Tag Archives: Health & Welfare

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!

How to choose a care home – Part 1

7 Nov

elderly_medicationHow to choose a care home

This is a very hard thing to advise on.  Moving into a care home is about moving “home”, so what one person would like as their home another person wouldn’t.  Therefore in many respects there are no right answers and no wrong answers, it is a matter of choice.

There are some basics though and the first thing is to understand the presentation of the person that is going into care and find out the category of home that the healthcare professionals think they should be in.  Then ask for a list of suitable homes in the chosen area and ring them.

First impressions count, so what was that first phone call like?  Did you like the response on the phone, were they helpful, courteous and respectful?  If they were, then hopefully they will be like that when your loved one moves in.

When you explain the presentation of the loved one what is the response, it is the metaphorical sucking of air through the teeth or are they happy to accommodate the required care.  Do they make you feel like you are you asking a lot or a little?  It maybe that you are asking a lot, someone with extreme aggression is hard to care for, so bear in mind what you are asking.

The next step is to arrange a visit.  This can be hard and if you go to the websites of Age UK or Alzheimer’s Society, they have a leaflet about moving into care with a list of things to think about and ask, print one off and take it with you, so that you won’t forget an important question.

It is a simple test, but step inside the front door and take a big sniff, what do you smell?  If it is something delicious cooking that’s wonderful, if it is something unpleasant, that is an important sign.  Most care homes have people with incontinence, so accidents happen, if some homes clean it up well enough that there is no smell, there is no excuse for the others.  I’ve been to the odd home where I not only want to have a shower and wash my clothes, but wanted to wash my shoes, handbag and briefcase; I couldn’t get out of there quick enough and nearly lost my lunch when I stepped inside!!

So having stepped inside the door, what are the staff like?  Are they warm friendly and welcoming?  What do they show you?  You’ll probably be shown a room and the dining room plus lounge, but can you see the kitchen?  What about the laundry?  If the areas that are “staff only” are nice, then this is a good reflection, but they may be grotty.

Are you offered a cup of tea?  The cuppa can be a good indication – is it a mug or cup and saucer?  Is there a tray?  Is it just a cup/mug or pot of tea?  Is there a doily on the tray?  Is there cake or biscuits? Are the cake/biscuits homemade?  Are the biscuits plain or chocolate?  When I go to care home, mostly I’m offered a cuppa, it is very rare I’m not.  It is also rare I get homemade cake and a doily on a tea tray with a pot of tea, but lovely when I do.  I’ve even been offered this in the garden on a warm day, so the venue of the tea can make an impression.

If you ask lots of questions and then ring later with another question, how is that call handled?  With patience or annoyance?

You’ll probably see an interaction between a resident and staff, how do the staff behave?  Are they respectful, treating the resident with dignity.  What are the residents doing?  Are they alert or asleep – this might be dependent on the time of day, residents often get sleepy after lunch.

Importantly, ask about the food, it may be a small pleasure but the residents deserve all the pleasures they can have, so is the food homemade or do they heat up ready meals?  What is the choice, when does the kitchen close (if at all)?  Can a certain dietary choice be accommodated?  Even if the choice isn’t exotic, can a resident have bacon & eggs for breakfast?  What about 4pm or 4am – can they have it then?

Ask all the questions you think are important; take a list of questions if necessary.  Then go home and try to sum up your impression when you are not there.  How do you feel about putting your loved one there?

Dementia – Part 9

31 Oct

nursing_home_careDementia – the carers

I work a lot with the families of people that suffer with dementia and it is hard on everyone.  For children it is hard to go from being the child, to taking over the role of the “parent” and looking after their parent, taking charge of things and often being the decision maker in situations.  This role reversal is difficult and can be resisted by the person with dementia, as they try to maintain control of their lives at a time when the have no insight into their condition.  They just cannot see how vulnerable they are.

I’ve had a client who said that they fancied fish & chips for tea and that they would pay for it, if someone would go to the chippy.  On return with dinner, the client counted out the money to pay for the fish & chips, but had mistaken £1 for £10 notes, so offered £50 for the meal instead of the £5 it cost, counting out the notes one by one.  They were fortunate to have an honest person who accepted only the right amount of money.

It can sometimes be a thankless task and numerous times I’ve seen the women of a family (usually of a generation younger) burdened with the role of caring for a loved one with dementia.  I’ve all too often seen others in the family come into the situation for a short visit, criticise what is going on and leave again without offering support in a real way.  Spouses are almost always willing to care for their husband / wife, as by then they may well have been together for 50, 60 or even 70 years and would not want to let down their spouse.  This is hard on them as they are elderly themselves, but they are at least a very loving carer (by and large).

Family members struggle to watch the loss of dignity; they struggle with the shame of the confusion and with the loss of body function, if they are for example incontinent.  It is hard to tidy up a mother, after she has wet herself, when she used to be the person who nagged you to tidy your room, do your homework and made it better when you fell over and grazed your knee!  And let’s be real, dealing with any sort of body fluid when it has come out in “the wrong place” is never a wonderful task we all look forward to.

Carers require support themselves and can and should ask for respite if they need it, they will be better carers for a break.  In some cases they will be entitled to carers allowance and should seek advice in that respect.  They are entitled to their own assessment of their needs and should not be ashamed to ask for help, we all need support from time to time.

Carers do an amazing job and should be admired and supported for the important role they play.

Dementia – Part 8

24 Oct

Dementia – the side effects

 

I’ve already been through some of the loss of memory and loss of functionality of a person with dementia, with their loss of ability to plan (the executive function).  So as well as loss of brain ability, they can also have a personality change and sometimes they don’t.

 

We are all individuals, we are all different.  I’ve met some clients with similar traits, but I’ve never yet met anyone who is exactly the same as someone else.  So like all individuals, people with dementia have their own presentation and journey through the condition.

 

I would stress once again, that I am not a clinician, but I am an elderly client solicitor with a lot of experience of dealing with people with dementia at all stages of the condition.

 

One of the most common side effects (if they are going to get any) is aggression.  This can be very upsetting for families to see their loved one who was always delightful come out with language they never knew they knew or hitting others.

 

Aggression is a spectrum presentation and can be anything from a cross word and a stern stare to punching, kicking & biting with all their strength and everything in between.  Some people with aggression may only be aggression (to whatever extent they are) some of the time and sometimes it is all the time.  I had one client who punched someone so hard, she broke her own arm!

 

An aggressive presentation is more common in the moderate stages and as the dementia progresses their aggression can wane, but this is not always the case, as already said – we are all individuals.  It is suggested by clinicians that this is a fear response, and as the dementia progresses and they don’t know that they don’t know, they become calmer.  I have had clients that were described as “internally agitated”, it is a more unusual presentation, but even in very late stage dementia, they can seem agitated, sometimes tearful and aggressive.

 

Aggression can take the form of abusive language, without physical aggression.  This is when families hear colourful language!  Or it can be threatening language without the swear words, spoken pointedly towards their loved ones.

 

There can also be a presentation of paranoia, but this tends to be in the mild to moderate stages, again it is assumed to be a fear response.

 

I’ve also seen the side effect of hyper sexuality, which is more unusual.  This is when the person with dementia is overtly sexual.  It can create a very difficult situation if the look like their parents, as the parent will look at their child and think it is their spouse in the earlier years, which may be where their world exists at that time.  Therefore when the parent makes overtures to their child, the child will of course rebut them, but the parent feels let down by their spouse, not having realised this was their child.  Even without this situation in families, the person with dementia is being constantly turned down and it is very hard for them, although they may not remember how many times they have been turned down (a small blessing).

 

There is lots of guess work in respect of people with dementia, as their condition develops and they lose the ability to communicate, no-one knows for sure what they think or how they feel, because they cannot communicate it.

 

Caring for someone with these side effects takes a great deal of empathy and skill to keep all parties safe and the person with dementia in the optimal health possible.