The most difficult decisions that I am faced with, and it hasn’t happened frequently, is when I am carrying out a Mental Health Act Assessment and have two signed medical recommendations in my hand and have to make a decision whether to admit or not.
Sometimes it is a very straightforward decision. The history, the presentation indicate that there is very little choice.
When I was training one thing that was instilled in our minds was that when you make that decision with an older patient, it can be unlikely that they will ever return home again as often the outcome of hospitalisation is residential placement. It doesn’t always happen this way but it is a common outcome.
I was faced with one of these decisions recently. It involved Mrs N who has dementia. She has refused any kind of care services at home – but, to cut a long story short, she needs some help. More than some – a fair amount actually. She immigrated to the UK decades ago with her husband. She is now widowed and has no family in this country.
She believes her husband is still alive. She talks to him. A placement had been arranged for her a few months back but when the moving time came, she refused to go because she did not want to leave her husband.
The risk and concerns come from her wanderings in the local area into the evening. She also seems to be switching her fridge and freezer off at times which leads to an excess of rotten/rotting food in the kitchen and concerns about what she is eating.
I attended the assessment and the medical recommendations were forthcoming but something felt very uncomfortable and I did not make the application. I suppose this has made me more conscious about ‘making mistakes’ in practice.
I spoke to her care co-coordinator and she put in a care package. It wasn’t a very conventional package of care and something that would never have been permitted in any previous role I had worked in.
We put in a couple of hours a day with a good local agency – not to do any particular ‘care work’ but to come in and sit with her and chat with her and get to know her. Also to keep an eye on her because the times that she ‘went out for a walk’ in the evenings were pretty well-known. This happened to be the same times that we sent someone round to her home. Is it restricting her liberty to send someone to her home at the time she likes to go out and sweet talk her into staying and having a cup of tea? Most likely – but it is less restrictive that being on a hospital ward.
I have, when permitted, used this before as a ‘way in’ to providing a service when people are reluctant – but usually I have only been allowed to authorise very short visits for the purpose – 30 mins max. This time it is a much longer period of time that we have made provision for. I wouldn’t like a complete stranger to be coming in and providing personal care to me so having a little ‘bedding in’ time can be a good way of getting a service through the door.
Once the carer is accepted, services can increase. One carer can introduce a colleague and so although there is no elimination of risk – the balance between risk and choice, even in the face of lack of capacity can be balanced.
I’m not saying things are perfect – it’s still a matter of us crossing our fingers and hoping things work out for Mrs N – but it feels that at least we have been able to make more of an effort for her before pulling her out of her home and causing no little amount of stress and distress.
It might not work – anything can happen – we could be presented with the newspapers at my door if Mrs N does come to harm. I am also fortunate that in my current setting, my managers will allow more flexibility with care packages if I can make a good argument and honestly, day time care at home is almost always cheaper than hospital care or residential care. I think though, and I don’t want to second guess outcomes, it does show how more funding can allow more flexible approaches to be taken on a very real level.