A Danger to Himself?


    PRACTICE PANEL Older people’s services – Leeds social
    services and primary care trust

     


    Case study

     


    The name of the service user


    has been changed

     



    SITUATION:



    Bill Thompson, 64, was diagnosed with Parkinson’s disease
    five years ago. His wife died two years ago. He now lives alone but
    is supported by a care package, including home care, meals on
    wheels twice weekly, day care and respite care. His daughter lives
    40 miles away but tries to visit him every fortnight.

     


    PROBLEM

    : Recently Bill’s mobility has deteriorated
    significantly.  Everybody
    involved with him – his daughter, care staff, neighbours and
    friends – are expressing concerns that he remains at home.
    Bill, a proud man, is adamant that he wishes to stay (and die) at
    home and becomes angry and agitated when residential care is
    discussed. However, his care package does not meet his needs. He
    falls frequently but refuses to be admitted into hospital when
    ambulance crews call to lift him. His slow mobility prevents him
    reaching the commode in time but he removes his incontinence pad
    during the night so he is soaking wet when the home carers arrive
    each morning. Bill also spends hours chopping wood during the night
    in his backyard, even though he has gas central heating and a gas
    fire in the front room where he sleeps. A fire guard has been
    bought for his wood fire but Bill removes this at times and spends
    hours lighting the fire. Bill’s social worker feels that
    supporting his right to self-determination is not easy when faced
    with such strong opposition.


     


    PANEL RESPONSES

     


    MICK RYAN


    As Bill wants to remain at home, it is important to explore the
    deterioration in his level of functioning. A thorough reassessment
    of his social care needs is required and this can be compared with
    any baseline assessment information that already exists from
    previous assessments. It is also important that the current
    progression of his Parkinson’s disease is considered by
    doctors. If Bill is not under a neurologist, with his permission he
    should be referred. If he is, a review would be helpful in
    determining the effect the illness is having on him.



    The disease may be affecting his cognitive functioning. Given the
    known links between Parkinson’s and dementia it may help to
    seek a psychiatric opinion. There may be depression issues. Bill
    has suffered a number of losses, chiefly the death of his wife and
    his diminishing independence through Parkinson’s disease. He
    is a proud man and may be struggling to come to terms with his
    increasingly dependent position. It is important here for the
    worker to listen to what Bill is saying about these issues and to
    help him come to terms with his reality. Bill’s expressed
    wishes are important and should be valued.



    There are risks to his current situation and these too need to be
    evaluated and the concern of family and friends acknowledged. The
    open fire is an obvious risk and Bill’s preoccupation with
    that activity needs to explored with him. Does it provide a focus
    for him? Could this focus be replaced with a less harmful
    activity?


    Connected to risk is the issue of capacity. Bill may no longer be
    able to make informed decisions and this would influence any future
    decisions about his care and his wishes.



    His mobility problems are exacerbating the continence difficulties
    and there may be practical solutions to this by moving his commode.
    It would also be useful to enlist the help of an incontinence
    adviser.


    This assessment should inform a new care plan to address
    Bill’s needs. The aim would be for the multi-disciplinary
    elements to work in partnership to provide an effective care
    package so that he can remain at his own home for as long as
    possible.


     


    SUE ORCHARD


    Within our area the primary care trust has enhanced the
    intermediate care team to include a rapid response capability to
    prevent unnecessary admissions to hospital.



    As this is now an NHS priority a pathway has been developed with
    the ambulance service to direct anyone who has fallen, but who does
    not need to be admitted to hospital yet requires some support for a
    short period, to the rapid response team.



    If Bill were to be referred, a falls assessment, which has been
    developed city-wide, would be undertaken and the most appropriate
    course of treatment instigated. This could be a referral to the
    falls clinic to determine the reason why Bill is falling. As he
    also suffers from Parkinson’s disease, there would be a
    re-assessment of his medication, as this could be a major cause of
    his continual falling.



    At the same time multi-disciplinary assessments would be undertaken
    to determine the effects of his poor mobility. An exercise
    programme may be introduced to help improve his mobility and
    balance.


    After all this Bill may be referred on to an outpatient programme
    to continue the exercises and to receive information on how to
    prevent future falls.



    Bill may also be referred to the advanced specialist practitioners
    (chronic disease case managers) at the primary care trust, who
    would monitor Bill regularly and encourage him to recognise his
    problems and to contact his specialist practitioner should he feel
    that he is regressing. The intermediate care team would also
    re-assess his continence needs.



    During this time Bill’s home carers would continue to liaise
    closely


    with carers. Home carers would be able to provide information on
    Bill’s abilities before his recent deterioration. His home
    care package may need to be increased.



    A referral would also be made to the community psychiatric nurse to
    assess why Bill had this need to chop wood and light his fire when
    he has adequate heating.



    Bill is a reasonably young man whose problems need to be sorted out
    and monitored in the future. All of this would need his
    co-operation.

     


    USER VIEW


    This is a difficult situation as it has reached the stage where
    even the extensive care package in place is not supporting Bill
    adequately. His behaviour seems to endanger his own health and may
    be a fire hazard to nearby buildings, write members of Knowsley
    Older People’s Voice and other service users
    . 



    It is clear that Bill has had a lot to cope with in recent years
    with the death of his wife and living with Parkinson’s
    disease. One concern is that attempting to force him into any
    changes in his lifestyle may be detrimental. He may even have
    severe depression, given all he has lived through.



    What may help is an assessment from a psychiatrist or a
    geriatrician to determine whether he has the symptoms of early
    onset dementia. This will also give an indication of Bill’s
    capacity to make decisions on his own future.  


    In the meantime, Bill’s care package should be adjusted so
    that he can live independently. It may be possible to offer him the
    option to increase his care package to four visits a day and daily
    meals on wheels. It may be that the family needs to speak to him
    about considering private care, perhaps with care assistants
    staying the night.



    There are a range of measures that can be offered to Bill to help
    prevent his frequent falls. These could include appropriate
    footwear, handrails and a visit from a representative of the falls
    prevention team.



    Bill’s habit of chopping wood and using an open fire within
    his property could be addressed if a fire brigade safety and
    prevention officer spoke to him. It might be that a more
    authoritative figure may have the desired effect.



    Further to this it may be that Bill has concerns over using the
    central heating and gas fires. These could be linked to fears about
    his ability to pay fuel bills or even whether he knows how to
    operate the central heating system.



    Bill’s sleep patterns seem to be causing him difficulties and
    it could be that this is a side effect of any medication he is
    taking. It may be worth considering reviewing his medication,
    perhaps when he attends respite care.  


    In conclusion, for Bill, his home is where he wants to be and
    measures should be provided to enable him to remain
    there.



    Knowsley Older People’s Voice is a
    self-advocacy


    group in Merseyside. Additional comments were


    provided by members of the Aging Well Group, Kirkby, and service
    users from St Mary’s Day Care Centre in Halewood,
    Merseyside


     


     


     

     

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