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Managing the affairs of someone else – Health and Welfare

6 Sep

 

Managing the affairs of someone else – Health and Welfare

 

In the past I’ve discussed creating LPAs, so that you can appoint another person to manage your affairs, if you become unable to do so.  It is probably worthwhile looking at this from the other angle, how do you manage the affairs of another person?

 

I’m going to take these subjects one blog at a time, starting with how to make health and welfare decisions for another person.

 

The only time that you can ever make decisions about another person’s health and social care decisions is when they lack capacity to make decisions themselves.  Each decision is different, it relates to the complexity of that individual decision and the time in which it needs to be made.  So people can lack capacity for complex decisions (such as what care to have or where to live) and still have capacity for simple decisions (such as whether they are thirsty or want to eat chocolate).  We almost all have something that is a pleasure to us, it becomes a habit, it might be a certain piece of clothing or a certain food (chocolate is a good example) and so people know for a long time that they like that thing, even when they lack insight into the bigger picture of their situation.

 

So the things to consider when making a decision is what would the person want?  That doesn’t necessarily mean that this is the decision that you will make, but it has to be a big influence on your decision.  Sometimes what people want isn’t possible (most people don’t want to go into care, but it might become necessary).  They might not want to make a fuss and accept what is going to happen, but that also might not be the right thing for them.

 

When making a decision you have to look at all the factors, the pros and cons of any situation and in the end you make the decision yourself, if you are attorney or deputy for health and welfare.  It must be an individual decision taking into account all the information that you know about this person, it should not be a generic decision about someone of the same age, race, gender, disability etc.  People have the right to make an “unwise choice” and should not be deemed to lack capacity because they do so and this also goes for attorneys, but the unwise choice must be in their best interests.  The primary purpose of the decision should not be to end or shorten their life, even if that is the case, there need to be another motivation to make a decision to shorten someone’s life, around why it is in their best interests.  This is to overcome the potential conflict of interest that arises when an attorney is a beneficiary of the estate and will ultimately inherit, so the shortening of life will hasten the inheritance.

 

Whatever you decide, you are responsible for the decision and the reasons behind the making of that decision, so if this is ever questioned by a family member of the authorities, the attorney will be able to stand by their decision and the reasons that they made it.  If the decision is not in their best interests, such as discharging a very poorly person from hospital to their home with no package of care, it would be considered neglect and an application to the Court of Protection to have that person removed could be made.

 

I’ve been consulted about lots of these kinds of matters and they are often around going into care, the continuation of medication etc, however I’ve also had the point raised by a client that they were a football supporter and did not want to wear the football strip of their rival team.  Universally the important decisions are often where someone should be cared for and their end of life decisions.  In order to help your potential attorneys, it is useful to have a conversation about these issues, so that they know your views.

 

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Protecting your home from care home fees?

23 Aug

 

Protecting your home from care home fees?

 

I’ve recently been asked a few times about what can be done to stop the property having to be sold to pay for care home fees.  The irritating answer is – it depends and possibly not much!

 

It is entirely understandable that people who have worked hard to save their money and own their house want to be able to pass it on to their loved ones.  However Local Authority care is means tested and in Plymouth the cost of social care is about three quarters of the entire Local Authority budget and resources are limited.  The Local Authority cannot avoid its statutory obligation, to care for individuals within their area who are in need of their support, so this means that the Local Authority will look closely at the cases where they consider that people have intentionally deprived themselves of assets in order to avoid paying for care.

 

Whilst I fully understand the issue about wanting to pass on wealth, I do not understand why someone would prefer to lose choice and potentially quality as well for the care that they might need, just so their relative can benefit!

 

So, let’s go through some of the rules:

 

If the property is occupied by a spouse, partner, relative over 60 or disabled relative, then the property is exempt anyway.  If the property is jointly owned and the co-owner refuses to sell, then the only thing that could be sold is a half share and this has little value on the open market, which effectively exempts the share of the property.

 

The requirement for care must be “reasonably foreseeable”, due to existing poor health and people often think about doing something with their property once they are in poor health.  However if someone gifts their property when they are in good health, then this might exempt it, if they need care in the future, but since they may never need care, gifting the house and the costs involved might be unnecessary, particularly since only around 20% of people end up in care.

 

If a sole owner of a property gives it away, which these days, is often done by putting it into a trust, then that person has to continue without the need of residential care for a period of 5 years, or under the Care Act, the Local Authority can pursue that asset and undo the transaction, which defeats the object of doing it in the first place.

 

If the gift is made an absolute gift to a family member, which would be very unwise, then the person can find themselves homeless, if the family member gets divorced, gets into debt or dies.  If they get divorced, their entire asset portfolio would be taken into account, which would include the gifted property and this might need to be sold to deal with the issues relating to the divorce.  If they get into debt, their assets are realised to pay their debt and finally, if they die and leave the property to someone else, that person can serve notice and the donor of the gift finds themselves homeless.

 

So what if they give the property away and put it into a trust?  Trusts are taxable in their own right and are subject to Capital Gains Tax (CGT), Income Tax (IT) and Inheritance Tax (IHT).  Depending on the drafting and set up of both the trust and the assets, on the sale of the property to purchase a different one, the donor can find themselves having to pay CGT on the sale of their home, when if they owned it, they would not have had to pay.  There are also 10 yearly charges to IHT for trust assets over £325,000 at 20%, however the detail of calculating the tax is complicated!  Trusts require Trustees to care for the assets and depending on the kind of trust, may require minuted annual meetings and registration of the Trust with HM Revenue & Customs.

 

So I revert to my original answer of what can you avoid paying fees – it depends and possibly not much!  But I would also that it’s complicated and you might end up with something that you don’t intend, such as an unwanted tax bill!

How to communicate with someone who has a cognitive impairment – Part 5

9 Aug

 

How to communicate with someone who has a cognitive impairment – Part 5

 

I would again like to thank Kate Smith from Memory Matters some of the information for this blog.

 

It is important to remember that no two people with a cognitive impairment will communicate or present in the same way, but here are some more ideas that will hopefully help.

 

People with dementia are often very good at reading body language and at interpreting tone of voice, even when fairly confused.  It is more respectful therefore to tell the truth, rather than challenge their view of reality.  If the person with dementia is awake and wandering about in the middle of the night because they believe it is day time, rather than tell them they are wrong, it is better to suggest that they go to bed and if they don’t want to, then sit and chat about the weather or distract them in some other way and later suggest they go to bed.  It is far less confrontational than telling them that they have made a mistake about time and they should go to bed, it can lead to them feeling shame for getting something wrong!

 

When you are with a person with dementia and their carer, it is best to talk to the person with dementia and not their carer if that is possible and if talking about them, ask permission to talk to the carer.  It can just make them feel uncomfortable if they are being talked over rather than to.

 

People with dementia don’t like to be tested about things, the rest of us don’t go through our lives being tested, so they might not want to answer questions if a lot of them are being asked at once.  So make the person feel comfortable and if you need information, see if you can get it in a more conversational way, instead of lots of questioning.

 

If at all possible, it is better not to say “don’t!  As soon as anyone is told “don’t do that” or “you can’t”, people do exactly what they have been told not to, it is human nature!  It is much better to redirect to something else and only at the point their life is at risk should they be directly challenged, if not, then they can be distracted instead, it is a much nicer way to behave towards people with dementia.

 

Everyone is different, not everything that I have discussed in this series of blogs is relevant to everyone, but hopefully it will be helpful, if you ever meet someone with a dementia.

 

It is also important to remember that the skills that relate to dementia are transferrable to other disabilities and situations.

 

Be calm, be happy, smile and this will have an impact on the person with dementia, this will be perceived by the person with dementia and they will appreciate that you are a safe person for them to be around.

 

The withdrawal of food and fluid – the right to die – a new Supreme Court case

2 Aug

The withdrawal of food and fluid – the right to die

 

There was an important case this week in the Supreme Court, which is the highest Court in the UK regarding the withdrawal of food and fluid for some people.  This is changing the way that these matters are going to be dealt with in the future.

 

The first case of this kind was the sad case of Anthony Bland in 1993, he was a survivor of the Hillsborough disaster and was in a vegetative state, from which there was no chance of recovery, but as he was otherwise a fit young man at the time of the incident, he could have continued to live for years.  He had even undergone surgery without the need for anaesthetic, as he was brain dead and did not feel pain.  The case decided that it was in his interests to stop his food and fluid, so that ultimately, he would die, which is what happened.

 

Since then all other cases of minimally conscious patients go to the Court of Protection for a decision and each case is decided on its own merits.   Every case is expensive both in money terms, but also for the distress that the hearings cause to the loved ones, in part because of listening to the medical detail and in part with the anticipation and unknown nature of litigation.

 

So what did the Supreme Court decide?  In future all patients who are in either minimally conscious states or vegetative states can have food and fluid removed without the need to apply to the Court for an individual decision as long as both the family and the health authority agree that this is in the persons best interests.  If there is any disagreement, then this case is not relevant and also if the person is not clinically in one of the relevant coma like states.  If the criteria are fulfilled, then the person can be allowed to die following the withdrawal of food and fluid.  Their death will be managed to ensure that they are not in pain or suffering in any way.

 

There are estimates that at any one time in the UK there are about 3,000 people that this case might be relevant to.  The Court of Protection deals with around 1,500 new cases each year, with a legal cost of £50,000 to the health authority in each case, that £75m per year that the NHS can spend on something else, as well as end the distress to the families that the litigation causes.

 

There will still be cases that the Court has to decide on, those that do not fulfil the criteria of this case, in particular, when the family disagree.  This is not a case of assisted suicide, as without this artificial support these people would not survive, the only reason they are alive is the medical intervention that keeps that so, but there will be no doubt arguments that it is a case of assisted dying.  With no chance of recovery and no quality of life, I endorse the decision by the Court to make the situation easier for all involved, however heart wrenching that decision might be.

 

How to communicate with someone who has a cognitive impairment – Part 4

26 Jul

 

How to communicate with someone who has a cognitive impairment – Part 4

 

I would again like to thank Kate Smith from Memory Matters some of the information for this blog.

 

It is important to remember that no two people with a cognitive impairment will communicate or present in the same way, but here are some more ideas that will hopefully help.

 

People with dementia can have difficulties in planning, putting the plan into action is called sequencing.  The often-discussed task is making a cup of tea, there are lots of different stages to this task, which we take for granted and if we get some of them in the wrong order, we do not have tea.  So for example, if we pour the water on the tea bag and then boil the kettle, we have a wet tea bag, but no tea.  People with dementia can also have problems with other everyday tasks and this includes talking about those tasks.  A difficulty planning is around the abstract thought process, I once had a client who held out her hand to me with a 50p in the middle of her hand and she asked me “is this 50p worth a pound?”!  She was able to identify the piece of metal in her hand, but did not understand its abstract value and therefore how it worked.

 

People with dementia can have problems with spacial perception, they will struggle to understand what is close to them or the distance between things, which can impact on how they talk about things.  This will also clearly have an impact on how they move about, which will also have an effect on how people treat them (if they look drunk, they might be treated as drunk!).

 

People hold maps in their head of their environment, so if there is a problem with the map, people can have difficulty finding their way around, except in the most familiar of places.  People with dementia who have difficulty finding their way around can begin to go out less or not at all, if they are alone, which can lead them to become isolated and lonely.  If they don’t go out, they might need a companion, they need someone they trust and feel safe with and they will happily leave their known environment.  When asked about places, they can get confused or muddled and mix places up or have trouble talking about them.

 

When talking to someone with a dementia, it is more respectful to accept their understanding of their world than correct them, unless it is not possible to do that.  So when someone in their 90s talks about their parents as though they are still alive, unless there is a risk to their life, it is better for that person with dementia to also talk about their parents as though they were living.  I had a client once whose husband had passed away and she thought he was having an affair and that was why he hadn’t visited, even though she had been told and had attended the funeral, she just couldn’t retain that information.  So her family told her lots of different things, but not that he had died, as she just got upset each time, as she re-grieved for him.  The family said that he had a cold and didn’t want to pass it on, that he would come next week or that he had come a few days ago and due to her confusion, she accepted all of these excuses and wasn’t upset at either his death or perceived affair!

 

When talking to someone with a dementia, if you do nothing else, but the kind, safe, smiling person.

 

How to communicate with someone who has a cognitive impairment – Part 3

12 Jul

 

How to communicate with someone who has a cognitive impairment – Part 3

 

I would again like to thank Kate Smith from Memory Matters some of the information for this blog.

 

It is still important to note that no two people with a cognitive impairment will communicate or behave in the same way, but here are some more ideas that will hopefully help.

 

People with dementia can have problems initiating something, they just can’t seem to get started.  A couple of years ago, I went on a dementia experience, when I had my hearing, vision and sensitivity affected by various pieces of equipment and was then told to do three things all at once, none of which I could hear properly.  It was an information overload at a time when I had impaired senses and it became too much for me.  I just sat down in the chair in the corner and waited for someone to come and tell me what to do next, as I had no idea what I was meant to do!  This is apparently a common thing that people with dementia do, when they don’t know what to do.  So, I sat waiting patiently and watched what was going on, as best as I could see.  People with dementia might need help to get things started, as they might not know how to in that moment.

 

The next issue that they may have is called perseveration and this is when they do get started they cannot stop.  I have had a few clients that walk, all the time in a care home.  They cannot even sit down to have a meal for any length of time and often have food that they can carry with them and eat on the go.  Even going to the loo can be challenging for these people that walk a lot, as they have trouble sitting for any length of time, which might not be the same time frame that they eliminate in!  It can be repetition of any action though, including moving their hands, feet or arms in the manner that they did for work years ago, if their work tasks were repetitive.

 

People with dementia can become bewildered with choices, so keeping the choices down to very simple ones can help.  Instead of asking if they want beef, chicken or fish for dinner, just start off my asking if they want beef, yes or no and if the answer is no, ask about chicken etc.  In this circumstance it is useful to know what their general preference is, so as to ask them about what is likely to be a positive choice for them first.  The person talking to them should keep the language simple, to ensure that they are as empowered as possible to make as many decisions for themselves as is possible.

 

People with dementia can have problems making good decisions, as they can have an impaired judgement.  When faced with the choice about going into care, often they say that they don’t want to and believe that they are caring well for themselves, but are remembering a time in the past when that was true, which then affects their ability to make a good decision now.  There are lots of different reasons for impaired judgement, this is just one example, however the person’s judgement might be impaired, so they might need support to make decisions.  It is important not to interfere with an unwise decision, as people with dementia are allowed to make unwise decisions, like we call do from time to time.  Impaired judgement is about exactly that, rather than about imposing on the person a different choice their loved one or family would rather they made.

 

The ability to make an unwise decisions is one of the five principles of the Mental Capacity Act 2005.  The issue about protecting them from an unwise choice is around their right to life, when a decision is so unwise it puts their life at risk, then their other rights can be overreached, such as the right to a private and family life or the right to free association.

 

If nothing else, but the kind, safe smiling individual for the person with dementia.

How to communicate with someone who has a cognitive impairment – Part 2

28 Jun

 

How to communicate with someone who has a cognitive impairment – Part 2

 

I would again like to thank Kate Smith from Memory Matters some of the information for this blog.

 

It is still important to note that no two people with a cognitive impairment will communicate in the same way, but here are some more ideas that will hopefully help.

 

People with dementia can retain some motor skills that those around might have thought that they had lost.  In general, people lose their fine motor skills, so their dexterity becomes impaired for wide-ranging things, however they still might retain muscle memory for something that they did a lot when they were younger, which is why people can play the piano, even if they have trouble getting dressed and doing up buttons for example!  This can be helpful with doll therapy and pet therapy, as the person with dementia is used to rocking a baby or stroking a pet.  The moments are familiar to them and feel safe, so they will relax.

 

One third of our brain relates to processing visual information, so if this part of the brain is damaged, then the person will have difficulty in some way process or misunderstanding what they see.  This can lead to what appears to be difficulty in walking, if for example they perceive lines in carpet as snakes on the floor or dark carpet / mats as holes, which they need to step over.  They might also have difficulty in recognising people visually, so a prompt, such as giving your name and relationship is helpful.

 

The person with dementia can lose insight into not just their condition, but lots of other things to.  They might act in a way that is considered socially inappropriate, such as greeting everyone like they are your best friend or spouse.  They might hold hands with someone, as it is comforting to them, without the insight into what is socially acceptable, they are behaving in a way that they want and is helpful or comforting to them.  In general, unless completely inappropriate, then it is easier for them if the people around them go along.  I have had clients who have hugged and kissed me like I was their child and have always appreciated that it was a lovely, warm and kind way to greet me!  It is nice to be liked!

 

Communication is relevant both ways, communication to tell someone something and communication when someone is telling you something.  The loss of the ability to communicate can be in both directions, but it could be worse in one than in the other.  People can have word finding difficulties, which can be frustrating, as they know that they know what they want to say, but have trouble remembering the specific word, so “pork” could become “bacon” or “pig” instead or they might use gestures to try to explain themselves.

 

Receptive language is about someone’s ability to understand what is being said to them and if this fluctuates the person can be thought of as having selective hearing!  It might simply be that their ability to understands fluctuates, like the rest of their presentation.  So, the person might need the carer to use simple language or different language.  They might need to use gestures or other nonverbal communication, anything that involves touching the person with dementia should be appropriate, usually touching their hand is considered appropriate, but what that is, depends on the perception of the person with dementia.

 

What is important is that the person with dementia feels safe with you, if nothing else, be the smiling safe person!