Social work and end-of-life care

Social work is important in end-of-life care

Archive for September 2013

Day in the life of a palliative care social worker article

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20130914 Pallcare swA recent Guardian website article follows a day in the life of a specialist palliative care social worker in Birmingham .

Link to Guardian Social Care article

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Written by Malcolm Payne

14 September 2013 at 10:47 am

Social workers asked to assist a suicide: Court of Appeal decision

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20130910 NicklinsonThis post is about right to die and assisted suicide cases, which were reviewed recently by the Court of Appeal (Civil Division), including the well-known Nicklinson case:

Link to the judgement (there is a good and authoritative summary of the present law at paras 16-36)

I’ve been looking at the judgement (about the Nicklinson and related cases) and find that it actually talks about the position of social workers (and carers) if they help someone to die out of compassion. Here is the paragraph (141):

The Lord Chief Justice does not accept that the guidance creates the uncertainty which we have identified. He believes that it is tolerably plain that if a social worker acts out of compassion, he or she will not be prosecuted even if paid for providing the service since the purpose of paragraph 43(13) is to deal with “profiteering”. However, the helper could not be the social worker or carer who has had the responsibility for caring for the victim since he or she is in a position of trust. This might be the proper construction of the guidelines, but we cannot, with respect, feel confident that it is. Clearly Martin’s lawyers and social workers are not confident that it is; and nor were the members of the Falconer Commission. If the DPP intends to convey the message as the Lord Chief Justice understands it, we see no reason why it should not be spelt out unambiguously.

Here is how the two majority justices set the issues out:

These appeals concern individuals who suffer from permanent and catastrophic physical disabilities. They are of sound mind and acutely conscious of their predicament. They do not want to suffer a painful and undignified process of dying. They wish to die at a time of their choosing. However, they are not physically capable of ending their own lives unaided…Each has a settled and considered wish that his death should be hastened by the requisite assistance. Each contends that as a matter of both common law and European Convention of Human Rights law (“the Convention”), those who provide him with assistance to bring about his death ought not to be subject to any criminal consequences. The current understanding of the law is that those providing such assistance will be committing the offence of assisted suicide contrary to section 2(1) of the Suicide Act 1961 (“the 1961 Act”) if they merely assist a person to take his own life, and murder if they actually terminate life themselves.

Social work is dealt with (in passing) because the justices decided they needed to consider the adequacy of the Director of Public Prosecutions’ (DPP) statement (for the Crown Prosecution Service – CPS) of the factors that he takes into consideration when considering whether to prosecute someone for assisting another person’s suicide. Basically, the more you can demonstrate a close relationship to the person and lack of self-interest, the less likely you are to be prosecuted. So a relative who clearly acts out of compassion is unlikely to be prosecuted. The reason why this came up was that one of the people who wanted help to die argued that the law (including subsidiary bits of law such as statements like the DPP’s) should be clear and accessible, but in this case it was argued that it wasn’t.

Link to the Crown Prosecution Service policy on assisted suicide  This is also set out in paras 127-8 of the case report.

Obviously, someone’s social worker does not come into the close relationship category, although they may be disinterested. Anyone who has worked in palliative care knows that social workers are often asked about the possibility of helping someone commit suicide, or facilitating the trip to Dignitas, the best-known option in a foreign jurisdiction for Europeans to get assistance with suicide.

Link to Dignitas  (I provide this link for information, not expressing any view about its policies and practice)

The point about this is that English law gives the courts and the DPP considerable flexibility in looking a a particular case to see if a prosecution is reasonable. Because the law has that flexibility, the European Court of Human Rights has determined that the English law (which contains a blanket ban on assisted suicide) is not an interference with people’s rights under Article 8 of the European Convention on Human Rights, the right to a private and family life. The implication of this Article is that states should not interfere with actions that people do as part of their personal and family life.

Link to the European Convention on Human Rights

So, the administrative flexibility is an important part of the law, but this sometimes makes it unclear what your position is when faced with one of these situations. the way hospices often deal with this is simply to say that as organisations that have a responsibility to comply with the law, their staff must comply with the blanket ban on assisted suicide. This is also a practical position to take, because, as most people who have worked in end-of-life care know, many more people are worried about medical help leading to an early death (hence the anxiety about the Liverpool Care Pathway) than are wanting to pursue suicide.

So social workers are usually in the position that they can help people discuss what they believe and want to do, but not actively help them with anything. This puts them in the category of ‘class 2’ helpers, and this may also include other carers who are not close relatives of the person who wants to die. The position of close relatives is clear, but not others, and therefore not social workers. The problem partly is that the DPP cannot produce guidelines that refer to the situation of the person who wants to die, because this would in reality introduce a situation in which homicide might be accepted legally as justified in such circumstances.

And although helping out of compassion is one of the factors that may mean that a professional is not prosecuted, this is only one factor and nobody can know how the DPP will exercise the discretion balancing that against the other factors in the list. Let’s look back at Para 141 of this judgment, which I reprinted at the beginning of this article, which refers to the views of the Lord Chief Justice (LCJ) in dissenting from the majority judgement in this case. The LCJ argued that the main aim of this provision was to prevent profiteering, and that social workers, even if they were paid, could assist out of compassion. But the majority in the Court of Appeal does not agree, and accepts that general view that a professional (or non-related carer) must still be quite uncertain. Hence the argument that this should be made clearer. We shall see.

Written by Malcolm Payne

11 September 2013 at 11:05 am

Chronologies of abuse – nice idea, but was it not obvious?

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20130903 Chronologies POVAA Guardian social care article describes a Welsh scheme for safeguarding vulnerable adults, which creates ‘chronologies of abuse’ for clients from the social services department records, that other agencies, and the client themselves can add to at strategy meetings – these are the meetings that discuss and make decisions about how to deal with safeguarding risks. Apparently this has got a grant and people are jumping up and down at the wonders of this innovation.

Perhaps nobody there has read anything about narrative theories of social work, but you do wonder about how seemingly obvious things to do are hailed as great innovations. In this case, the approach is to write down in order every instance of abuse that you’ve found out about, and check this with other agencies and the client. Were they not doing that anyway? Or was it that their computer program didn’t tell them to? Or was it so that they got a grant for this great innovation, and could carry on with their ordinary work without cuts in service affecting them? Or was it that the website can’t find out anything but the obvious to write about?

Link to Guardian social care article

Written by Malcolm Payne

10 September 2013 at 11:45 am

Competition to provide healthcare in the USA and UK

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Curious readers who are interested in finding out about how the Obama changes in the American healthcare system are going might like to read this newsletter from an American ‘elderlaw’ firm:

20130903 ElderlawLink to Elderlaw Newsletter.

The changes come into effect soon, in January 2014, and will mean that there will be local ‘marketplaces’ for health insurance.

This is all the more interesting in the UK, because of the recent Competition Commission report suggesting that local markets are not working in healthcare in the UK; this probably means that the system can only get worse, as healthcare reforms bite in England (which is the most privatising of the UK countries in the way that it is providing healthcare). Alan Maynard in The Guardian recently was critical of the whole history of ensuring competition in UK healthcare. He argues that we must try harder for transparency and competition if we are going to have a more marketised healthcare system.

Link to Competition Commission documents

I have suggested here before that competition regulation is going to be an important area of campaigning if we are going to continue to support fair healthcare provision in England.

Guardian comment by Alan Maynard on healthcare competition.

20130903 Maynard

Written by Malcolm Payne

4 September 2013 at 11:03 am

Personal Independence Payments (PIP) official info: includes stuff on the special rules for terminally ill people

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The government has produced some public advice about the Personal Independence Payment (PIP) which is replacing the Disabled Living Allowance for many disabled people, or not if you don’t meet their assessment. It continues to provide for people who would have got the Allowance under the ‘special rules’ (these are the rules that expedite payouts for people who are terminally ill, so that they get them before they die, and the system doesn’t have to tell them directly ‘you’re getting this because you’re dying’). Here are some links:

Link to the Info about the system and providers of the assessments

This includes a link to the ‘special rules’ information, and also information in Welsh. The providers include the controversial ATOS (who I see are expecting claimants to go mainly to their assessment centres, and who are making the decision about whether it will be ‘appropriate’ for them to do a home visit – in other words, who can tell what inconsiderate rules they will introduce) and Capita (not much less controversial, who are expecting a somewhat higher proportion of people to be visited in their own homes). People are being divided into geographical ‘lots’, which determine who provides their assessment and when.

Link to the general information for organisations that support claimants.

Written by Malcolm Payne

3 September 2013 at 5:29 pm