Social work and end-of-life care

Social work is important in end-of-life care

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Websites for people experiencing bereavement

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Someone asked me for information about useful websites for people experiencing bereavement, and I thought you might find my response useful:

The NHS Choices website is a good resource on bereavement, offering authoritative articles, with good illustrations and a number of useful videos covering the main issues that often come up. http://www.nhs.uk/Livewell/bereavement/Pages/bereavement.aspx

The ‘Moodjuice’ guide, published by the Scottish NHS (which has a good reputation in this area of healthcare) is more informal, and suitable for young people, but is equally authoritative and contains pencil and paper exercises which you can use to think things through. You can use the website, or it downloads as a booklet: http://www.moodjuice.scot.nhs.uk/bereavement.asp

The main voluntary organisation providing bereavement services is Cruse Bereavement Care. From the Homepage: http://www.cruse.org.uk/, click on ‘About grief’ and it offers a wide range of information, including downloadable booklets that give more detail.

The best-known organisation for bereavement care for children is Winston’s Wish, which publishes a variety of resources for young people and their parents and carers. The website Homepage: http://www.winstonswish.org.uk/ offers a wide range of information; click on ‘supporting you’, and there are lots of books and other activities to download, or buy, especially from the ‘support information’ page. There is also an ‘adult-free zone’ for young people to use. Its stories about young people’s experiences are often helpful. Unfortunately, some people find the Winston’s Wish publications a bit expensive, so check the prices before you buy anything from them.

Macmillan Cancer Support also has a website, which has good information on a range of worries that people have throughout the whole process of being diagnosed, treated for and living with cancer. It is particularly good on the practicalities around and after death; a lot of the information is relevant for people who are experiencing other illnesses http://www.macmillan.org.uk/HowWeCanHelp/Bereavement/Bereavement.aspx.

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Written by Malcolm Payne

15 May 2014 at 12:49 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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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

Memorials among the fishes

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130617 Eternal reefsThis is another (American) way of creating a memorial for someone who has died: you have an environmentally-friendly concrete doodad sunk in the sea with your ashes and a plaque, which fishes and coral can inhabit and grow on. The website, under ‘family resources’ also has sensible brief words of guidance for families going through a dying process.

Link to ‘Eternal Reefs’ website.

Written by Malcolm Payne

18 June 2013 at 12:02 pm

All-Party Parliamentary Groups relevant to palliative and end-of-life care

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I’ve recently been looking at the work of All-Party Parliamentary Groups on palliative and end-of-life care and have compiled a listing of links to groups.

Link to listing of links to All-Party Parliamentary Groups relevant to palliative and end-of-life care.

Written by Malcolm Payne

26 November 2012 at 11:56 am

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

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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.

Written by Malcolm Payne

14 August 2012 at 12:19 pm