Hello – is anybody out there?

IMG_1442

 

Almost too demoralised and depressed to blog (almost, but not quite, as you can see).

The situation at home is now pretty dire. Nobody seems able to help. I feel, as a GP, that I should be able to offer some clear guidance as to how we proceed but there are dead-ends and rabbit holes everywhere. One person says ‘Oh, you need a social services continuing healthcare funding assessor’ the other says, ‘You need a district nurse to do that,’ another says ‘Your mum’s not on the district nurse list, so computer says no.’

Mum falls out of her chair. She’s fallen six times in the past two weeks. The occupational therapists have given Dad a hoist to use – the hoist doesn’t reach the floor. It reaches six inches off the floor – if Dad is going to lift her into that he might as well lift her back into the chair. The neighbour is called – he helps Dad. If it’s late at night then Dad feels bad about calling the neighbour so he begins the arduous journey of inching Mum across the floor, out of the sitting room, across the hall and into the downstairs bedroom where the mechanical bed does at least descend to a point where he can roll Mum onto it.

The occupational therapists have now ordered a special cushion to slide under Mum that will inflate her up to hoist height – they need to show Dad how to use it – the care agency, still providing one hour a day paid for by Dad, have already said that they will not use it as it requires two people. Dad says if he had two people he wouldn’t need the bloody cushion. Dad’s training session is booked for a month’s time (what with Christmas and all) – will he be given the magic cushion then? Who knows. Will Mum have slipped and broken her hip by then?

We phone the GP surgery  – Dad is given an appointment – it’s an hour long face to face consultation with a nice girl who is in fact a social prescriber and can do very little other than signposting. As I have said in clinical meetings with my own commissioning group at work, signposting is only helpful if there are services out there to signpost patients to.  The social prescriber did however use up a good fifteen minutes of the appointment talking about her own experience of dementia; her father had Alzheimer’s apparently. They had a lot of difficulties. He’s dead now. Oh. Cheers for that then.

The social prescriber, in an attempt to have something definitive to show for her hour of chatting, books a home visit with the GP for today. I go to see Mum and Dad so I can be there when the GP arrives. Not to be the heavy mob but just to give a bit of context – just to say ‘we know how stretched services are, I work in these very services, but we’ve never ever asked for help before. Please take us seriously now that we are asking.’

We have lunch. Dad spoons soup into Mum who we’ve managed to navigate into a kitchen chair. We phone the surgery just to see when the doctor might be coming – they can’t say. I get that. No problem. But could they just tell us whether she’s left the building? No, not yet. We wait. The phone rings. Is the home visit urgent? Well no, not really. Mum’s not acutely unwell. Could they rebook it for two week’s time.

My dad is fed up of being badgered by me. I’m fed up of trying to defend the services that should be here to support us. The people working in those services are absolutely fed up of working like trojans for little reward and attempting to provide care on a wafer thin budget that has been mauled by years of austerity and that people seem to be in danger of voting into oblivion.

We have however, now reached crisis point. Mum is doubly incontinent, she cannot feed herself at all or drink unassisted, she can only tolerate semi-solid food and has no communication – as a result we are unable to assess her needs, her pain or discomfort. Her mobility is significantly restricted. She can mobilise a few steps from bed to chair but is incredibly unsteady and falls repeatedly.

All reservations about a nursing home are gone – I am happy to accept that this is now where we are – but how to find the £50K per annum that constitutes the cost of even a basic home place in our area? And will we need to fund that for the next twenty years? That would only take her to eighty-seven…

I emailed the GP today after the visit was cancelled – I know this isn’t really her problem. She has sick people coming into surgery – her clinic will be full, her home visits will need acute assessment. She will see at least forty people today and make over a hundred clinical decisions. I only hope that we can be one of them.

This is what I said:

“The situation is currently unsafe – mum is at risk of further falls, damage to pressure errors due to prolonged immobility as well as urine infections. She is unable to let us know if something is wrong. Dad is struggling to cope as sole carer. He has managed incredibly well for the past seven years but I have concerns about his mobility and risk if he continues to have to move Mum. I hope you can help.”

I feel like I’m sending a message in a bottle out across a very turbulent sea and watching it sink.

 

 

P.S. I am quite determined that this shall not be my last post of the decade – how depressing would that be? Will dredge up something festive in the next three weeks, fear not.

What’s the point? (Don’t worry – there is one)

IMG_1381

The current situation with Mum is that she remains at home, quietly withdrawing from the world. Dad now has a wheelchair-compatible-car, she has a wheelchair, compatible with a wheelchair-compatible-car (not a foregone conclusion it would appear) and they have a hoist, an easy access shower, a toilet seat raiser and a mechanical chair and bed which allows a fairly easy transition between. She has carers from The Bluebird Agency (every one, without exception, complete bloody superstars) for an hour in the morning – they get her up, washed and dressed. Alison comes twice a week to take Mum out to get her hair or nails done and my sister and I visit when we can.  This is the entirety of her world and she is comfortable and peaceful within it. She sleeps a lot, she sits quietly for the remainder of the day and she sometimes smiles. She enjoys her meals, she doesn’t like her nails being cut but appears to experience neither significant distress nor overwhelming happiness. The range of her emotional experience is narrow but her mood usually sits somewhere around contentment. So we are at another plateau. Nothing bad is happening.

As discussed previously, this is the time that one needs to think about planning ahead. Much better to do it in a period of relative tranquility, and thus Dad has been trying to motivate himself to look around residential homes again, just so we know what resources are available if they are needed. We may get to a point where Mum is completely immobile and has greater need in terms of number of carers and frequency of visits. Currently Mum’s care package (when one factors in the above appliances, agency fees and occasional respite at the ‘nice nursing home’ out of town) run to a similar cost as privately educating a child at one of the more exclusive public schools – if this cost increases it may be difficult to afford to keep her at home.  It may also become too difficult to manage her care at home although at present I find it hard to believe that she would be capable of being difficult, challenging or any of those other pejorative terms that the dementia community rightly find degrading. She simply doesn’t have the physical strength to wander off or assault anyone and she has such reduced vocal capacity that she couldn’t insult or hurl abuse at a carer. Her ability to ‘misbehave’ is limited and in saying this I am neither trying to be offensive or wanting to belittle the experiences of those who do care for people with more complex needs.

She is happy. We are lucky.

 

Nonetheless, it is important that we investigate other avenues, just in case. The battle has always been getting Dad to take the next step (whether it be taking away the car keys, employing a cleaner to help around the house, or moving to downstairs living). So there have been conversations taking place and today the subject of visiting people in nursing homes came up. Dad’s question was ‘What would be the point?” – if Mum was so reduced in her circumstances to need residential care would she gain anything from seeing us? Would she know whether we had visited or not and would she care either way? Whilst I agree with the question and understand the reasons behind it, I think that there are hidden advantages of maintaining a frequent visiting schedule, even if the person you are visiting is completely oblivious to your presence:

  • Taking kids into a Nursing home is good for them and good for the other residents, even if Mum doesn’t recognise her own grandchildren from Adam. Nursing homes can be scary places. Often people have never set foot inside one until they need to consider their own care or that of a loved one and it can be an assault to your senses; the noise, the smell, the institutional feel. I imagine it is similar to visiting prison, hospital or, to use my previous example, an exclusive boarding school. These places have their own individual character and can be intimidating if one is unaccustomed to them. So, normalising it; making the building and the rooms familiar to children is a good thing. It broadens their range of experience, it introduces them to how we care for our elderly and frail and it reduces the secrecy and stigma associated with shutting people away, out of sight. Additionally, the benefits to other residents of having children around are enormous. Toddlers and teenagers provide variety; new noises, new smells and new sensations in an otherwise limited environment. So yes, I will be taking the kids to visit Granny if we ever get to that point – and I will make sure that they have an activity to focus on when we see her. I might ask them to read to her, play her a piece of music or draw a picture. We might wheel her into the garden or sit in the communal area to finish a homework project but I recognise that there needs to be a purpose for the visit rather than simply sitting waiting for some piece of existential wisdom to emerge from Granny’s mouth or to witness any evidence that she is actually pleased to see us.
  • Regular attendance from family members is an indication to the care home staff that this person had other shit going on in their lives prior to this juncture.  Of course, staff know this already, but even as a visiting GP it makes me view a patient slightly differently if I see them when their wife is in the room, or if their niece has just left and passed a message to the nurses to ask me about their cough. Knowing about the existence of a support network puts that person in context and, whilst I am not suggesting that staff would knowingly treat a resident better if they were expecting a visitor, there must be an element of wanting to actively demonstrate the family that the care being provided is good. Do residents who have no visitors receive a poorer standard of care? Probably not – but it can’t hurt to focus the minds a bit.
  • Regular involvement and good communication between family and care home staff reduces the likelihood of inappropriate decisions being made. An inexperienced nursing auxiliary faced with a deteriorating patient in the middle of the night is much more likely to call an ambulance and have that person admitted to hospital if there hasn’t been a clear message from the family that this is not what the person would have wanted. If however, this message has been documented and reinforced through numerous recent visits, the nurse in charge can say, “Oh, well – her son was in today and he knows that she’s becoming more unwell, but he was very clear that she wouldn’t have wanted to go into hospital.” It is then a lot easier for staff to use their clinical judgement, make the patient comfortable and get them assessed on a routine visit from the GP the next day when a more informed, less ‘knee-jerk’ decision can be made.

 

I remain hopeful that we may not ever need to put Mum in a home. Having seen her over the past few weeks I think she is slowing down completely and she may just quietly doze off in her chair one day and not wake up again. It would be classic Mum to pop her clogs without a fuss and a drama. But equally, she’s still young and her body may continue to function for many, many years – so we need to have a plan. And if that plan, for whatever reason, ends up involving residential care, I hope I will be able to visit regularly and that my children will feel the same. I make no judgement on others – sometimes visiting a loved one may be just too distressing for those who are left behind – but I would say that there are hidden benefits beyond the need for companionship and that these should be considered when making a decision.

There is a point to it all – even if it’s not immediately obvious.

 

 

Who decides enough is enough? – Why Dignitas and Dementia don’t mix

FullSizeRender (25)

 

It’s another cheery one for the summer holidays – Assisted Dying and Dementia!

There was an excellent article Dementia is our collective responsibility  in last week’s Guardian written by Nicci Gerrard, an erudite and considered commentator in this field.  The main thrust of the article was the idea that society needs to take ownership of dementia, understanding that it is now a common enough condition to be considered universal (her concluding statement; ‘If not you, someone very near you. If not now, soon.‘ says it all).

As is sometimes the case, the comments following an article such as this can prove to be more polarising and provocative than the original piece – after all, one purpose of journalism and sharing a viewpoint is to stimulate discussion and debate. This particular article presaged a tidal wave of comment regarding the option to end one’s life when given an ultimately terminal diagnosis of dementia, slightly missing the original point but channeling the worst fears of readers who dread the lack of control that dementia brings.

There is a view that Assisted Dying is the key to restoring this control. People cling to the notion that such a process would enable them to end their life prior to the indignities of incontinence, immobility and dis-inhibition.  They hope to be able to make a rational, detached decision that; “Enough is enough – I am no longer myself and I no longer wish to burden this world with the thing that I have become.”

And indeed, that hope – the idea of ‘taking back control‘ (now where have I heard that before?) – is so pervasive that most would welcome such an option with open arms. I entirely understand these sentiments. It is a scenario I have considered myself, as has everyone with a family member unfortunate enough to have a progressive neurodegenerative disease. We have also all surely debated the ethics of aggressively prolonging life in the husk of the person we used to know. But, in these musings we often come up against the ‘How?’ and the even stickier wicket of ‘When?’

Assisted dying was initially legalised for extreme cases of intractable suffering (and I am not going to open that old can of worms about ‘suffering’ and dementia because it DOES MY HEAD IN). Where the law, the medical establishment and the wider society of a particular country could see and accept that an individual was suffering beyond all hope and redemption there seemed to be a case for allowing an end to it. So far so good. This all sounds reasonable, humane and morally robust.

However, one man’s intractable suffering may not be the same as another’s. There is now a situation where people with what is perceived to be ‘less intolerable suffering’ are not allowed to end their own lives. Their blighted existence, or the conditions they live with, have been deemed ‘tolerable’.  Some of these people have argued that it is against their human rights to discriminate against them in this way. Who is The State to say what is bearable for an individual? Who makes that decision to say, “Yes, Mr Jones, on my checklist your particular scenario constitutes intractable suffering. Please proceed to the departure lounge” ?

Maybe instead we should leave it to the individual to decide for themselves whether their continued presence on the earth is worth preserving. But in some countries being “tired of life” is now considered sufficient indication to assist a person’s death.  Do we really want to ease people off this mortal coil because they are bored by living? Could we not try and make their lives more fulfilling instead? And what about those people who have been persuaded that they are a burden or that they would be better off dead – should doctors really be the final arbiters in existential questions such as ‘what is my life worth’ and ‘what is the point in being alive any more’?  We are scientists after all, not philosophers.

Another question (and this topic is full of them) is whether someone who is suicidal can really be deemed to have capacity? We detain people under the Mental Health Act if we perceive them to be a danger to themselves. We admit them for treatment, ‘section’ them, medicate them back into believing their life has meaning and worth. Isn’t saying ‘I want my life to be over’ openly admitting to being an active danger to oneself? Again we return to the cognitive ability to make these decisions which is so pertinent in dementia. Because making an active decision to end life requires mental capacity and dementia robs people of that very facility.  An unhappy conundrum.

When do the scales tip from being cognitively sound and able to say ‘I want to die now‘ to becoming the individual we fear; the one who doesn’t even really understand what it means to be alive any more? And from a more practical point of view, when do we then sign that document, book the flight to Switzerland or take that lethal cocktail?  If there was a magic time frame, a moment in the disease process where one could say with certainty ‘this is it, the end of my mind and personality, the end of my time as a functioning member of society. Now it has to stop,’  maybe assisted dying could work. But there isn’t.

So, does someone with a dementia diagnosis choose to go before they lose capacity, thereby potentially missing out on a few more years of good quality life spent with one’s family? Henk Blanken’s article for The Guardian’s Long Read My Death Is Not My Own is, as the name suggests a long read, but well worth it, not least because the author has full cognitive function but is facing a future where he may not. He is also a citizen of a country where assisted suicide is legal, well-supported, openly discussed and, some may say, actively encouraged.  For him to suggest that there is a problem with the underlying principles allowing people with dementia to access assisted dying in those circumstances is significant.  People who currently live in countries where assisted dying is illegal talk about how a change in the law would help those with intractable life limiting conditions to have a dignified death, but the vast majority of people who I see at the end of life do not have the capacity to take advantage of this process, even if it were legal.  So what is the answer?

Personally I think we need to take a slightly different look at things.  We are working on the assumption that there is only one way to actively intervene in our own destinies but in reality there are countless small decisions we can make to affect and effect our own demise.  There is a difference between ending a life and simply not prolonging it.

Currently in the West there many things we do medically to extend life, in fact one could argue that we extend it unduly and against better judgement. We actively resist nature taking it’s course. Medics work on the principle that if something can be treated we should treat it or we should at least offer treatment.  The offer is made in such a way that the patient and family assume proceeding with the treatment would be the right thing to do, consent forms are signed, tablets are taken, life is prolonged and lengthened, and on we go.  I have see patients in nursing homes who have, what would appear to be, fairly poor quality of life that is preserved, nurtured and medically enhanced far beyond what would be considered ethical in an animal. The level and type of intervention varies but to give an example: Let’s say a person with advanced dementia reaches a point where they start choking on their food and a decision is made to artificially feed them. This may be considered the ‘safe’ thing to do, particularly if the options are presented to the family in the following terms: ‘Do you want to…

a) see your loved one choke on a piece of cabbage and possibly die of an aspiration pneumonia

or,

b) have a simple procedure to allow sustenance through a tube in their tummy that will enable them to live for longer?’

The answer most families plump for is option b. The answer I would go for and hope that my family would choose for me (if my quality of life was sufficiently poor) is a. Pneumonia wasn’t called ‘Old Man’s Friend’ for nothing and two, three, four further years of being bed bound, at risk of pressure sores, unable to communicate, unable to even eat food any more, seems infinitely worse than a short bout of respiratory infection and a Cheerio Lads. (Note that artificial feeding for people with a good quality of life is often an excellent treatment option – I’m just using it as an example of a life-prolonging intervention that may not always be appropriately administered).

This planning around decision-making processes is perhaps easier for me because I’m a doctor. None of us can predict what is going to happen but I am at least aware that the medics don’t have all the answers and neither do they want all of the responsibility. I know that I am well within my rights to say; ‘I don’t want that treatment for myself’, or, ‘No. That treatment for my mother would not be appropriate at this point.’ I’m happy to take ownership of those decisions even if it brings about a slightly earlier death, maybe even because it brings about an earlier death. But people without a medical background simply aren’t aware that they are allowed to request a ceasefire in the battle for life, either for themselves or on behalf of a relative, so they take up the offer, they go along with the plan, they ignore the nagging voice of doubt because the nice GP or paramedic says that Dad needs to go into hospital and have intravenous antibiotics or he might die.  They don’t say to themselves, would Dad actually prefer to die?  Or if they do, they feel completely unable to voice that opinion out loud for fear of being cast out of normal society or arrested.

Wouldn’t it be easier if those who want to die, those who don’t want to live any longer and those who wouldn’t have wanted to live like this are not actively pushed along the path of existence any further than they need to be?  There are many options for withdrawing intervention and allowing natural death to occur earlier; stopping preventative medication for one thing – why take statins to prevent heart disease, why take anticoagulants to prevent a stroke if actually the idea of a quick coronary or brain event would be just the terminal incident you’re after? There just needs to be a common sense approach and people need to be treated (or indeed, not treated) on an individual basis.

Obviously most people would wish to be kept comfortable and for their symptoms to be alleviated, so if you were in pain you would have the best analgesia, if you were nauseous the best anti-sickness medication etc. Palliative care in the UK is the envy of the world. We are great at looking after people who are dying, we’re just not very good at allowing them to tip into that category. Instead we let medicine force their bodies into a longevity that their brains can’t keep pace with.

Surely it is better to keep the lifesaving stuff for people who actively want to carry on living and simply withdraw it from those who don’t? As doctors our default position should not always be to aggressively investigate and manage frail people with a terminal illness – we don’t have a mandate for that. Instead we have a duty to do the best by our patients, to do the right thing. ‘Do no harm’ should have higher standing than ‘Keep alive at all costs’ – I think if the public knew that a more nuanced view would be taken by the professionals involved in their care at the end of life perhaps they wouldn’t fear it so much.

 

P.S.  This is a controversial post and I am sure I have over-simplified in some areas, over-looked others and probably ridden roughshod across some readers’ strongly held beliefs. Like all my blog posts my intention is not to cause widespread offence and outrage but to make people think. However, I am fully expecting a backlash of biblical proportions….

Keep in touch with yourself – self care for carers

IMG_1775

 

Keep in touch with yourselves! was a phrase used by my father when departing a get-together, usually followed by; Love to the family! – the comedy element coming from the fact that we were the family, obviously. Like most fondly remembered sayings and mottos, you kind of had to be there, the side-splitting humour doesn’t translate terribly well and would be unlikely to win me a spin-off series, but more pertinently, I’ve realised we don’t say it to each other any more.  Dad taking his leave of us is no longer an event packed full of light hearted japery – and without mum rolling her eyes at his idiosyncrasies the in-jokes lose their impact.

However, it seemed a good title for this post which is concerned with the importance of carers caring for themselves.  A wealth of blog posts, newspaper columns and self-help books have been published on the topic and I suspect it’s unlikely that I am coming out with anything groundbreaking here – but as far as I’m concerned the profile of carers can never be too high, the unique and lonely plight of a carer can never be over-estimated.

It follows that if we are concerning ourselves with the needs of carers we must not only highlight the problems of burn-out / stress / depression / pure unadulterated rage – we must also look at answers to these problems.  Increasingly I am aware that in this country, and throughout the developed world, we are constantly wringing our hands about our universally deteriorating mental health without addressing the possible solutions.  This is usually because they involve money, whether it be funding acute and community psychiatric services or asking social media platforms (ever so nicely and politely) to stop promoting suicide sites to our vulnerable teenagers at the risk of a minor drop in their astronomical profits. Anxiety is rife, individual and collective self-confidence is at rock bottom – and most people are teetering on the edge of an existential crisis on a daily basis, worrying about climate change, antibiotic resistance, Brexit, Trump… (my current faves).  Add into this febrile mix the constant, grinding hideousness of caring for someone who no longer recognises you, offers no emotional connection or payback for the care you provide and, in fact, has the potential to wound or insult you physically or verbally – and you have a recipe for a pretty miserable day.

Anyhoo! Crashing on! The reason for this post is to look at the opportunities for escapism out of this dire quagmire.  The good news is that there are things you can do to lose yourself (or indeed rediscover yourself) for a while, whatever the circumstances.

1 – Twitter (other social media platforms are available but I don’t really understand them) 

Recently someone contacted me on Twitter having received the devastating news of her mother’s dementia diagnosis.  I recognised the panic in that single tweet and thus, hearing the claxon call of distress I responded as soon as I could.  My tweeted reply alone would clearly not have been enough to single-handedly rescue this person (feel the hubris) but it did trigger a deluge of advice from all the corners of the globe. This is not because I am some sort of social influencer (‘Really?’ I hear you cry) but because it is incredibly easy to start the dominos off. Within moments there were people getting in touch offering support, advice, smiles, virtual hugs and kisses, thoughts, prayers and practical local resources (which I suspect may have been the more useful of the above).

I have talked about Twitter before and whilst I can see that there are problems with the  ‘Wild West / Here there be dragons nature of the medium, I have never found it to be too antagonistic.  There are some awful individuals out there but I knew that already from work and life in general.  Trolls, shaming and rape threats aside, I consider Twitter to be mainly a force for good.

2 – Exercise / Physical activity / Fresh air / Walking the dog

I’ve put these all in the same category under a general heading of  PE-teacher-isms and obviously all true but dull to write about.

3 – Sex and Drugs and Rock and Roll

Not dull to write about but beyond the scope of this blog and my limited coolness.

4 – Games

Not the outdoor variety as mentioned in point 2, nor the clothes off variety as mentioned in point 3, but the good old fashioned chess / bridge / cribbage / backgammon / tiddly-winks combo beloved of elderly French-men in provincial cafes and also my father, who is neither elderly nor french.

5 – Cooking and Baking

Good for many of the same reasons as point 6 below; therapeutic, practical and immersive. BUT potentially perilous for the waistline of carer, caree and attendant friends or relatives who will receive and consume the fruits of your labours with varying degrees of restraint, or lack of.

6 – Creativity / The Arts

My personal favourite; a sorely overlooked means of escapism and life enhancement in its many forms.  Painting and drawing can be enormously beneficial as well as virtually free (other than materials). Pottery, sculpture, knitting and sewing are often sociable (as evidenced by the success of Stitch and Bitch groups) as well as productive of tangible items that may even be of some practical use, so long as someone like me isn’t the creator or designer.

Music too, whether listening, playing an instrument or singing – all activities can be as social or personally mindful as you wish and all have proven therapeutic benefits (it’s not a scientific journal so I’m not going to reference this comment with articles of evidence, but just ask Gareth Malone.)

And finally, the best of them all – reading and writing; free at the point of use, no spendy outlay, no materials needed – other than a book or a pencil – and the greatest ever means of escape without having to actually leave your own home, or the person you care for.

I started this blog as a means to off-load, a therapeutic intervention of sorts.  I have always used writing to do this; the diaries I kept through medical school, whilst neither as side-splittingly hilarious or beautifully poignant as Adam Kaye’s  This is Going to Hurt, are nonetheless fairly hair-raising and I have continued to scribble away when the mood takes me, writing articles, entering competitions and having the odd moment of recognition and success (including the offer of a book deal which admittedly looked a bit dodgy. Reader, I didn’t take it.) And writing this blog has been cathartic and satisfying for me, although you may beg to differ.  But recently, as avid followers will confirm, the blog posts are dwindling. This is not because I am any busier than previously but because there is no longer very much to say.  The funny anecdotes have dried up – mum simply doesn’t do anything remotely amusing any more, in fact she doesn’t do anything. Which is fine. She’s not a performing monkey after all and the blog is about me and helping others like me, not about pretending things are more entertaining than they are.

If I had wanted to write about practical and medical aspects of dementia, I would have done so.  Equally, if I had wanted to give a sanitised, ‘everything is brilliant’ view, I might have considered it (unlikely – they really piss me off) but this blog was always about trying to keep things honest and lighthearted. There are plenty of sensible, seasoned bloggers out there who can tell you all you need to know about the serious aspects of dementia, and whilst I value their work enormously, I never wanted to be one of them.  Equally I don’t want it to deteriorate into a bitter rant about perceived injustices – I don’t feel especially hard done by; life is shit for many people in many different and horrid ways and I consider myself lucky. I really do.

A post I wrote a few months ago basically outlined the limits of mum’s current existence and I had a profoundly upsetting comment on the back of it, telling me that I obviously didn’t love my mother and had no regard for her as a human being.  It was the first time in the four-year history of mumhasdementia.com that I’ve had feedback of that sort and it wasn’t a high point, to be honest life is tough enough without additional, virtual aggro. But it was payback for being unflinchingly honest, and that is sometimes par for the course. I am not a purveyor of fake news. My product is sold as seen.

So, I will continue this blog in its slimmed down form and gain strength from the positive feedback I receive. I will continue to read all the fiction I can get my hands on and write stories until my mind is quiet – to wallow in an imaginary world when reality bites. But I urge you all – those of you caring for someone with dementia or those of you who have stumbled here accidentally – to find your thing.  The thing that makes you happy – and as long as it’s not illegal and doesn’t make anyone else feel rubbish, then you crack on. Whatever gets you through the night.

 

 

Apologies – many Care Homes are clearly a FORCE FOR GOOD

IMG_0044

My last post was a ranty one – hands up, it’s a fair cop.  I allow myself a ranty post on an annual basis and this was it (obviously, there is now absolutely zero chance of anything bad happening to mum this year that might warrant further ranting – because that’s how it works – phewf what a relief). The post generated a bit of deserved push-back when  some followers took umbrage at the suggestion that residential care would be the horrific Doomsday scenario I had envisaged.  Their case, politely and kindly put, was that residential care can sometimes be the best thing since the proverbial sliced bread, and that for me to be perpetuating the myth that these institutions are run along similar lines to Bedlam, was unhelpful and frankly, a little disappointing.

I agree.  I overstepped the mark.  I painted a picture where, in the one corner we had a pastoral scene of loveliness; mum in the tranquil surroundings of home, attended to by smiling, rosy-cheeked family members and spending her last days basking in the warmth, luxury and comfort of our domestic idyl. And in the other corner we had a Fourth circle of hell, Dickensian workhouse (insert any other literary allegories at will) horror show with mum huddled in a corner, manacled to the other inmates, sitting in filth, howling, wailing and gnashing her teeth. Top marks for me, master of nuance and subtlety; I gave you a binary, Brexity scenario, and we all know how useful that type of thinking is.

In my defence, I was deliberately highlighting the extremes because I was frustrated by the lack of available options.  I still firmly believe that if a family wants to keep a loved one at home and if the person is happy at home, there should be the capacity in the system to allow such an eventuality.   I am also somewhat blinkered by my professional observations of poor care homes in action; some things you can’t un-see. But I accept that in many circumstances residential care can be a good outcome, sometimes better than fighting to stay at home in the face of significant odds.

Below are some of the very encouraging replies and responses to the last post.  They are so detailed and helpful that I felt they deserved their own little slot on the blog (my generosity knows no bounds) and hopefully they will help add a little balance to my previous Daily Mail shock-tactic reportage.

 

“My heart goes out to you…this is an awful dilemma. We kept Mum in her own home for nearly five years with live-in care provided by a private agency and cover care for three hours an afternoon, provided by a different agency. Yes, it was expensive, but it was worth it. Where she lived, at least, an OT assessment was reasonably quick, provided one paid for the assessment, and we found a home visit chiropodist. The district/community nurse bit was much harder; we got visits from a community nurse in the mental health team at times (when she hadn’t been discharged by the psychiatrist – something that happened if we didn’t contact the service for six months). We also had a visit from a nurse in the Bladder and Bowel team (different service), who was great and was able to scan Mum at home and sort out the supply of continence pads etc. We also had a very understanding GP who would make a home visit, if necessary. Mum was, however, still mobile and so pressure sores and wheelchairs etc were not potential issues and neither was the difficult moving about, but some agencies at least are able to supply appropriately qualified people.
That is not to say that everything was plain sailing – getting a urine sample out of Mum if we suspected a UTI was next to impossible and there was, at times, a low level background feeling of enormous responsibility and dread about what else might go wrong.
Our experience of a care home, now she is in one, is far from your fears and, unless she becomes acutely ill, she is very unlikely to end up in hospital. The care home has a nursing floor as well, with a special section for those with dementia and whose needs are great enough to be on the nursing floor (the dementia unit is headed up by a mental health nurse and always has at least one general nurse among the two on duty as well as the carers). It is not at all a bleak or difficult place to visit. Sometimes Mum is asleep and, when she is awake, she doesn’t necessarily recognise us, but we can still read stories and nursery rhymes together (she knows all the words), listen to music or walk in the care home’s garden. The staff (many, as you suggest, from EU27 countries) recognise us, are friendly and are observably good with Mum, who seems generally happy with their interactions.” – Annabel

 

“Advantage of residential care = 24/7 staffing/company, professional help with lifting, mobility, eating and continence. We all feel person best off in own home, but condition changes & cognisance/priorities with that. Guilt at considering move may be unwarranted” – Ming

“Soon after my wife was diagnosed with Alzheimer’s a retired nurse told me of her experience looking after her husband. She lived by the mantra “I was a nurse, I can look after anyone”. So she looked after her husband at home for several years because she “was a nurse and could look after anyone”. Eventually it became so difficult that she had to give up and her husband moved into a care home. She had failed. After a week she realised she hadn’t failed, she could sit with her husband whenever she wanted, take him for walks and have meals with him. At the same time she could have a good night’s sleep and not have to do any of the messy jobs. After a few weeks she started thinking of herself as a wife not a carer. He was only at the home for 6 months but her memories of him now are of a husband not of a burden.
If you’re concerned about what happens to your Mum then take control of the situation (along with your Mum and Dad). Look for suitable care homes, visit them and ask yourself “could I live here?”. If your Mum is likely to be self-funding for a couple of years then forget Social Services, they don’t have to be involved. Start by looking at a purpose-built care homes, it will be easier for residents and staff. Your Dad will know that even with all the adaptations you propose a normal house or a converted manor house are not ideal for someone with such mobility issues.
My wife has just moved into a care home (“put her in a home” sounds like a bad Eastenders ending). Our house was on the limits of being suitable, imagine mobility as you describe but with full incontinence and Parkinson’s causing random falls with no warning. The house had no meaning for her despite the fact that we’ve lived here most of our married life and brought our children up here. Trips out were scary as she had no idea where she was going until we were there. She enjoys company but even if visitors and daycare take up 20 hours per week that leaves 148 hours with just me. She had chosen her care home many years ago as it does daycare through to nursing care. It suits our “ageing hippy” attitudes with no explicit rules and an attitude where the resident knows best and the carers do their best to make it happen. The carers also enjoy this as their job becomes one of making people happy which then carries over to the more routine tasks. One night she was in bed at 10pm, watching her television and eating a bacon bap! She had gone for 2 weeks respite care and after a few days she asked me if she could stay. The activity programme has activities at least twice a day – not just bingo and dominoes but events such as flower arranging, pottery classes and choir, and that’s not to mention ad hoc singing and games lead by carers simply because they can. The home has equal numbers of dementia and non-dementia residents and mixes them fully. Yes we are very lucky to have one of the most forward thinking care homes close to us and it only available for people who are self-funding but it serves as an example of what a care home could be.
Really what I am saying is that keeping a person with dementia at home is not automatically “doing the right thing” and it doesn’t guarantee the best quality of life. A care home is not a prison, people can visit and residents can be taken out. As the person loses their understanding of their real family they may create a new “family” within the simpler environment of a care home – that’s probably not what anyone wants to hear but it may be the best thing for the person.
I’m sure your “what I think will happen” scenario does happen sometimes and it hits the tabloid press. The reality is that most care homes are extremely good. Some will struggle with low staff levels, lack of facilities or poor organisation but almost without exception carers care.
Sorry to be negative about your post, I normally enjoy them and I’ve found them very supportive. Moving someone to a care home can carry a social stigma. There is a hope that things will stay the same if your Mum stays at home, then one day Christmas means nothing to her and a family gathering becomes scary. What matters is what is best for your Mum not anyone else. Maybe I’m hard-hearted but I have no qualms about my wife being in a home, she is happy and looked after with a level of care I could never achieve.” – David

 

And a little update on our current domestic arrangements: 

  • Mum still at home
  • Wheelchair in the process of being purchased
  • Wheelchair accessible car also being ‘actively looked at’ (dad’s words)
  • Chiropodist in attendance (again, privately funded)
  • Care agency contacted (multiple agencies contacted but only one replied) and can provide care in home for two hours a day without financial ruin in the short term
  • District Nursing team still to respond
  • Social Services still to respond
  • Dad continues to be bullied relentlessly by both daughters – when describing situation above he said “It’s basically all ready to go when I push the button” – to which the obvious response would be “PUSH THE F##KING BUTTON THEN! OMG YOU ARE COMPLETELY IMPOSSIBLE” etc etc – but if there is one thing I’ve learnt over the past ten years with dad it is that he has to do this in his own time. My sister and I can chew our own faces off with frustration but it makes no odds.  At least he seems happier – and at least there’s a plan.  And at least we can afford to access the above – WTF do the people who are just above the threshold for social care do?

 

On that cheery note I leave you – big kisses to you all, especially those who take the time and effort to share your experience for the benefit of others XXX

House and Home – Being Accommodating

Why is it so bloody hard to keep a loved one in their own home?

Why, when the NHS and Social Care budgets are stretched to maximum capacity, is it so very difficult to say ‘let’s provide residential care in someone’s actual residence‘?

God knows.

 

fullsizerender-16

 

We have reached a point with mum where things are difficult (note the understatement).  Her mobility is restricted, she has no understanding about putting one foot in front of another or transferring her weight to maintain an upright position.  A geriatrician once described to me the risk of falling in the frail and elderly – he said that it is similar to flying a plane – the majority of problems arise during take-off and landing.  Whilst this explanation did little to allay any fears I may have about air travel it is a truth I have seen borne out over years of working with older people.  Once upright and moving they become confident and the momentum seems to carry them forward, reinforcing neural pathways and muscle memory.  I have described before how getting mum into the car could sometimes be achieved if one could engineer a seamless natural progression from walking, to seeing the open door, to stepping in and sitting down.  If there was a pause, all was lost and the series of actions made no sense to her.

Take off (getting out of a chair) and landing (sitting down in a different chair) can’t now be managed independently. They have instead become a project involving at least one other person and a combination of wrestling, heaving and dropping haphazardly whilst hoping for the best. Imagine moving a very drunk person, a person so inebriated as to be almost comatose. Now maybe add in some recreational drugs to instil a degree of paranoia and fear rather than the giggling stupor that would accompany alcohol alone (let’s say someone who has consumed two bottles of tequila and popped a couple of tabs of acid whilst watching the Blair Witch Project and listening to thrash metal).  Moving mum is worse than moving a dead weight because she panics and actively resists your efforts.  One is constantly aware that the process of transferring her is distressing for both parties; she seems to find it terrifying and does not understand our explanations of why she needs to move – and when your lumbar spine is screaming at you to stop, it is tempting to abandon the project altogether.  But sometimes she does need to be moved.  She is not bed-bound – yet – and I know too well the slippery slope of decline that will surely follow a period of confinement to bed (pressure sores,  blood clots, swallowing issues, chest infections, urine infections, the list of joys is relentless).  I would like to delay the inevitable for as long as possible and that relies on keeping her mobile.

Add into the mix the fact that there is now absolutely zero communication between mum and the outside world and the issues become more complex.  If mum could understand why we needed her to move her bottom slightly forward into the chair perhaps it would feel less of a molestation.  Similarly if she could tell us whether she wanted a drink or if she was getting a bit too hot sat in the sun, then attending to her needs would be infinitely easier.  We now have two identifiable emotional states of being – passively ‘okay’ and actively ‘not okay’ – but no real way of distinguishing what causes a shift from the former to the latter. So, as I say, things have become difficult.

However, dad is still managing – whatever that means.  The situation has not crossed any red lines regarding safety – mum is not wandering (evidently) and is not exhibiting any of the challenging behaviours associated with dementia (I know there is a universal hatred of that phrase but by ‘challenging’ I mean that mum is not smearing shit on the walls or throwing punches at people’s faces – hey-ho, small mercies). But the situation feels precarious to say the least.  The risks of a fall and perhaps a subsequent hip fracture for her are enormous, the risks of a slipped disc or a complete mental breakdown for dad are equally huge. And again we return to the age old conundrum of what are we waiting for?  How bad does it have to be before a change is needed? And what is that change?  Because, although I’m skirting round the issue, clearly what I mean is, Does mum need to go into a home?

 

Here is my best case scenario:

  • Mum stays at home with dad
  • Dad gets carers in twice a day who can get mum out of bed, get her washed and dressed, give her breakfast and transfer her to the sitting room.  They would then return at bedtime and reverse the process, popping her on the loo before bed for the necessary (mum is not yet doubly incontinent – as I say, small mercies)
  • The District Nurses come in to assess mum regarding continence, pressure areas, risk of infection and alert the GP if there are any acute health needs
  • The Chiropodist sorts out mum’s Quentin Blake toenails
  • The Occupational Therapist and Social Services Manual Handling Lead (who knew but apparently there should be one) assess mum and provide hoists / sliding mats / raiser cushions / water-flow mattresses as needed
  • Dad gets a wheelchair for mum, a nice padded one that is comfortable to sit in all day and has been designed with sufficient ergonomic insight as to stop her sliding down and out of the chair like a blancmange.
  • Dad gets a wheelchair-adapted car – he can then take mum to the shops / park / daughters’ houses and, accompanying a more visibly disabled person he would probably discover a greater level of tolerance amongst the public (sad but true)
  • Dad has increased freedom and can enjoy time spent with his wife (in a limited capacity) without having to worry too much about intimate hygiene issues or wiping gravy off her chin
  • Mum is comfortable, well cared for and in familiar surroundings – her daughters visit regularly and bring the grandchildren – Easter, Christmas and family birthdays relocate to mum and dad’s house like the old days and mum remains central to the life of the extended family
  • After a period of time, mum’s health deteriorates further but she has a detailed care plan – inappropriate intervention is avoided, any palliative care needs are addressed and she dies comfortably in her own bed surrounded by those who love her

Cost to NHS / Social Care = minimal

Emotional burden on family = tough but mitigated by knowing we are ‘doing the right thing’

Impact on mum’s wellbeing / quality of life = as good as it can possibly be

 

Here is what I think will happen

  • Bugger all help will be available despite willingness to pay through the nose and sit for hours on the phone waiting to be connected to the relevant department
  • Mum ends up in residential care, confined to bed because nobody has the time or the inclination to move her
  • Because she is ‘no trouble’ she will quietly moulder in a side room, occasionally attended to by a stressed overstretched HCA who is being paid less than the minimal wage and just wants to get back to her family in the Ukraine, since Brexit has made her feel completely unwelcome
  • Mum is visited regularly in the early weeks by her husband and daughters who will become increasingly depressed and guilt-stricken about their role in her incarceration and start to avoid visiting – not least because she will not appear to know who we are, or display any positive reaction to our visits
  • Mum develops some sort of infection, the out of hours doctor is called and she is admitted to hospital with little thought as to the appropriateness of such a course of action
  • Mum dies on a hospital trolley in A+E – entire family feel terrible about outcome for the rest of our days – Yay!

 

I will keep you posted…… (she says darkly)