You don’t need to have end-of-life conversations all at once

A Boston radio station is discussing the importance of having advance care planning conversations about your end-of-life wishes. An important point here: most people find these conversations tough.

Answer: you don’t have to have them all the time, or all at once. Have them as stuff comes up.

BUT: keep a note in a place you agree on about what you decided.

CommonHealth: Making End Of Life Conversations Easier | Radio Boston.

Memorial seat using the initials of the deceased person

Another memorial in a public place, this time in the National Trust gardens of Nymans, in Sussex, England. It is made with the initials of Anne Rosse (look at the back), and was placed there by her children, nephews and nieces in 2004, the fiftieth anniversary of her handing over the property to the National Trust.

Broken memorial

Another garden memorial in the gardens of Wakehurst Place a National Trust property in Sussex, England operated by the Royal Botanic Gardens, Kew as a country estate, and the site of the Millennium Seed Bank. A memorial seat, now broken; with missing slats, in the Japanese iris garden.

Public memorials: a stone seat from Lady Price

Another memorial in a public garden, in the gardens of Wakehurst Place a National Trust property in Sussex, England operated by the Royal Botanic Gardens, Kew as a country estate, and the site of the Millennium Seed Bank. this seat was given by Lady Price, the widow of Sir Henry Price, who gave the house to the National Trust in 1963.

Garden memorial: a gazebo at Wakehurst Place

Another series of memorials over the next few days, of a different kind this time. These are all memorials of people given as contributions to enhance what are now public places.

A gazebo , given in memory of Peter Bowring, in the gardens of Wakehurst Place a National Trust property in Sussex, England operated by the Royal Botanic Gardens, Kew as a country estate, and the site of the Millennium Seed Bank.

Private healthcare company fined for death of BBC health correspondent’s father

Private healthcare company fined for death of BBC health correspondent’s father – Lexology.

A national private healthcare company (this legal note politely avoids naming it) had a man in its deluxe hospital accommodation for an op., lovelier than many NHS places I should think, because it had patio doors to a balcony, which he fell off. They hadn’t locked the door, they hadn’t done a health and safety risk assessment. Obviously rich people don’t need really looking after; the people running private healthcare probably think that all this health and safety nonsense is just for the public sector. The fine was £100,00 by the way, plus costs of £29K+.

Legal case on duty of care to multiprofessional colleagues (and carers)

It’s not often you get an authoritative legal judgement about health and social care professionals working together. But here we are: an interesting Court of Appeal judgment that relates to multiprofessional working has been issued.

Link to the judgement.

A social worker employed by the local authority was attacked and injured by a mentally ill patient on leave from a mental hospital. Before he left the hospital, he told staff of the healthcare trust that he was going to kill her, and they knew he was hearing voices and had other symptoms of mental illness that made him dangerous to her. They did not inform her of the risk. She sought damages from her own employer (which refused to pay out on the grounds that because it didn’t know about the risk in law it was not responsible, and anyway it was her fault she didn’t find out about the risk – I think that was a callous decision for a local authority to make about one of its employees doing a difficult and dangerous job). She also sought damages from the two health trusts on the grounds of their responsibility for the failure of their staff to warn her.

There was a detailed official protocol on Working Together signed by the three authorities, and working relationships between the staff were very close. There is, apparently, a recognition in the courts that multiprofessional working is to be encouraged in difficult cases like this. However, the health trusts applied to have the case struck out, that is, they wanted a decision that it should not go to trial.

They did this on the grounds of a long line of cases that say that public authorities are not required to warn people or do something else about risk to them, unless there is a very clear and immediate risk, or unless they had formally accepted the responsibility for a warning. So, for example, it has been decided that the police have no responsibility to issue a general warning to people who might be affected because a criminal is dangerous. And housing welfare officers do not have to tell other people that a tenant might be dangerous. This is reasonable, because it would lead to defensive behaviour on the part of the authorities and the allocation of a lot of resources to give people routine messages ‘just in case’. The health trusts argued that they had a responsibility to the patient, not to anyone else.

I have said before, often, that the healthcare professions carry this noxious argument about their responsibility to their patients too far. Yes, of course it’s right that they focus on their patients, but they are part of humanity (healthcare managers? you ask – but I think the evidence suggests they are human). They ought not to go out of their way to ‘encourage’ as the judge put it, the man to go home when he clearly had serious symptoms and was uttering worrying threats about a public official. A normal human being type person would forget about the medical niceties and warn the non-employee whose life was being threatened.

However, the social worker wanted to argue that the protocol and the close working arrangements put her in a special position. She was not a member of the public wanting a general warning, she was one of a small number of professionals, known well to the people who knew about the risk, a ‘quasi-employee’ of the health trusts. It is accepted that the duty of confidentiality may and should be breached to protect employees. She (through her lawyer) argued that this showed that it was not an immutable duty, and put forward a stream of cases that showed that the facts of the case should be considered, rather than her points being rejected out of hand by ‘striking out’.

And she won, so presumably it will go to a hearing.

Now, let’s be careful about this. The judges are not saying that everyone in health and social care owes a vague and woolly duty of care to each other, but they are saying you should make a sensible decision based on the facts. And if someone thinks you didn’t, they should be able to argue the case in court, not have it automatically assumed that everyone but the gilded few employed by health care trusts are the only ones to be given protection. I think that health trusts and professionals need to square up to their shared responsibility when they have joint working arrangements. Joint working arrangements are designed to benefit all the members of the public and services involved not just their patients and their own organisation.

But there’s a point to be made about this in a more general way. We are moving towards a healthcare system in which healthcare workers will be cooperating with all sorts of providers of care. Look at that word again ‘cooperating’. ‘Co’ means together and ‘operating’ means doing it: the word (with or without its hyphen) means ‘doing it together’. Doing it together doesn’t mean the private sector organisation that’s trying to make a profit can do what it likes because it’s not a public body and its profits are inviolate, but equally it means that the NHS employee is not in a separate legal category of people who doesn’t have to take account of anyone else.

That doesn’t just mean social workers. It means keeping carers and patients involved as well. There were a number of cases in the 1990s where family members were attacked or killed by patients because healthcare professionals maintained their duty of confidentiality to their patients, and didn’t think they should take account of the patient’s family.

How does a nurse hold your hand to restrain you?

The Court of Protection made an interesting decision in the case of a man without mental capacity to make the decision for himself that he could be restrained to have kidney dialysis in his own interests. The case has not been officially reported, because it was settled by consent, but a legal information service says:

Mrs Justice Parker granted permission for the trust’s clinical staff to restrain Mr S, during dialysis if he continues to refuse treatment. She is quoted as saying, “[n]obody is suggesting that the gentleman is restrained in a straight-jacket or anything like that, it has to be proportionate … he should be gently restrained by having a hand-held by each nurse so it is possible to put in a catheter.”

…Mrs Justice Parker concluded that it would be in Mr S’s best interests to implement the weekly invasive treatment which “has a capacity to be cruel to him” in order to save his life.

This judgment is interesting not only because of its uniqueness, but because “gently”  restraining someone raises very practical issues of difficulty in implementation. In Mr S’s case he has since submitted to the treatment (ie, restraint is not required) and the order has been extended indefinitely.

In what way does a nurse hold your hand to restrain you, I wonder.

You can see this item here in the Mills and Reeve Health Legal Update.

Link to my list of useful legal updates.

Local authority adult social care should always include planning for end-of-life care

I recently gave a link to the Internet debate on end-of-life care that I took part in.I wrote an opinion piece which you can still see on the debate website, at SWSC Media, and there is a report on the debate, with all the things that people tweeted.

My message was that social care for older people should always include planning for end-of-life care. this led to various questions, and here are some of the bots mots that I tweeted off the cuff. I have now turned them into a brief comment on this topic.

Do resources in local authority adult social care make engagement with end-of-life care impossible for local authority practitioners? Older people know they are moving towards the end of life, and should always have the opportunity to plan for this, and get help to be planful. Healthcare professions, social work and social care all make different contributions to end-of-life care. Social work often focuses on the human and the family; medicine/nursing on different things mainly any illness and physical care that needs attention.

Social work with adults is not about working with decline, but with helping people achieve a quality life whatever their circumstances. Older people often want to talk about how they will live the end of their life. Do we and their families let them? A short interaction or the way you do things is important in end-of-life care as in all social work. Including end-of-life care can sometimes be done as part of what you have to do for care management. Helping people keep control of their lives is really important because illness makes people feel they have lost control

What should local authority managers in adult social care do to develop end-of-life care? Insist on commissioning services for older people that include end-of-life care and support social workers to provide end-of-life care with their time and social care services.

Children’s social care needs to be concerned about end-of-life care and universities should help students be aware of end-of-life issues with children, young people and other client groups: we are all bereaved.

Link to my opinion piece at SWSCMedia on ‘social work and end-of-life care’.

Link to the report of the debate on SWSCMedia.

End-of-life care doctors should think about child protection

The GMC’s advice to doctors on what they should do in child protection matters was updated in July. Why am I commenting on this on a blog about end-of-life care? Partly because the advice makes it clear that doctors working with adult patients  should be aware of risks their patients might pose to children. A patient’s increasing frailty, or their worries about their health may precipitate a crisis in the care of a child.

The fact that they are at the end of life also means that children in their lives are going to be cared for by someone else. What are the plans? Even if they are grandparents, their care or involvement in their grandchildren’s life, may be keeping children safe, and their death may mean that a parent is more under pressure and a child more at risk.

So end-of-life care doctors should be looking round at the children in the lives of their patients. Of course, their worries are likely to be passed straight on to social workers: palliative care social workers if available or…just what are the arrangements in your end-of-life care services for worries about child protection?

Another reason for making sure that there are social workers in end-of-life care services. And if you’re a child protection practitioner involved with doctors in some other connection, you might need to think through how to bring this to your medical colleagues’ attention. Because, bearing in mind the large number of ‘musts’ in this document (the GMC says ‘must’ means they’re potentially in trouble if they don’t do it) they ought to be concerning themselves with this.

Link to the GMC guidance on doctors’ responsibilities in child protection

Citation: General Medical Council (2012) Protecting children and young people: the responsibilities of all doctors. Manchester: GMC.