Need for a swift decision

PRACTITIONERS: Jane Boulton, team manager and Rebecca Linton, dutysocial worker.

FIELD: Hospital social work.

LOCATION: Leicester Council.

CLIENT: Doreen Richards was 93 when she was admitted to hospital in October 2002 when first contact with the hospital social work team was made.

CASE HISTORY: In 2000, Age Concern contacted social services about various problems including Doreen’s health and her ability to look after herself. However, Doreen decided that her family were going to help her and she didn’t want social services involvement. However, the department was again contacted in October 2002 with further worries around Doreen’s health. She was hard of hearing, had bouts of forgetfulness and had been falling. She also had Crohn’s disease, which affects the small intestine or colon or both, causing pain, diarrhoea, tiredness and loss of weight. The family felt that an assessment of Doreen’s needs at home was now needed, with a view that residential care might be required. Five days later a family member found Doreen had got out of bed and was unable to get back in again and decided to take her to the accident and emergency department.

DILEMMA: Doreen wanted to go home although indicators suggested that a placement might be a safer option.

RISK FACTOR: By going home there was a danger that Doreen would neglect herself.

OUTCOME: She was returned home but 10 days later was placed in short-term care for further assessment, and died a short time afterwards.

By its very nature, working in an accident and emergency department requires crisis management. Decisions are made under pressure. So ensuring that a calm social work perspective is part of that decision-making process is crucial for the short and long-term needs of service users.

A case that illustrates this concerns 93-year-old Doreen Richards whose family, despite making an earlier community referral, felt that her inability to get in and out of bed required hospital intervention.

“Doreen was checked by doctors who considered that there was nothing that required hospital admission or treatment. It was thought that depression might have something to do with why she wasn’t managing too well at home,” says Rebecca Linton, duty social worker at the hospital.

The accident and emergency discharge team, whose primary task is to prevent unnecessary admissions to hospital through quick assessments of risk, referred Doreen to the social work service.

“One of the risks was that she wasn’t getting in and out of bed safely. Her legs were very heavy and swollen and often she would not sleep in her bed, preferring a chair or sofa,” says Linton. The discharge team also considered that Doreen would need help with personal care – although more through prompting than physical assistance. Although able to carry out kitchen tasks she hadn’t been eating very well.

In planning a possible move home, her home itself presented a further problem. Linton explains: “Doreen’s local authority flat is accessed through an intercom system. So getting into the flat would be a problem because the care agencies can’t carry keys. However, there was a local authority residential care home in the same street and it was able to hold a key temporarily for the carers.”

This made it possible for Doreen to go home. “Talking to her, Doreen did say that residential care was something she had given thought to and felt it was something that she would eventually need. But she preferred to go home and think it over,” says Linton.

The family present at the time – Doreen’s son, daughter-in-law and grand-daughter – respected her decision but thought residential care inevitable. “The family were probably torn between wanting to respect their mother’s wishes, but equally believing that her needs would be best met in care. The family were being called very regularly throughout the day and night and clearly a lot was falling on them,” says Jane Boulton, team manager of the hospital social work service.

For Linton and Boulton it was a case of deciding whether residential care was required or whether the immediate risk factors could be dealt with to create more time and space to talk to Doreen about her options. They chose the latter. “We provided help with bed transfers and ensured she had prompting and assistance with personal care and domestic tasks. We got her home and arranged a follow-up assessment,” says Linton.

“We use this rapid assessment service quite a lot,” adds Boulton. “The team is made up of a social worker, a district nurse, health care assistants and a physiotherapist. They can offer intensive home-based assessments over a maximum of five days. Sometimes this is sufficient to get people back on an even keel. They can fast-track pieces of equipment and so on.”

The team found that Doreen’s mental state – her poor motivation and her depression – was a significant factor in how she was functioning. “She was prescribed medication but it would take a while to take effect. They also felt that although things were being held together, Doreen’s low mental state meant there was a strong risk, despite promptings, of self-neglect,” says Linton. “The rapid assessment service in this case did show that while things were possibly achievable at home they were not sustainable,” adds Boulton.

Linton continues: “We wanted to do further assessments – and so after 10 days at home Doreen moved to a local authority home, but unfortunately her health deteriorated while she was there. It is impossible to say how that might have related to anything we did or didn’t do.”

Doreen was subsequently admitted to hospital where she died. However, crucially she got to spend most of her last days where she wanted to be: at home.

ARGUMENTS FOR RISK

Although recognising that a return home was in all probability a short-term measure, critically it was Doreen’s express wish to do so. The workers did their best to make this happen and as safely and comfortable as possible.   l  Doreen was at home for 10 days. As Boulton observes: “It wasn’t long but she was able to get home and deal with unfinished business.”  l  Importantly, any longer term decision for Doreen would not be a rushed one made in accident and emergency. The decision to move into residential care was made in her own home. “An A&E environment can be difficult for service users, families and social work staff to be honest. But it felt that this came together quite well,” says Boulton.  l  The intended four-week assessment in the care home was intended to give Doreen’s anti-depressants time to begin working and to consider other options: a form of supported accommodation, for example.

ARGUMENTS AGAINST RISK

Supported and extra care accommodation or residential care can still be positive choices. They are very much part of community care – people can still live in and be part of a community, even if not in their own home. Some form of care accommodation was certainly on the minds of Doreen, her family and the professionals involved.   l Doreen was clearly unwell as her deterioration after moving into the residential care home for the four-week assessment shows. A residential or similar placement might have been able to deal more positively and more urgently with her poor mental health.  l While people might feel pushed into quick decisions when sometimes more time for reflection is needed, there is no doubt that working with people in crisis situations can create opportunities for people to be more open to ideas of change. It could be argued, given Doreen’s rapid deterioration, that a placement should have been more strongly considered.

INDEPENDENT COMMENT

This case had a sad outcome; an old lady died, she did not die at home as she would have wished, and her last weeks of life were disrupted by moves, writes Jef Smith.  There is little evidence that Doreen could not take decisions for herself; “bouts of forgetfulness”, “poor motivation”, and “depression” do not add up to incapacity. Her decision to go into care was clearly taken under pressure from professionals and her relatives. Such a move can be severely disorienting – even fatal – for frail older people; the death certificate presumably referred to Doreen’s Crohn’s Disease, but it might equally truthfully have said “Loss of will to live”.  Two reasons are offered for the eventual transfer to a home – to give the anti-depressants time to work, and to continue the assessment of need. But the fact that medication was prescribed so late in the day reflects many doctors’ unforgivable practice of not bothering to treat depression in older people early enough.   And what additional methods of assessment were proposed for the period of residential care which could not have been carried out in Doreen’s own home? Further home-based assessment would probably have been relatively expensive and is obviously less convenient for hospital-based professionals, but it would surely have produced a more realistic picture of her needs.   Jane Boulton and her colleagues deserve full marks for trying to meet Doreen’s wish to stay at home despite all her troubles; it is sad that this ultimately didn’t happen.  

Jef Smith is a writer, trainer and consultant specialising in the care of older people