Sunday 31 August 2008

Continuity of care

Continuity of care. Does it matter?

In Primary Care, bloggers have been vocal for over a year, raising awareness that government policy is to shift Primary Care away from an established GP practice with GPs looking after you (and other staff supporting this) to a new style of clinic. In these (often private) clinics, access is easy but the consultation is usually not with a doctor. When medical input is necessary, it's with who ever is working in the clinic that day, so there's no continuity of care.

You speak with a doctor about your problems. Tests are arranged, there's uncertainty over diagnosis, there's sensible safety netting and a review is arranged for a month to see what the clinical course has been. But when you're reviewed it's by a different person. So how can they compare if things are better or worse? How can they tell if the chest auscultation is clearer, or the heart murmur is harsher, or the skin is more icthyotic, or the dyspnoea more intense?
Much badness.

Patient surveys have consistently shown that patients would prefer to see the same doctor. In psychiatry, surveys have shown that this is also true. Who wants to give a frank account of their life to a doctor, start to develop a relationship and perhaps feel some trust, to then see some random soul and pick up consultations with a stranger? Much better to work with someone who knows your medical history but more (and this to my mind is the crunch) with someone who knows something of you. You can't get that in medical notes. It's about rapport, about relationships, about a shared understanding and shared confidence and shared trust.

Patients will trust me and I will trust them. That develops over time, it's generated through honest dialogue and evidenced actions that we undertake together over a period of time. Then, if I'm suggesting something they're sceptical about, they know it's because I genuinely feel it's the right thing to offer, knowing and having experienced appropriate care over time, so having a degree of trust.

I know colleagues who work in other hospitals/mental health Trusts, in other regions. Mental health isn't a huge field. Some colleagues work in systems where patients see a different team for different stages of their illness.
First you see an Early Intervention team.
Then, if things aren't great, you see a Crisis Reolution or Home Treatment team.
Then, if you need support within a hospital, you are transferred to the Inpatient team.
You're then discharged to the Community team.
Not cured? Then let's transfer you to the Rehab team.
A patient has been bounced through 5 teams before they've even entertained specific teams that might add in to care pathways (lithium clinics, drug/alcohol services, clozapine services, early onset dementia teams).

5 different teams, 5 different Consultant Psychiatrists. What if one is very much a community psychosocial medic who likes holistic interventions and minimum use of medication and another is a very biomedical medic who like the medical model and drugs? Care is ghastly. You get no drugs in one part of the service, you're admitted and given oodles of drugs, then discharged to the community where you're picked up by someone who doesn't think you should be on lots of drugs, but now you are. What to do, what to do.

As well as a lack of consistency of approach, there's then the tension of boundaries. The community team feels risks are significant and treatment isn't working and the patient and family aren't coping, so arrange for a hospital admission. The inpatient Consultant hasn't experienced what it's like for the patient and family at home so can't see what's so bad that hospital in-patient care is necessary, so promptly discharges the patient back to the frazzled community team, bitter that community folk are always turfing work to the in-patient wards whenever they're stressed or busy or have real work to do. The community team is bitter that the in-patient team never sorts problems out and only's interested if a patient needs detaining or needs ECT and sees everything else as something the community team should manage outside of hospital.

Speaking with folk from 3 areas who do work in this way, this scenario sadly isn't fiction but is the world that some folk now live in. Mental health services are already like this, in some parts of the country.
Much badness.

I don't work in this system. I cover a geographical area and manage all the patient's care where ever they may be. There's no tension over what area should be doing what, it's still my work whether they're an in-patient or in the community or in a care home or whatever. There's no tension with me having one philosophy of care and another psychiatrist with different views giving conflicting care. There's no problems of patients and families seeing a different person each time (only I do an out-patient clinic, there isn't even a junior doctor's clinic list, so I see follow-up patients myself).

I would be driven to burn out if shackled to out-patient clinics all week. Or in-patient wards all week, without seeing the follow up and positive results in the community.

Polyclincs in Primary Care. Fragmented services in Secondary Care. It's worth speaking up about them, and speaking up about them now, before things change for the worse. It may not feel immediate or directly and personally relevant. It's still an issue that should be fervently opposed.

"When the Nazis came for the communists,
I remained silent;
I was not a communist.

When they locked up the social democrats,
I remained silent;
I was not a social democrat.

When they came for the trade unionists,
I did not speak out;
I was not a trade unionist.

When they came for the Jews,
I remained silent;
I wasn't a Jew.

When they came for me,
there was no one left to speak out."

- Pastor Martin Niemöller (1892–1984)

Thursday 28 August 2008

MDT Teaching

Like many better other folk, I am enthusiastic about teaching.

I teach medical students often, both on wards and in clinics and within the community as well as formal classroom teaching. I'm often asked to do some teaching outside our organisation, this month it's been within a GP surgery, two care homes and our hospice. But I also teach members of our teams.

Teaching small groups of nurses and social workers, student nurses, occupational therapists and support workers does give people the opportunity to ask about small things they would like to know about or clarify. It also means we can share new information. It's healthy for teams, I feel, since we can all get together and bat out our views on a topic and there's a sense of collective "buying in" or cohesion at the end of it.

This week I have been struck by just how much people learn within the working week :
- one nurse queried with me whether a patient we're seeing with atypical dementia (and still trying to formally diagnose what the problem is) could have Binswanger's disease.
And she's quite correct, it fits very well indeed, he may well do.
- one nurse student, on seeing a patient on an anticonvulsant who had recently been initiated on olanzapine, queried the dose. Starting at 5mg, she questioned whether the dose would be therapeutic because wouldn't the anticonvulsant mean that her cytochrome P450 would metabolise the olanzapine so there'd be less to work?
The answer was almost meaningless but it was the process, her thoughts on the medication and consequences of interactions, that was spot on . . . stunningly good thinking. We've titrated the dose up now but she was absolutely right that the patient was on an enzyme inducer.
- a social worker asked me if a younger patient who's been on donepezil for 4 years for Pick's disease should stay on it. It's working very well, but the patient's had a arthritis, has taken over the counter tablets since last year and now has heartburn and is being investigated for stomach ulcers.

An atypical diagnosis, impact of pharmacology on clinical care and knowing cautions of drugs we use. I'm really am blessed with such a good team.

Tuesday 26 August 2008


There's been a lot of talk in my corner about interests.

I was reading The Guardian this weekend which was saying that drug companies influence doctors through gifts and that this influence isn't adequately disclosed.

It's human nature that when someone is kind to you and gives you a gift you want to be kind to them. If they're wishing for you to prescribe more of Drug X and give you a gift, you're more likely to prescribe Drug X. There's research that shows this to be the case, even though most prescribers believe they're not suggestible and not influenced by drug reps or gifts. The evidence is that they are.

So how do prescribers deal with this? Are patients informed that the pharamceutical company of Drug Y has visited 17 times this year, left £300 worth of gifts and brought in food for a few team lunches but we don't think it affects our use of Drug Y?

In our Trust every 12 weeks we've got to sign a statement of all gifts and hospitality that drug reps provide. Increasingly it's easy. I've never yet had anything to sign for and as time passes that's the case for more and more of us.
The only way I can be certain I'm not influenced by drug companies is to not see them. So I don't. And all my study leave is paid for by the Trust, not by a drug company. I don't accept any gifts from drug reps, not even a biro.

So I'm not sure how representative The Guardian's piece is, nowadays. Drug Reps can no longer enter our premises unless invited to by a Consultant, so we simply don't have contact with them any more.

That way, when my colleagues or I'm talking with patients about their treatment, we can be wholly up front in knowing that our prescribing choices aren't influenced by pharmaceutical companies' machinations.

Monday 25 August 2008


The media portray madness in many ways. Okay, this is simply a shameless excuse to share what I think is a hillarious take of one archvillain, The Joker, who says, "Am I crazy here? Okay, I know I'm crazy . . ." :

Well I thought it was funny!


Burried deep within the comments of an interesting post on nurses' training experiences 'bout medication I found this gem.

FOFOY training.

Fuck Off and Find Out Yourself training.

I like being spoon fed. Undergraduate education seems to have swung too far away from this, though, with espoused "adult self directed learning" ideas.

FOFOY. It really is how far too much medical (doctors and nurses) training seems to be, nowadays.

Sunday 24 August 2008


I met with a 66 year old lady to tell her the results of her investigations.

She'd been referred a month ago, with a 2 year history of memory problems. She was widowed, having a bereavement when her husband died 2 years ago. She lives alone and can't see her daughter now that she's in hospital a lot with her child who's had 9 operations and needs more. She calls the police once a month or so because the kids outside throw things at her and her neighbours windows, so she no longer feels safe (and they really do throw quite hard, I saw the dents in her garage door and the marks on her walls).

Talking with her, she had no evidence of a neurodegenerative process like dementia.

She scored normally on MMSE, Camcog and DemTect. NPI was fine, BDI II and HAD were not.

Her lack of focus seemed more to do with psychosocial stresses than through structural brain changes.

Still, since this was new to her, I thought it was worth absolutely excluding any treatable dementia, such as Alzheimer's or Lewy Body disease. As well as the raft of blood tests the GP kindly did before referring, I requested a CT scan of her brain. It came back wholly normal.

I shared the good news with her. The history, clinical course, presentation, mental state, objective cognitive assessments and brain scan all suggested she didn't have dementia. Hurrah! But before being able to move on to address her stresses and how things could be improved, she frowned and asked, "Can't you do a deeper scan, doctor?"

I explained the CT again and why there was no "deeper" scan then moved on to managing her mood and helping her cope with packages of support being offered and gratefully received. She didn't think she may need all the home care support a social worker's arranged but she is awfully grateful that all the visits and 2 days at a day centre will get her out of the house, get her talking with others once again and help her loneliness.

It got me thinking, though. A "deeper" scan? Where does this notion come from, I wonder. A plain x-ray* goes all the way through the body. Lots of them, put together to form a CT scan, also penetrate all the way through the body. MRI scan shows everything. Looking at structure of a brain, CT and MRI are perfectly good at seeing absolutely everything, no matter how "deep" it may be. CT scans are generally better at showing cerebral atrophy (which happens in Alzheimer's disease and Lewy Body disease). MRI is generally better at showing vascular damage and tiny changes of other neurodegenerative processes.

As well as the CT and MRI scans showing how the brain looks (it's structure) we can do tests to see how the brain works (it's functioning). SPECT scans look at blood flow, showing areas of poor perfusion. DAT scans show dopaminergic pathways and abnormalities that arise in Lewy Body disease.

Therefore investigations are sought to confirm or refute a diagnosis based on what's being looked for.

There isn't a better or deeper investigation to do. Which is where I started. Where did this notion that there are "deeper" investigations come from? Next time I see my lady, I'll have to ask her!

* I don't usually talk of x-rays after a harrowing experience at medical school. "X-rays are part of the electromagnetic spectrum! You' can't see them! There is no such thing as a chest x-ray at all, it's a chest radiograph!"
Exams were failed on such pedantic whimsical details, so it's stuck. I talk of "a chest film" rather than "a chest x-ray" to this day. Ho hum.

Friday 22 August 2008


A lot of decision making I am asked to undertake involves an element of risk management. Whether it's risks of leaving mentally unwell folk in their own home or whether it's around timing of discharge planning (when folks aren't cured but are things "good enough" to go home?), or of course prescribing. Stopping or initiating medication has clinical consequences, and thus risks.

My team has, I believe, a healthy attitude of positive risk taking. External agencies, partner organisations, patient and carer groups and our own Trust Board agree, so hopefully my belief is reasonable.

There are scenarios when I'm twitchy and would see risks as unacceptable. Almost always, since these are discussed as a team with the patient/carers, concensus can be reached and a sensible management plan generated. With prescribing it's a little different since I do that in discussion with the team but prescribe independently. We do have nonmedical prescribers but they're not independent prescribers and I don't envisage a day when nonmedical prescribers will initiate or change medication without discussion with a Consultant Psychiatrist. Currently our clinical governance framework requires this and it's firmly entrenched in our Medicines Management structure, so although nonmedical prescribers support, review, titrate and advise, the initiation or withdrawl of medication always always involves a Consultant Psychiatrist. Almost always it's the Consultant Psychiatrist doing it, since nonmedical prescribing is a tiny proportion of our prescribing.

Prescribing practice is singularly unique in my corner in that the risks (unlike other risks) are almost wholly carried by the Consultant Psychiatrist. It's therefore of interest to me how my colleagues and I prescribe (and an area that's audited and reviewed).

One theme that's arisen has been of varied prescribing of anti-dementia drugs.

I prescribe widely almost wholly irrespective of severity of the dementia (i.e. whether it's mild, moderate or severe I'm keen to prescribe if the medication's of benefit) which is outside the NICE guidelines (technology apprasial TA 111) which directs us to prescribe just for moderate severity dementia. I feel uncomfortable waiting for someone to deteriorate before prescribing, so prescribe for mild dementia. One colleague does not, sticking pretty closely to NICE guidelines. It's hard to say they're doing the wrong thing, it's easier to say I'm doing the wrong thing. Either way, there's a difference in clinical care, depending which of us you see, which is determined by where you live.

So I prescribe a lot of anti-dementia medication. At the other end of the spectrum is a colleague who prescribes far less anti-dementia medication than I do. A potential risk of the medication is to slow the heart rate down (bradycardia). At some point the heart rate is normal and all's fine. At some point it's so slow it's hugely abnormal and you're unconscious. There's a range in between where it's not perfectly normal but it's having no clinical consequences, through to sometimes causing problems, to having ongoing minor problems, to being more serious. This gives a grey area then, at what stage should a doctor no longer offer medication because the possible risk of possibly getting bradycardia may possibly make the heart rate slower and possibly cause serious problems? Some doctors prescribe readily with a pulse rate of 60, some won't prescribe. Either way, again there's a difference in clinical care, depending which doctor you see, which is determined by where you live.

The drugs also ramp up risks of conduction abnormalities within the heart, a lot of elderly folk have ECGs that aren't perfect and aren't totally normal, which of these folk are excluded from having medication? Again, it's up to the doctor to decide what seems too risky, with different clinicians having different views of this.

Postcode prescribing. I really can't see a way around this.

Tuesday 19 August 2008


Some people are vibrant, cheery folk, come what may, most all the time.

Some are not.

Dr Brown acknowledged that he's not been full of smiles a lot of the time of late and says that, "It's true that my attitude to things tends to be serious and gloomy."

This got me thinking because it's the second time in the recent past that I've heard a medic say this. The last time was from someone (a physician, not a psychiatrist) who had embraced this in a very healthy fashion.

Imagine medics sitting around a table having dinner. They're all Consultants or senior GPs so are old enough not to be larking about throwing buns at each other or getting pissed on tequila slammers. Such is for the younger students to aspire to.

Through the chatter, folk who knew this particular Consultant well were talking about her persistent low mood and depression. She took it all in her stride (she's a formidable woman) and explained that she didn't think she was clinically depressed. She just was a glass half empty kind of person.

When it was suggested that maybe things could be different, maybe she could be happier, her take was interesting. Different? Maybe yes. But no, that wouldn't be better. "Why, then I wouldn't be me!"

She embraced and accepted how she was, was an essential bit of who she was. That makes for being a pretty grounded and content kind of soul. Thus, chasing permanent bliss or happiness isn't desirable for everyone, there's sense in having other dispositions also.

Sunday 10 August 2008


The folk over at Mental Nurse are discussing the art/science/craft of nursing and after baiting them (why do they never bite when I try and wind them up?) commented on the medics role of pushing drugs.

Got me thinking.

How many prescriptions for antipsychotics do I dish out and hope for the best. As Mr Zarathustra says :
"Writing a script for some olanzapine and hoping for the best is being a “highly trained professional” is it?"

So, having some time on my hands, I've been through my last weeks activity. I guess it's fairly representative of a typical working week in terms of activities, but with a change of junior doctor and inductions I was doing and teaching and PCT/other meetings and management stuff taking up several afternoons, the absolute numbers seen are lower than my weekly average. This week clinical activity included :
- meeting in-patients (of which I currently have about half a dozen) throughout the week on different occasions to talk with them
- a formal weekly review of in-patients, with ward staff, pharmacy, CMHT et al
- meeting daily with the CMHT to discuss their visits and day to day patient care (what's the point of having an MDT if we don't think through and have a voice in all patient care?)
- a formal weekly CMHT meeting
- an out-patient clinic seeing 4 follow-up patients (each for half an hour)
- 2 home visits (joint visits with with a CPN) to see new patients referred
- 1 home visit (joint visit with with a CPN) to see an urgent referral on an evening
- 1 case conference at a GP's surgery with a CPN, Consultant Physician and GP then a home visit by the CPN and me to convey outcomes
- 2 case conferences to discuss care with patients and families
- 5 early onset dementia patient reviews
- 2 formal Best Interest meetings with patients, families, social services, care staff, CPNs, care staff (and lengthy 'phone calls with the GPs who couldn't be there in person but being fair they knew the patients well and visited frequently)
- 3 home visits (joint visits with with a CPN) to follow up patients and discuss medication with them
- 1 home visit (joint visits with with a social worker) to follow up a patient
- 1 care home visit (joint visit with with a CPN) to see an urgent referral, one from police
- 1 care home visit (joint visit with with a CPN) to see an emergency referral from the police
- 3 care home visits (joint visits with with a CPN) to review care
- 4 liaison referrals from our neighbouring acute hospital Trust
- 1 section 136 assessment (joint visit with an ASW, ward nurse and a home treatment CPN)

Only 35-ish patients that I saw directly, with a similar number discussed. 70 patients whose care I influenced last week. That's a very different world from Primary Care.

Going through these patients, what prescribing decisions were made? Prescriptions :
- in-patients : 0 antipsychotics, 3 acetylcholinesterase inhibitors, 1 duloxetine, 4 lorazepam, 0 sedatives/sleeping tablets
- out-patients : 0 antipsychotics, 3 acetylcholinesterase inhibitors, 1 lorazepam, 0 sedatives/sleeping tablets
- community : 4 antipsychotics (trifuoperazine, amisulpiride, 2 olanzapine) continued, 1 atypical antipsychotic stopped (aripiprazole), 1 depot antipsychotic (fluphenazine) stopped, 5 acetylcholinesterase inhibitors, 1 citalopram continued and titrated to 40mg, 1 citalopram stopped, 1 mirtazepine, 3 lorazepam
- liaison : 3 haloperodol stopped, 2 acetylcholinesterase inhibitors, 1 mirtazepine, 1 lorazepam
- 136 assessment : 0 antipsychotics

Antipsychotics prescribed : 3
Antipsychotics stopped : 5

The 5 stopped were 3 inappropriate prescriptions for haloperidol, 1 depot that no longer seems necessary and 1 aripiprazole for BPSD that hasn't done anything tangible.

The trifluoperazine was continued in a lady who asked for it. She'd been on it since God was a lad, and after so many years and trying so many drugs she had confidence in it, wishing to take it 3 times a day. It's working for her, so we're running with it. No more hallucinations. Delusions that she's being spied on gone. No longer wanting to move house. All's good.

The amisulipride 300mg is a relatively low dose since it's for BPSD and is working, the husband can now take her to the shops with him and she's settled. All's good.

Olanzapine 20mg is for BPSD in someone who smokes. I know, I know, high risk (2% a year) of CVA. But smoking halves the amount of olanzapine available so effectively she's just on 10mg. And it's cured her symptoms of BPSD. No more wandering at night, no more physical hostility, no more paranoia about family that she's acting on. Still awfully muddled, still swears like a trooper. But family can manage her at home, now, and even after discussing risks are adamant that she's a new woman on this drug so wish to continue it. And I agree, it's in her best interests to be functioning better and less distraught. All's good.

The other olanzapine 20mg is for bipolar disorder and is working. From being on section 2 this Summer the lady's now back home, off lithium and off her depot and on just olanzapine. She's content/a touch high which is exactly where she likes to be. Lots of energy and motivation, lots of creativity, but insightful and able to manage her relationships with family (that're damaged when she's hypomanic). So she's stable and well. All's good.

So there we have it. In one week I've stopped more antipsychotics than I've prescribed, which is pretty typical. It's not too bad, is it?

Friday 8 August 2008


Bob Geldof has it all wrong. Maybe he should have stuck to the Boomtown Rats. Solving starvation in Africa is a laudable goal. I'd favour him doing something a little closer to home, though.

I spent a couple hours on a general hospital ward. It's on a different site so I'm always a little piqued that parking's a nightmare and I can't easily get to see their patients for them, but I was remarkably calm 'cause there were oodles of spaces today. A splendid start, I can at least get to their hospital, hurrah.

I got up on to the ward, along with a colleague (a community mental health nurse who's brilliant). We find the patient's medical notes, sit down, read through them, then weep. Much badness. We find nursing staff who can tell us a bit about the patient, but not much. We find a qualified nurse who can tell us a bit about how the patient's not always taking her tablets and doesn't always eat, but not much more. Ho hum.

We spend time talking with her. Nurses say she can't walk and we'll have to talk to her at her bedside. Oddly, a miracle unfolds. My nursing colleague helps her up and walks her to a parlour and chat for an hour. She suddenly can walk; a miracle!

She used to live alone, in her own home, managing fine. Now she's had confusion (from an infection) that the medics have treated and she's again fine and medically fit for discharge. Has been for 3 weeks. Why is she still on their ward, then, I ask? "But she can't go back home!" Erm, why? "She's not right, she gets confused, she needs to be in care." And my oh my, they're good, better folk than me, 'cause they've made this decision without any discussion with the patient, family, no social work input and no occupational therapy assessment. That ward, must be geniuses, the lot of them.

Rather risk averse, my neighbouring Trust. Patients families complained a lot, they're terrified of being seen to put patients at risk, now nobody can make a decision with an ounce of common sense.

The lady was well. She hated being in hospital. She became depressed in hospital, 4 weeks ago. She was given an antidepressant on our advice (we assessed her then, too) which improved things. Then she stopped taking it regularly at 10.00pm and staff can't offer it at any other time 'cause it's prescribed at 10.00pm and can only be given within 20 minutes of that time.

After speaking with her we spoke to the registrar, Consultant Physician, nursing sister, discharge manager, intermediate care manager, social worker and 'phoned the family. The acute hospital refused to send her home. So, you are forcibly detaining her here against her will under what law? Hmmm, tricky one that. Right, so you're detaining her here unlawfully then, at least we can all honestly agree on that starting point.

3 weeks ago she could have been discharged home with a package of care, but they didn't. Now she's depressed after 3 weeks of incarceration where no treatment or hope or care's been offered and she's fading away. She's lost masses of weight. She's thoroughly disinterested in anything. She spoke perfectly sensibly and rationally to us, presenting with major mood disorder now, but able to articulate her frustrations and deterioration lucidly.

Worse, whilst we were doing all this, she starved.

She, "didn't want breakfast," so this was the first food she'd had all day. Food was brought and placed at the end of her bed, yet she was in an adjacent room. She was told where it was by the same nurse who told me she can't walk. My nursing colleague, in a fit of fury, bollocked the nurse and got a small table from the far end of the ward, brought it for the lady and put the food on it. She enouraged her to eat, which she did. Slowly. Too slowly, since staff came to whisk her food off her just 3 or 4 minutes after she started it. No exaggeration, we were making 'phone calls and documenting it all over 6 pages of notes in the end so we had the times written down. 4 minutes. Hmmm. The food removed, she's nothing further to eat 'til tea time when, again, food will be offered (invariably out of reach) then left then removed.

No wonder she's lost weight.

At a liaison psychiatry conference I'd heard that folk on general hospital wards with dementia die of starvation and I never truly believed it. No nurse would let that happen to their patient, surely? But it does. Sitting at the nursing station and seeing food brought, placed, staff calling out to a patient where it'd been left, leaving them then collecting the food, it's all about the process. Nobody was looking at the anxious and bewildered elderly lady, nobody was seeing her experience of this, nobody was helping her.

Hospital care. Not great care, really. Pretty malign care, if truth be told.

Gets one thinking.

So when she's fretting, and Sir Bob is fretting, shouldn't he be harping on about starvation of vulnerable folk 'pon our own shores, maybe?

Wednesday 6 August 2008


When to meddle?

I've a lady who's not coping perfectly well (past diagnoses include panic disorder (moderate), major depressive disorder, emotionally unstable personality disorder (impulsive type), PTSD) but manages. She's been managing for a few years, now. I know this because I've been seeing her at home at frequent intervals over the last couple years. She's making errors (unable to recall recent events accurately, unable to appreciate the value of assetts, unable to understand meaning behind interactions). She has been prompted to do activities of daily living for years, so cues in to meal times, bed time, time to bathe, when to change clothes according to when she's directed to do so. She only takes medication when prompted to do so.

She lives with her husband. He has mild dementia. He has coped with her mental health problems and his role as carer through self medicating with half a bottle of spirits a day, every day, for years. He doesn't act on things adeptly but in fairness this is longstanding and hasn't changed (e.g. every time I go I end up throwing out mouldy rotten food from their fridge). Sometimes he drinks more, gets drunk and falls over. Every couple months an ambulance crew attend.

Social services have offered support which has been accepted then after a short time refused. They don't want folk in their home, meddling.

He prompts her to take medication. He does this suboptimally. She has arthritic pains and dyspepsia. He gives her over the counter medication including paracetamol, ibuprofen and aspirin. The NSAIDs will probably be making her dyspepsia worse but since they're pain killers and she has mediastinal/stomach pains, they use more of them. Ho hum.

It's not a great situation, is it? But, somehow, they've managed for a year or so, limping along together. No serious harm has befallen them. They're living as they wish to, together, in their own home. On deciding future care and where to reside, both are incapacitated adults, within the meaning of the Mental Capacity Act 2005.

They're refusing practical support. There's no medication that can improve their experiences or mitigate risks. The choices are therefore quite stark. Do we leave them to limp along, or are they placed in 24 hour care?