‘If i can’t go home i’ll die’

Case study

The names of the service users have been changed

SITUATION: Mary McManus, 89, lives alone in a fifth floor flat. Her daughter, Maria, 71, visits daily and sometimes takes her out. Previously unknown to social services, Mary was admitted to hospital for a routine operation. She was promised that she’d be home in a couple of weeks at most. Unfortunately, the operation went wrong causing ruptures and internal bleeding, and leaving a severe wound in her stomach. She also caught MRSA (methicillin-resistant staphylococcus aureus) and remained in hospital receiving intensive nursing care.

PROBLEM: Two months into her hospital stay and unable to get out of bed, Mary became depressed, seeing no light at the end of the tunnel. A once energetic and lively woman, she was now withdrawn and fearing the worst. If she was to return home there was a concern that she would be too isolated in her flat. Also social services could only offer, at best, an at-home package that would amount to four visits a day, but it was believed that Mary needed 24-hour care. The consultant considered that a return home was out of the question given that her daughter could not physically be expected to care full-time. He concluded that Mary’s best interests would be served by a nursing care placement. He also had delayed discharge pressures to contend with. Mary believes that if she can’t go home she will die soon. Maria is not sure what is for the best.

Practice Panel: Older people’s services – Leeds social services and primary care trust

Sue Orchard, clinical leader, intermediate care ; Jackie Dawson, district nurse ; Mick Ryan, principal case worker, adults ; Joanna Gare, clinical leader, intermediate care ; Kathryn Evans, senior nurse, health care development

Panel responses

Sue Orchard
Before a decision is made about Mary’s future there must be assessments carried out by the physiotherapist and occupational therapist within the hospital to determine Mary’s ability to move and to carry out tasks such as washing and dressing, meal preparation, and taking medication. A social worker should also be involved at this stage.

Following these assessments the best form of care for Mary can be determined. The social worker would then call a care plan meeting to discuss future care with the appropriate carers.

If she is able to move short distances and able to carry out some of her personal care then a referral to intermediate care might be appropriate for a further period of rehabilitation, either within her own home or in a community intermediate care bed.

With intermediate care she would have assessments and treatment from nurses, physiotherapists, occupational therapists and clinical assistants, who would, after a period of rehabilitation, be able to determine the level of care that Mary would need in the future. There would also be a dietician on hand who could assess how well she is eating.

Following discharge, intermediate care can provide, in the short term, several daily visits to encourage and support patients in their daily care. These visits are reduced as the patient improves. Night sitters may be available for the first few days to assess the patient’s overnight activity.

If Mary is unable to carry out any personal care or is unable to move then she could still go home with an at-home package of care and the use of a hoist. The hoist would enable home care staff to move Mary between bed, chair and toilet. There wouldn’t, however, be any care overnight and Mary would be alone between visits from home care. The district nurse would become involved in order to monitor Mary’s pressure areas and well-being.

It could be that following a stay with intermediate care or having at-home care or both, Mary, along with her daughter, may decide that she does really want to be in care and the appropriate steps should then be taken to assist them in the transfer of care.

Jackie Dawson
If this were my case, my initial involvement would be to attend a care planning meeting on the ward that Mary was currently staying on. The meeting would include various professionals, (nursing, medical staff, social worker, homecare team leader, occupational therapist, physiotherapist) and most importantly, Mary and her daughter, Maria.

The meeting would enable all parties concerned to discuss Mary’s progress to date and her future needs. Additionally, the risks of Mary returning home and her well-being would be discussed. The aim of this type of meeting is to ensure that Mary is discharged safely following her hospital stay.

In this situation it maybe that Mary returns home or else goes into a nursing home placement. Most importantly, Mary’s involvement and her choice to return home would be taken into consideration at this meeting.

Should Mary return home my role would firstly, involve liaison with the ward team regarding equipment needed to make this happen, this may include a hoist, hospital-type bed, commode, pressure relieving equipment. All this equipment would be ordered by me in advance of Mary’s return home. I would ensure that all Mary’s carers were able to safely use each piece of equipment. For example, training would be carried out to show the carers how to use the hoist to safely move Mary.

Also, in conjunction with the ward team, I would assess Mary’s wound to her abdomen. The assessment would involve the type of dressing and frequency of dressing changes. In addition, a photograph and “wound mapping” would be carried out with Mary’s consent on her discharge home to enable progress or deterioration of the wound to be monitored.

Should Mary have MRSA in her wound, additional infection control measures would need to in place at home, including supplies of aprons, gloves and alcohol handwash. Soiled dressings would need to be incinerated through the local collection service. I would help teach Mary’s carers and her daughter about hand hygiene to reduce the spread of MRSA.

My role would also involve supporting Mary and her daughter at home ensuring her needs were being met, referring back to Mary’s assigned social worker as needed.

User View
This case study highlights the invaluable support given to older people by their family and friends and how when anything happens to the older person, pressure increases on the family, write members of Knowsley Older People’s Voice.

Mary’s needs are not being met by the consultant’s suggestion that the only option is for her to go into nursing care, when two months ago she was capable of living alone and looking after herself with support from her daughter. Mary’s choice should be the key factor in deciding what care she receives.

The primary concern should not be that Mary is bed-blocking but that she is in the most appropriate place to regain the quality of lifestyle she experienced before her operation.

In Knowsley, Mary would have the option to be transferred to an intermediate care facility where she would have intensive physiotherapy and occupational therapy over a six-to-eight week period. This would aim to increase Mary’s mobility and confidence and during this time steps could be taken to assess and treat Mary’s depression.

All the professionals involved, in order to help Mary return home, should adopt a multi-disciplinary team approach. As Mary’s daughter and main carer it is essential that Maria is also involved at all stages during the planning of Mary’s care.

Maria will need support to look after Mary or she could become ill herself. This support should be in place before Mary is discharged from intermediate care. The support could be enhanced by the use of assistive technology and providing various adaptations to help improve Mary’s independence.

If Mary decides that she can no longer live alone, further information needs to be provided about the availability of sheltered or extra care accommodation, so that she and Maria can discuss the options available, in order to make an informed decision.

In Knowsley there is a network of support for carers. It would be helpful for Maria to have such support so that more help can be provided. It could also give access to a circle of friends, experiencing similar circumstances to both Maria and Mary.

The aim should be to help people, such as Mary, to have the option to stay in their own home for as long as possible; health and social care services need to work to this purpose.

Knowsley Older People’s Voice is an older people’s forum based in Knowsley, Merseyside