Social work and end-of-life care

Social work is important in end-of-life care

Archive for January 2014

Think through and spell out your social work reasoning for ‘draconian’ decisions

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20140128 Adoption caseSome points in an adoption case made by the President of the Family Division of the Court of Appeal, Sir James Munby, can inform social workers about what it means to make holistic decisions, even if he’s talking about the law. He’s talking about child care services and adoption, but in the quotations that follow, I have taken out most of the references to that, so that you can see that his points have general application to all sorts of decisions by social workers (and other professionals).

Link to a legal commentary, which contains a link to the judgement

I’ve picked up this point from the legal commentary, and then expanded on it here.

He’s saying that once you have dismissed all but one option for good reason, you still have to look at that option to see if there are good reasons for rejecting that option too. If so, it may mean that you have to reinstate a less than desirable option you rejected earlier, because it’s not so undesirable as what you are thinking you should impose on a client. And, in particular, you must not accept the rejection of an option because it’s inconvenient or expensive for the service, or difficult for the social worker; otherwise people can take judicial review and judges will (or, Sir James is saying, should) be asking you some cogent questions about your reasoning.

If it’s too difficult for the social worker, get yourself a new social worker. Good practice ethics requires us (including our supervisors and managers) to think ‘am I good enough to do this or should I get someone who’s better than me?’ All social workers are not interchangeable.

We can all think of situations in which this happens: it’s not practical to make sure that someone is OK at home, so we end up by thinking she should be kept in hospital or care home, because she won’t be safe all the time on her own. But we forget, in making that choice, that the option we’ve ended up with may be safe, but it may not offer her the freedom or flexibility in her life that anyone would prefer. But because we ruled out all the other options, we don’t look at the downside of loss of freedom against the downsides of the other options.

Here’s how Sir James puts it:

2   …the appeal not merely requires us to determine an important question of law…; it also raises some very significant matters of more wide-reaching importance.

28   …the court’s assessment …must take into account the assistance and support which the authorities would offer. So “before making an…order … the court must be satisfied that there is no practical way of the authorities (or others) providing the requisite assistance and support.” …The local authorities must deliver the services that are needed and must secure that other agencies, including the health service, also play their part, and the parents must co-operate fully.” That was said in the context of supervision orders but the point is of wider application.

29.   It is the obligation of the local authority to make the order which the court has determined is proportionate work. The local authority cannot press for a more drastic form of order, …because it is unable or unwilling to support a less interventionist form of order. Judges must be alert to the point and must be rigorous in exploring and probing local authority thinking in cases where there is any reason to suspect that resource issues may be affecting the local authority’s thinking.

32. It is time to draw the threads together and to spell out what good practice, the 2002 Act and the [Human Rights] Convention all demand.

33.   Two things are essential – we use that word deliberately and advisedly – both when the court is being asked to approve a care plan …and when it is being asked to make a non-consensual placement order…

34.   First, there must be proper evidence… The evidence must address all the options which are realistically possible and must contain an analysis of the arguments for and against each option.

41.   The second thing that is essential, and again we emphasise that word, is an adequately reasoned judgment by the judge.

43.   In relation to the nature of the judicial task we draw attention to what McFarlane LJ said in Re G (A Child) [2013] EWCA Civ 965, paras 49-50:

“In most child care cases a choice will fall to be made between two or more options. The judicial exercise should not be a linear process whereby each option, other than the most draconian, is looked at in isolation and then rejected because of internal deficits that may be identified, with the result that, at the end of the line, the only option left standing is the most draconian and that is therefore chosen without any particular consideration of whether there are internal deficits within that option.

“The linear approach … is not apt where the judicial task is to undertake a global, holistic evaluation of each of the options available for the child’s future upbringing before deciding which of those options best meets the duty to afford paramount consideration to the child’s welfare.”

…44.   We emphasise the words “global, holistic evaluation”. This point is crucial. The judicial task is to evaluate all the options, undertaking a global, holistic and (see Re G para 51) multi-faceted evaluation of the child’s welfare which takes into account all the negatives and the positives, all the pros and cons, of each option. To quote McFarlane LJ again (para 54):

“What is required is a balancing exercise in which each option is evaluated to the degree of detail necessary to analyse and weigh its own internal positives and negatives and each option is then compared, side by side, against the competing option or options.”

45. McFarlane LJ added this important observation (para 53) which we respectfully endorse:

“a process which acknowledges that long-term public care, and in particular adoption contrary to the will of a parent, is ‘the most draconian option’, yet does not engage with the very detail of that option which renders it ‘draconian’ cannot be a full or effective process of evaluation.

So, in making decisions and writing reports and records of the decision, it’s important to think through and spell out all the arguments for and against options, particularly if they involve imposing solutions on an unwilling client or family. Because what the judges are saying in relation to child care can equally well be said about adult care cases as well.


Written by Malcolm Payne

28 January 2014 at 3:08 pm

Modern Social Work Theory – new edition published

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I thought I’d just mention the new (fourth) edition of my book Modern Social Work Theory – it’s bigger, better, easier to read and heavily updated. And, inevitably, calls on my most recent social work experience in eMSWT4nd-of-life care for some of its examples and thinking about practice.

Link to its British publishers, Palgrave Macmillan.

Link to its American publishers, Lyceum.

Why do they think blue abstract swirls sell a book?

Written by Malcolm Payne

20 January 2014 at 2:38 pm

Berlin memorial to Nazi book-burning is significant everywhere and for everyone

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Book burning memorialUsually when I post a picture of a memorial, it’s about a person, but this is a picture of the memorial in Berlin to the Nazi book-burning: it is empty library shelving let into a hole in the ground in a square, the Bebelplatz.

Memorials to a significant event express meaning that may affect everyone, and may memorialise many life experiences, by making you think about how everyone everywhere gains for the right to freedom of expression and education.

Written by Malcolm Payne

17 January 2014 at 4:36 pm

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Social work is needed when people with long-term illness are helped to live their lives rather than treated aggressively

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Renal medicine often presents problems for palliative care because people with serious or end-stage renal problems are often on a treadmill of regular and frequent dialysis and sometimes waiting for a transplant. Because of this it can be very hard for their medical teams to identify when they have reached the point when they should be seen as dying, and their service should take on a more palliative tinge. They often are – and feel – very ill a lot of the time, but may not experience the fear or ‘death sentence’ that people associate with cancer. At least, people used to associate the death sentence with cancer. Increasingly, though, people with cancer are treated successfully, go into remission and survive for many years and so the same issue sometimes applies: when do I decide that enough is enough (and how do I get my doctors to accept this)?

An interesting article compares survival of people with end stage renal failure who go on receiving dialysis, and those who are treated conservatively, with symptoms being managed and advice about managing their lives. At age 70, those on dialysis live longer, but may spend more time in hospital. At 80, they do not survive longer. And in both cases, those not using the hi-tech dialysis often lead very satisfactory lives.

This study speaks to a lot of things. First, they included a social worker in the team to support the conservatively treated patients. this is sensible: if healthcare services are going to focus on living a good life successfully, then people’s social relationships and arrangements for their lives are going to become more important.

Second, it raises some questions about assisted dying. Perhaps we should be looking at assisted living for people at the end stage of major illnesses, rather than arguing that they might be helped to die, or treating them aggressively and then despairing when this does not provide a very god lifestyle. Conservative treatments for major illnesses are not assisted dying, but they are providing the kind of assisted living that people feel is valuable.

Third, there is often far more choice about how you are treated if you have a major illness than the stark choice of suffering aggressive treatment or dying.

Link to the article.

Written by Malcolm Payne

16 January 2014 at 12:12 pm

Good nursing and care for relatives in the NHS

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Malvern Community Hospital sideAnd good care for dying people is not only available in big urban hospitals. Our uncle Don (aged 95) was recently cared for at the new Malvern Community Hospital in the last weeks of his life. It has 18 GP beds and a minor injuries unit. With her extensive experience of palliative care, Margaret says with appreciation that the nursing for patients and support for relatives was a good as any hospice.

Link to Malvern Community Hospital website

Written by Malcolm Payne

15 January 2014 at 12:15 pm

Good care for dying people in NHS hospitals is still possible

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140113 Death in hospA thoughtful article in the Guardian by Julie Myerson, who suggests that often in the NHS you can get wonderful care for dying people, even in the biggest urban hospitals and busy wards. It is a story of effective nursing and good communication with relatives in a busy London hospital. And, incidentally, the hospital that Cicely Saunders started out from in her experience as a social worker which eventually led to her contribution to the origins of the hospice movement. Good to see that the medical and nursing skills involved still exist.

Written by Malcolm Payne

14 January 2014 at 12:06 pm

Hospice volunteers’ experience adds bite to training role plays with doctors

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Role play 140111In an interesting article, a German researcher looks at volunteers from hospices who act as patients in role plays with trainee doctors. The volunteers rely on their experiences in working with patients to inform their acting; it gives added reality to the role plays. Hospice volunteers also have their own experiences to draw on, since many people volunteer in hospices because of a positive experience as carers of their own relatives. It sounds like a useful way of adding a little bite to what can bean undemanding way of learning.

Link to the article

Written by Malcolm Payne

13 January 2014 at 12:47 pm

Posted in carers, hospices, professionals

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