‘Don’t cart me off’

The death of her husband has left an 88-year-old woman trauma tised, isolated and unable to cope alone. Our panel advises

Case study

The names of the service user and her husband have been changed

SITUATION: Margaret Thomas is 88 years old and lives alone following the death of her husband, Oliver, last year. She has no family or friends. Oliver had suffered a haemorrhage in the night while in bed with Margaret. He was dead by the time the ambulance crew arrived. Traumatised by the event, she twice took an overdose of tablets. Although now over the initial shock, her husband’s death has completely altered her state of mind. She refuses to use the bedroom and for the past six months has found it impossible to go upstairs – and sleeps on the sofa. Two months ago the house was burgled and vandalised – and now Margaret refuses to leave the house. Her neighbour, a retired home carer, shops for food for her each Friday and suspects a mild dementia in Margaret.

PROBLEM: Although unknown to social services (she fears they would want to “cart her off to a home to die”), Margaret is known at the nearby city hospital because of her history of falling. Most of her falls happen when she bends down to turn her gas fire (her only form of heating) or the television on and off. Following another fall and some stomach pains, she was again admitted to hospital. Hospital staff say it is not safe for her to return home – but she has told the hospital social worker that she must go home or she will kill herself.

Panel responses – Leeds Social Services department and primary care trust

Sue Orchard
Margaret should be given an opportunity to live at home once more with support from community services. While in hospital she should be assessed by an occupational therapist, to determine her ability to carry out daily living tasks such as washing and dressing and meal preparation, and by a physiotherapist to determine her mobility.

If Margaret is still finding it impossible to use her bedroom following her husband’s death an environmental visit could be undertaken by the occupational therapist to determine whether downstairs living is an option. Referral to the falls clinic at a local hospital could be made to find out if there is a medical reason why Margaret is falling.

Once these assessments have been undertaken and Margaret is deemed medically stable, then a referral needs to be made to intermediate care to help establish Margaret back at home. A discharge home visit could be arranged with the hospital occupational therapist and intermediate care.

On discharge from hospital a care package needs to be in place to provide assistance with shopping, cleaning and possibly laundry. This has to be done with Margaret’s agreement and it should be explained to her that this is to provide her with the support that she requires at home, and can and will be reduced as and when she improves.

With intermediate care she would have assessment 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 Margaret would need in the future.

There would also be access to a dietician who could assess and treat her nutritional status. While with intermediate care she could be screened for dementia by the mental health team and plans put into place to monitor her future progress. There would be daily visits from intermediate care and night sitters for the first few nights if these are deemed necessary. As Margaret improves, the visits would be reduced and at some point a decision will be made as to the amount of care she will require. A referral would be made to social services and Margaret would be discharged from intermediate care once this is in place. 

Chris Rawson
Margaret would be an ideal candidate for assessment by a community matron. We aim to cut unnecessary hospital admissions for older people with long-term conditions, and co-ordinate health and social care needs.

Initially, I would liaise with the ward team and gather information; the social worker’s impression of Margaret’s lucid state needs to be clarified by a psychiatric assessment in order to determine if the patient has the capacity to make her own decisions.

Evidence regarding her mood state, memory lapses and independence in daily activities such as washing and dressing needs to be gathered. Margaret is desperate to go home, but it is evident from her recent history that she cannot be discharged safely without support in place at home. Assuming she has capacity, she needs to be reassured that such support is available, and with her consent a plan can be made for her discharge.

I would liaise with the medical team regarding her frequent falls: a review of medications and investigations into suspected postural hypotension and balance impairment would be needed as well as explaining the cause of the recent stomach pains. A mental health follow-up would be requested including a referral to the memory clinic.

I would request an assessment of the home environment, looking at the need for aids and adaptations, and improving heating, lighting and security. As Margaret refuses to go upstairs, a bed and commode could be placed downstairs. A compliance aid (which helps people remember when to take their medication) would be organised. An intensive level of support could be provided initially by the intermediate care team (ICT) while providing a multidisciplinary assessment. The caring neighbour would be encouraged to remain involved with Margaret.

I would follow up the patient post-discharge and communicate with ICT regularly. Having accepted support from ICT, Margaret is less likely to reject long-term support from social services. I would continue to work with her towards reducing her isolation: once trust is established she might consider attending a day centre or accessing respite, which would help to ameliorate her loneliness. The mental health team would support Margaret as she deals with her grief following her bereavement.

User view
Margaret appears to have been generally well and able to look after herself up until the trauma of the past 12 months, write members of Knowsley Older People’s Voice. These events have caused her to lose her independence and confidence and she is now living in fear, trusting only her neighbour.

While in hospital Margaret needs to have a complete health check and review of any medication she is taking. We need to rule out any medical reason for the falls and ensure she has no urinary tract infection, as this can present with signs and symptoms of dementia. We also need to identify why Margaret is now having stomach pains: is she eating properly? Is she taking medication on an empty stomach?

There is no indication that Margaret has had any kind of bereavement or trauma counselling following her husband’s death. It is essential that this service be offered to her now.
We need to build Margaret’s confidence and trust in other people. She needs to feel secure in her own home. We would organise a visit, with Margaret’s permission, of the crime safety officer to ensure her home is safe and secure with door chains, window locks and window alarms. In Knowsley we could ask the neighbourhood wardens to call in on Margaret to establish a supportive relationship with her, helping her to feel even more safe and confident in her home. The neighbour who is shopping for Margaret may, in fact, be contributing to Margaret’s dependence, as Margaret has come to rely on her.

With Margaret’s permission, we would organise for her home to be checked by the accident prevention team, to ensure it is a safe place to live and that Margaret is not tripping over loose wires or carpets. We would also call in “Care and Repair” to move the sockets and gas fittings to a better height so that Margaret doesn’t need to bend when using them.

In Knowsley, we think that Margaret would benefit from referral to the Well-Being Service. This is a joint health and social care team that visits vulnerable older people following referral and with the person’s permission. After first offering a full health check, the team will discuss with Margaret, any “low level” services that may be of benefit.

It is essential that Margaret understands that no one wants to “put her in a home to die”, but wants her to live a happy, independent and safe life. Margaret still has the right to make her own choices and that must never be forgotten.

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