Suicide – The aftermath

20 Jul

 

Suicide – The aftermath

 

The politically correct way to discuss suicide is to describe it as “taking their life” as the phrase “committing suicide” refers back to the time when it was criminal and is therefore a shortened version of “committing the criminal offence of suicide”.  Taking your own life is not a criminal offence, aiding, abetting, counselling or procuring (ie helping or encouraging in any way) are all still are criminal.

 

Taking their own life, is the biggest killer of men under the age of 45 in the UK.

 

So when someone takes their life, the friends and family that are left behind are hit by the tragedy.  Before they took their life, options are possible, there are choices, even if that person doesn’t see them for themselves.  Afterwards, those options have gone.  And they are never coming back, so nothing will ever be the same again.

 

If someone attempt to take their life unsuccessfully, then the options are still possible and those around that person are on notice that they need help, even though they might not have asked for it.  It can entirely change the situation, as the person may have done serious harm to themselves in the attempt and their life is irrevocably changed by the new situation.  And the person, their family and healthcare professionals all must deal with the outcome and the new situation.

 

If someone is successful at taking their life, those who are left behind are firstly numb, then the questions start.  What could I have done differently?  What opportunities were missed?  And by whom?  And all whilst this is going on, there is sadness.  Sadness for the life that could have been.  And a sense of loss of the missed opportunities and lost life.

 

The family and friends will be bereaved and have stress to deal with and may well become depressed.  The families that I deal with when their loved ones took their own life really struggle, they are confused and their speech can get confused, it is all a sign of their stress and anguish.

 

When someone takes their own life, it is sad for the survivors, but they did it because they saw it as their only choice out of their pain.  It is not an easy decision, it is not the decision of what to eat for dinner or what colour shoes to wear.  It is a big important decision and it takes a lot in the moment to carry it out.  For the family who are left behind afterwards, you have my sympathy, living with the aftermath is very hard.

 

#MentalHealthMatters

 

Do Not Resuscitate – Completing a TEP

29 Jun

Do Not Resuscitate – Completing a TEP

 

Firstly, what on earth is a TEP?  Many of us will have heard of DNR orders, but have no idea what a TEP is, it stands for Treatment Escalation Plan and is the NHS document regarding end of life and resuscitation.

 

It has 3 sections; part A looks at whether this patient is at the end of their life with a poor prognosis and starts the question “Would you be surprised if this patient died within the next 6 – 12 months?”.  When I talked to healthcare professionals about death and dying, they will often say that they cannot predict when someone is going to die.  They can try and they will often get it right or close to being right, but not always.  People can unexpectedly rally and recover and continue to live for months or years.  I had a client who was Catholic and approximately annually the priest was called in the early hours of the morning to give her last rites and asked not to wait until office hours as she wouldn’t survive until then.  She finally succumbed in the 4th year, having survived last rites 3 times!

 

The next bit of section A looks at any advanced decisions that person made and whether they have the capacity to participate or make the decision themselves and if they haven’t, it allows the doctor to decide whether or not to resuscitate in the event of cardiorespiratory arrest.  In other words, is someone going to do CPR (chest compressions and restart their heart if it stops).

 

Part B then looks at a slower less dramatic decline and considers the circumstances “If the patient is currently very unwell or in the event their condition deteriorates”.  There is a series of boxes to tick Yes/No including some that are only relevant in hospital (aka acute setting).  The 5 questions for outside of hospital are:

  • Is admission to acute hospital appropriate?
  • Are IV fluids appropriate?
  • Are antibiotics appropriate?
  • Is artificial feeding appropriate?
  • Is De-activation of Implantable Cardioverter Defibrillator (ICD) appropriate?

 

TEPs are important documents, they are life and death decisions.  They are not however written in stone and can be changed by a doctor at any point in time that circumstances change.  And when circumstances change a new TEP is completed and placed in the patients notes.  Until it is changed, the current TEP will be followed by the healthcare professionals looking after that person, including doctors, nurses and paramedics.

 

I’ve seen lots of these completed, I’ve even been part of conversations around end of life in vague non-specific terms, but I’ve yet to see a doctor complete one in full consultation with the family, so they clearly understand what a tick in each of the boxes will mean.  It does have to be completed by a doctor, it is their signature on the form, but even when there is a health and welfare attorney with authority to make decisions about life sustaining treatment, the doctor still doesn’t fully consult with the attorney, or at least I’ve never yet seen that.  This means that they can get it wrong!  Not every family member wants to discuss this in detail and if they don’t that’s fine, that’s their choice.  But they should be given the option!

 

Part C is about organ donation, so is only relevant at the time when the other decisions are all over!

 

TEPs can be scary, they deal with circumstances that family members don’t want their loved ones to be in – very poorly!  If anyone needs support in dealing with a TEP or understanding it, then let me know.  I’ve been involved in others and I understand.

 

 

 

 

 

 

 

 

 

 

 

 

Plain English

15 Jun

Plain English

 

There has been a campaign in recent years for legal advice to be in plain English and long may it continue.

 

Sometimes the complexities of a legal case or legal argument may be hard for the layperson to understand and in which case it is the role of the solicitor to explain as best they can, but so they do understand.  Some unsophisticated clients just want to know that their case is being handled in a skilled manner and don’t feel the need for a detailed explanation of the situation.

 

Any case law or arguments in legal language should be a discussion between lawyers and should not involve the client, unless they have the requisite understanding, as some sophisticated clients do.

 

Historically the language of law was constructed to ensure that lawyers were seen within society as highly skilled and educated.  The process of becoming a lawyer was intentionally hard to keep the numbers in the industry small, the skill level high and in a really historic way, the province of rich white men!!!  This historic construction of the industry meant that lawyers were well paid and usually well respected in society.  Today we are still reasonably well paid and hopefully reasonably well respected.  We are closely monitored by the Solicitors Regulation Authority and are required to have training every year to ensure that our knowledge is up to date.  It is still hard to become a solicitor and as one there are lots of outcomes we are required to follow to ensure that we at all times act in the best interests of our client.

 

Some lawyers take extra exams to distinguish themselves from other lawyers and better qualified, most lawyers I know take a huge amount of pride in their work and go to great lengths to ensure that the advice that they have been given is of excellent quality, myself included, I’ve passed my Solicitors for the Elderly (SFE) exam and my Society of Trust & Estate Practitioners (STEP) exam.  In my area of law the only other exam I can take is the Associate of Contention Trusts and Probate Specialists (ACTAPS), but as I don’t litigate, it seems fairly pointless.

 

There is a LOT less Latin in the legal language than there used to be, but still some, it must be said, which is a good thing, as I never did Latin at school!!!  The detail of some legal arguments can sometimes still be hard to follow, but that should not put off the solicitor from trying to explain it to their client in a language that their client will understand.  By using plain English we are helping the client to understand that we are on their side, that is what all the regulation of the legal industry is about, the SRA has little or no sympathy for a lawyer or law firm that has not treated the client fairly.

 

So long may it continue, long may we used plain English to demonstrate to the client that we are on their side and hopefully we will be rewarded and respected for the great quality of the work that we do.  I know that’s always what I strive very hard to do.

 

 

Acting as a Health & Welfare Attorney

1 Jun

Acting as a Health and Welfare Attorney

 

The first thing to understand about acting as a H&W attorney is that the attorney can only make decisions that the donor lacks capacity to make themselves and that is true for each big or little decision.  So a person may know that they like chocolate but not be able to make a decision about a complex medical procedure, capacity is “time and decision specific”.  This means that the donor may well be making some decisions about their life, but not others.

 

The next thing to understand is that when acting for someone who is found to lack capacity, the attorney must decide in their best interests.  That’s not just an average person’s best interests who is a bit like them, but in that one individual person’s best interests and to do that, the attorney would need to know something about them.  H&W attorneys are usually family members, so hopefully they do know something about them.

 

There is also the issue of life sustaining treatment and the donor can choose to allow the attorney to make decisions or not.  If they donor chooses that the attorney cannot make decisions, then whilst there might and should be consultation with those closest to the donor by the health care professionals looking after the donor, the final decision maker about life sustaining treatment is the health care professionals.  If the family disagree with that decision their only recourse is an application to the Court of Protection, which can be expensive, time consuming and very emotive for family members.

 

If the donor allows the attorney to make decisions about life sustaining treatment, then their decision is binding on the health care professionals, in the same way that the capacitated donor’s decision would be.

 

So apart from life sustaining treatment, what other decisions can the attorney make?  In short – any medical or social care decisions, which would include decisions about treatment, including medication and surgery.  Social care decisions such as what to wear, what to eat and who visits you.  Importantly where to live, which includes whether someone goes into care and if so, which care home they go into.

 

They attorney can request a particular kind of treatment, but it will only be offered if it is clinically appropriate, this is the same as if the donor was capacitated.  The attorney cannot demand the treatment.  The attorney can refuse clinically appropriate treatment, in the same way that the capacitated donor could, which includes things like discharging from hospital against medical advice.  However, the place that the attorney is taking the donor needs to be in that person’s best interests and if the health care professionals believe that the attorney’s decision is too risky, then instigate an application to the Court of Protection to have the attorney removed.

 

People take risks, people make unwise decisions, this is normal and happens all the time and people with a cognitive impairment should also be able to do, as far as possible, what everyone else can do.  The issue becomes the balance between the unwise choice of the attorney honouring the preferences of the donor and the risk that this will incur.

 

Acting for someone when they are unwell is always hard emotionally on those that must make those decisions and care for them.  And making decisions about life sustaining treatment is particularly hard.  For any attorney who needs help, please contact me, I would be happy to support you in this role.

 

 

Acting as a Financial Attorney

18 May

Considerations when acting as a financial attorney

 

When someone has appointed you to act for them, there are several duties that the attorney should fulfil.  The most important consideration is what is in that donor’s (the person for whom you are acting) “best interests”.

 

Firstly you must collate all the information, so that you can understand the situation.  How can you manage someone’s financial affairs when you don’t know what assets and liabilities they have?  The next thing is to work out how to manage those affairs going forward to get the best result for that person, whilst taking into account what they have done in the past.

 

So in the past they may have ethically invested and as long as this investment strategy is still going to provide a reasonable return, then that should continue.  However if that person gave away a big proportion of their income each month to someone who should be more financially independent, then continuing with this strategy is not appropriate.  The donor’s money is for them first, not anyone else.  The only extension to that is other people to whom they have an obligation to provide for, such as minor children.  That doesn’t mean that the donor cannot give gifts of any kind, but the gifts need to be for birthdays / Christmas / marriage etc, which is otherwise known as “on occasion”!  Importantly gifts need to be appropriate to the size of the estate.  It is considered to be in the best interests of the donor that their friends and family “remember them fondly”, but clearly within reasonable limits.  There can at times be a conflict of interest between the donor and attorney, if they are spouses or parent and child, because the more spent on care, means the less the attorney will inherit!  The money remains the donor’s, so the best interests of the donor, not the ultimate beneficiary is what is of paramount importance.

 

The next thing to ensure is that the donor is as well cared for and comfortable as can reasonably be managed, but clearly some of these decisions involve “caring” decisions, which are beyond the authority of the financial attorney, nevertheless whatever care is decided upon has to be paid for, which the attorney has the authority to deal with.

 

All the time, circumstances change, so for example on admission to a care home, that home might be able to meet that person’s needs, but 3 months later after a major deterioration, they may no longer be able to do so, in which case a new placement must be found.

 

Acting as an attorney can often be a lonely, difficult and thankless task.  If you are an attorney and you need help, please contact me, I will be happy to assist you.

Caring for a dying relative

4 May

A coffin with a flower arrangement in a morgue

Caring for a dying relative

 

This is a very hard subject.  We don’t like to think about ourselves or our loved ones dying, but it is nevertheless an important subject.

 

If our loved one dies instantly, it is a huge shock, especially if we have not been expecting it.  If you have not had a conversation, then the next stage is commonly a state of shock before you can move into a more active mode of sorting out the arrangements.  This state of shock can last varying amounts of time, we are all different and how we deal with grief is different.

 

The death needs to be registered, the funeral arranged and then afterwards the estate can start to be sorted out.

 

If our loved one dies fairly quickly, this may give us an opportunity to say goodbye, to thank them for being in our lives and to let them know that they can go, if that is the right thing to say to them.  Saying thank you and goodbye is something we do for us, for them too of course, but letting them know that it is OK to go is something we do for them and a bit for us.  How we do that and whether we can do that will be different, sometimes we are not ready to let our loved ones go, especially if they are still young and we think that they have not finished their lives.  We can then have a little time to process the situation and try to emotionally deal with it.  And we cling to hope.

 

If our loved one dyes a lingering death, then we have that time to say thank you and goodbye and assure them that it is OK to go (assuming that it is).  We are upset and then process how we feel about it, however we cannot live on the adrenalin that this heightened state of anxiety will give us, so we get slightly used to it.  During this period of waiting, our loved one might rally, so we are given hope, perhaps only a glimmer or maybe a shining light, but we have hope.  And then they deteriorate and our hope dies.  If they have a fluctuating presentation, we can cycle through these emotions of despair and hope and we start living slightly on edge all the time, just waiting and not knowing.  This is very hard to watch as we see our loved one slowly slip away.

 

What happens if our loved one experiences a painful death?  Pain is something most of us fear.  We often wish we could trade places with a loved one in pain, but we can’t.  We can hold their hand, talk to them, feed them, play them music and lots of other things to try to comfort them and us, but we cannot take their pain.  Pain can be managed with drugs, but often it cannot be eliminated, watching a loved one in pain, whether or not they are dying is a horrible experience for both them and us.  I have been involved with many families when they are dealing with a loved one dying and a “peaceful” death is preferable, even though the death is often dreaded.

 

There is a finality with death, our relationship is forever changed, we can still love them, just not in person.  Death may be the time we stop and grieve, but if we are involved in sorting out their affairs, we may keep ourselves busy with that and not grieve and it is only when that is over that we do finally stop and grieve, which can come as a huge shock to anyone not expecting it, particularly since the death was some time before.  Greif takes time, but we can get over it and move on with our lives.

 

If during any of these stages we need help, friends and family may be around, but if we are faced with administration, legal or advocacy issues, I am here to help.  And I understand.

Care Fees – Top ups

20 Apr

Senior businessman showing a document

 

Local Authority Funding for care homes – Top-ups

 

When someone goes into care and they are not eligible for NHS Continuing Care funding, they must pay for their own care.  This payment of care is means tested, so if that person has limited assets then the Local Authority will pay part of their care, if they have savings, they privately pay.

 

The Local Authority will fund the care subject to an income contribution once the value of the assessable assets falls below £23,250.  This limit used to go up annually, but it hasn’t changed for a few years now.

 

When assessing how much they should pay towards their care, they are allowed to keep £24.90 per week from their income, this should be used to purchase their personal items, including new clothes and toiletries.  The rest of their income, they will have to contribute towards the cost of their care, including any pension (state or private) and any other income (with the exception of a few specified benefits).

 

The Local Authority will have a “standard rate” for the level of care that they have assessed that that person needs.  The Local Authority will then pay the difference between the “standard rate” and the person’s income contribution, so if their income goes up, the amount the Local Authority will pay goes down.  If this standard rate is not enough to cover the cost of care in the care home, then there may be a top-up involved.

 

Following the Care Act 2014, this is now payable to the Local Authority, who are responsible to the care home for any non-payment.  It is known as a “Third party top-up”, the first two parties are the Local Authority and the person in care themselves, so anyone who isn’t one of those two parties can pay this top up.  Which usually means family members.

 

So how can this be challenged?

 

The first thing to understand, is that the response of the Local Authority is likely to be to threaten to move that person to a cheaper care home, which if they are settled, is not what you want to hear!!  However, they can only move them if:

There is an alternative place that will take them

That has a vacancy

That can meet their needs

That will accept the rate

 

It is not enough to say that the care home down the road takes the Local Authority rate if they have no vacancy.  And importantly wherever they go, the placement must meet their needs.  What the needs are is defined in the care plan that the Local Authority should have done.

 

When the Care Act came into force, it brought in the concept of “wellbeing”, which has a statutory definition that the Local Authority has an obligation to promote.  The key way to set up the challenge is to look at the care plan and make sure that it is personalised and relevant to that individual.  So for example if that person has lots of friends in the vicinity, then it will have a detrimental impact on their wellbeing to move them to a cheaper care home that is 3 miles and 2 bus rides away for their friends to visit.  Or perhaps they need a home where they can bring their cat with them and the other nearest is 10 miles away, which is too far.

 

So the work on the challenge of the top up, is around looking at the care plan to make sure that it does meet that individual’s needs and not just an average person in care!

 

If there is no alternative placement at a cheaper rate, the top up shouldn’t be charged and is therefore challengeable.