Tag Archives: Health & Welfare

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.

 

Advertisements

Going to hospital with a loved one

5 Apr

 

Going to hospital with a loved one

 

There is that horrible phone call, from the police or paramedics that lets you know that something terrible has happened.  It’s almost always at an inconvenient time and they want you to drop what you’re doing and head off to the hospital or come to where they are, if you are near enough.

 

If the matter is a life and death emergency, then you will be advised to meet them there and they will be blue lighted to the hospital or possibly even by helicopter.  If not the ambulance will make its way to the hospital and you can meet them there.

 

Depending on where you are in relation to your relative and the hospital, if you arrive before them, then the emergency department administrators will know they are on the way and will be able to give you an approximate time of arrival.

 

There is a four hour target of arriving at A&E and being discharged from there, either home or into the hospital, possible to a medical assessment ward (MAU).  This four hours does not start to run, until the paramedics have handed them over and there can be a queue for that, which can take up to an hour or even more.  Therefore the expectation that this will be done within 4 hours of the ambulance pulling up at the hospital doesn’t necessarily take this extra time into account.  So when you get to the hospital and pass by a place that sells food and drink, buy some, you could be waiting a long time and might need sustenance.  Make sure that you have a book or your phone is fully charged, as the waiting may be boring and you might need something to occupy you.

 

There are periods of activity and a lot of waiting as the staff undertake their investigations, they undertake a lot of their work with you nearby, but not there for reasons of access and dignity.

 

The area can be very busy, depending on what time of day and what day of the week, late on a Saturday night is not a great time for an elderly relative to have a fall!  The staff are busy and are trying hard to do their jobs effectively in a challenging environment and many retain great empathy skills even when under immense pressure.

 

If you have a power of attorney for health and welfare and your relatives has issues with their mental capacity, then it is worthwhile ensuring that you have a copy of it available, if possible.  If you’re loved one lacks capacity to make a decision, then you make it for them, so you will need to let the staff know that you have it, to ensure that any decisions that need to be made are done so, having discussed them with you and asked for your final decision.

 

If there is no power of attorney for health and welfare, then they should still discuss the situation with you and ask what your loved one would want, however the final decision as to what to do is the healthcare professionals and they are required to make a decision in that person’s best interests.

 

When someone you love is poorly, it is always a distressing time, watching them ill and/or in pain.  You are there and you are trying your best, that’s all you can do, so be kind to yourself about how stressful this situation is.

 

My key suggestions therefore are:

Be prepared for a long wait.

Get some food and something to drink during that wait.

Bring your health and welfare lasting power of attorney.

Be patient and respectful to the staff.

Be kind to yourself with how upset you might feel.

 

 

Lasting Powers of Attorney – practical issues – Health and Welfare

1 Mar

Lasting Powers of Attorney – some practical issues

 

There are two types of Lasting Power of Attorney, one dealing with financial affairs and the other dealing with health and welfare decisions.  In this blog, I’m going to give some practical examples of how the health and welfare one works.

 

One of the key features of the LPA for health and welfare is that it cannot be used unless the person has lost capacity to make their own decisions.  And as capacity is time and decision specific, for each issue that arises, the carer will need to check on whether that person has capacity to make a decision.  This does not necessarily need a formal assessment of capacity, no-one wants that each time a cup of tea is given!  However it might mean asking the question about how much milk and/or sugar goes into the tea and assessing the answer.

 

Each day, we make thousands of health and welfare decisions, how much butter is on our toast and how big a gulp of tea we take in the morning, each one of those is a separate decision.  And for most of those decisions, we might not be that bothered if the carer makes that decision.  But we all have our personal preference on for example how hot our tea is, how much milk and sugar there is, so if the care communicates that, it is helpful to those providing care.  And as long as someone is dressed it might not matter if their t-shirt is red or blue.

 

So if the carer is going to make lots of these decision, why create the LPA?  Because it resolves the big issues and the issues where there is a dispute!

 

Lots of people say that they want to stay at home for as long as possible, but according to the House of Lords post legislative scrutiny of the Mental Capacity Act, Social Services are risk averse and healthcare professionals are paternalistic.  And in either case, they are not necessarily empowering the individual to make their own decision, including the “unwise choice”, which is a principle of the Act!

 

So having an LPA in place will mean that the attorney can insist that the person is cared for in their own home or discharged from hospital.  It will mean that the care that is provided to them is done in accordance to the attorney’s instructions, as long as it’s possible to provide that care.  This is not an entitlement to something that is not clinically appropriate.

 

If you have any questions about LPAs, please contact me.

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.

 

 

The Elderly in hospital

5 Mar

shutterstock_9022426 (20)

The elderly going into hospital

 

I’ve had a number of clients who have had bad experiences in hospital and it is worthwhile considering the reasons why in more detail and considering what, if anything can be done to make the experience better.

 

The issues are often around confusion and mobility, although not exclusively.  Mobility means that they need more support to get around, which often means that the hospital will catheterise them, so that they don’t have to be assisted to the loo so often.  They can end up sitting in the same place for an extended time and therefore can end up with pressure damage, although fortunately this doesn’t happen that often.

 

The confusion can be a big issue though.  They are in a new confusing environment, a place that can be active 24hrs a day, a place that they are unfamiliar with, the food tastes different, they can’t find the loo and all the faces are different.  And on the basis that they are in hospital for an acute reason, add to that that they may be in pain and it is easy to see why problems arise.  They get upset at the change and can get aggressive, which makes caring for them even harder, but even if they are not aggressive, they are struggling to adjust to the change of environment, only to be moved on in a couple of weeks.

 

Families will sometimes choose not to have a loved on admitted into hospital and go through all of this, when they think that the end is inevitable anyway.  There is no short right or wrong answer to this dilemma.  If the end is inevitable, it is easy to understand why the families would want their loved one to stay in the environment in which they are familiar, to die as peacefully as possible.

 

The problem with the “inevitable end” is that I’ve been told it is really hard to predict, so may in fact not be as inevitable as we think.  Hospital may be the answer to resolve the acute problem, with the aim to get them back home to a familiar environment as quickly as possible.  Or if not a familiar environment if the acute episode has changed their presentation sufficiently that they have to go to a new place, but again the aim should be to have them into a long term environment and out of the short term environment of hospital, which simply isn’t designed for people to stay in for long periods of time.

 

As for what is to be done, it is for the individual and their families to decide there is no one right or wrong answer.  The point is to understand the issues, take advice and try to make the best decision possible with the information that they have.  And very importantly even if hindsight indicates a different decision may have worked better, remember that hindsight is a perfect vision that we are not blessed with at the time of making the decision.

How to choose a care home – Part 3

21 Nov

elderly_womanHow to choose a care home – part 3

From the earlier blogs I’ve indicated, this is a very hard thing to advise on.  It is about moving home and where people feel “at home” is very much a matter of personal taste.  Following on from my last blog:

A common question that I’m asked or healthcare professionals advising are asked is “if this was your Mum/Dad where would you put them?”  The problem with that issue is the same as the point I’ve made above, where my mother would feel at home is not the same as where someone else’s mother would feel at home.

I have been to some homes where I would be happy to put my mother, if she were ever to need a care home, but which one would depend on her presentation and her care requirements at the time of needing to go into care.

So we are then down to the personal choices, can your loved one take in her own furniture.  Ask about things going missing, as people with dementia often pick up things belonging to others.  They see a watch and think “I have a watch, that must be mine” and pick it up, but it is easy to blame the loss of things like that on someone with dementia and I’ve no doubt that sometimes things are simply stolen because it is easy to do.  So think about this carefully when you decide what is to go into care with your loved one.  How precious is it?  How easy is it to steal / pick up?  How much will your loved one benefit from having it?  How much would your loved one notice if a precious thing wasn’t there?  How would you feel if it got lost, for whatever reason?

Personal choices can include things like pets.  If your loved one has a cat, can the cat come with them?  Does the home has pets and does your loved one like or loathe pets?  If the home has pets and your loved one is allergic, then this is not the right home for them, but it may be perfect for someone else.

Imagine your loved one living in that home, imagine a day, a whole 24 hour period – what will happen during that 24 hour period?  What if there is an emergency during that day, what do you imagine will happen?  Is your loved one going to be not just safe, but optimised and as happy as they can be?

Remember hindsight is a perfect vision and you are not making the decision with the benefit of hindsight, you have to make the decision with the information you have.  And you have to live with the decision, but if you’ve made the decision and with hindsight you would do something different, just remember you didn’t have that benefit.  Once you’ve mentally made a decision, sleep on it, does your decision still stress you?  Putting a loved one into care is always stressful, so which care home stresses you the least?  If you can live with the decision it is probably the right decision.

How to choose a care home – Part 2

14 Nov

nursing_home_careHow to choose a care home – part 2

As I’ve said, this is a very hard thing to advise on.  Moving into a care home is effectively moving home and where people feel “at home” is a matter of choice.

So picking up from the last blog, hopefully you have asked about the activities of the care home, seen around the grounds and asked if the residents can go out.

Also ask about staff turnover, how long have the staff been there?  A stable set of staff is a good indication of good conditions and happy staff.  The theory is that happy staff should hopefully take good care of residents.

I’ve been told by a member of an ambulance crew that the most telling time to see a care home is 7am, but having said that, the home are probably not going to be pleased to see you there then!

Ask about visitors, when will you be able to see your loved one?  Can you stay for meals, can you stay overnight?  If you stay for a meal, do you have to pay?  If you stay for lunch every now and again and have to pay for the extra meals it is a bit nitpicky!! Care home are profit making organisations, and if you stay for lots of meals, then paying for them makes more sense, but is does not give a strong caring vibe.  What do you feel the balance between profit and care is?

Ask about the local GP, as they may well need to change GPs.  You can always ring the local GP surgery and speak to one of the nurses or GPs there (if they will take your call).

Having visited the home you should check out the CQC website and see the last inspection reports (you can do this either before or after the visit).  What do the reports say?  Is there an area within the home where the inspection found unsatisfactory?

Once you’ve read the report and visited the home, then just have a think about your overall impression.  Choosing a home is not so much a cognitive exercise as an emotional one.  What is important is not just what you think about the home, but how you feel about it!