are. If there are simply no appropriate storage places in a patient's home, then nurses might consider bringing them to each visit, assuming of course that the frequency schedule of prescribed medication safely allows. If medicines are stored on the patient's own premises, it goes without saying that a careful and continuous check should be made that they have indeed been properly stored and that they are in date. It is easy to forget such precautions in the ‘heat’ of the moment.
A final word
Legal questions prompted by the effects of heat on patient care are no different in kind from those which relate to the every day life of a community nurse. However, they may be pointed up by climatic differences. Such differences, as do exist, are part of the price to pay for what we want to call ‘a fine day’.