Sunday 29 March 2009


I feel vexed.

This is A Bad Thing because, although I don't get cross often, when I do I'm not always wholly reasonable. No no no, not in a "red mist" kind of way. More in a didactic, assertive, "I know best" kind of way which surprises folks 'cause it's typically alien for them to see this, coming from me. But, when vexed, I am wont to be classically Consultoid and Have Things My Way and assertively progress this state of affairs.

By chance, a social worker commented on assessing capacity. Her rather splendid blog should be known to you, if not, shame on you. Nip on over to here and rummage around.

What perturbed my calm mien was after a member of our CMHT visited a care home for a meeting around a patient's care, returned to the office and discussed things with me. Let's call the care home Limbo. Most care homes in my area were woeful, most are now decent, two are excellent (and I would happily have them care for my kith and kin). This care home she visited is a curious place. The environment is spot on. A modern, purpose built home with structure and content that's pretty much without fault. The staffing is uncertain. Really uncertain. Sometimes I speak with a nurse who's got oodles of common sense, is very patient centred and utterly devoted to those in her care. Popping in to Limbo when she's on shift is a joy. Every other RMN has less enthusiasm, motivation, common sense or interest in residents than my daughter's goldfish. This is not a slur against nurses, it's a comment on the dichotomy 'tween great nurses and those undertaking poor nursing practice.

This makes for curious states of affairs. One care home in our area that's poor (an in, CSCI are involved and they's an embargo sort of poor) had a resident moved to Limbo where care could be better. It was a transfer made from one home to another with the same registration, notionally providing the same level of care. A gentleman who wasn't being cared for by staff was moved to Limbo to receive appropriate care, which he wasn't getting in his previous placement. In Limbo he had exceptional care.

Seeing him in his old home, he was a state. Wild hair, soiled clothes, smelling rank (from not bathing for many months, from incontinence that wasn't attended to, faeces matting up in his pubic hair), he had food that had drippled on to him, his clothes, his beard, had dried and become adherent to him, his beard. Not good.

He was moved to Limbo, the next day I didn't recognise him. No, not an idle comment, I really did walk past him in the entrance foyer, failing to clock who he was. He'd been bathed, shaved, cared for. The nurse (who's exceptional) gave a rich account of how he'd been, despite only having known him for a two shifts.

She had spoken to him and his family. She knew what he liked, what irritated him, what relaxed him, what topics/hobbies interested him, she'd sought an understanding of him even down to what flavours of food he liked and didn't. Person centred care. Superb.

Limbo has other nurses and, sadly, to a one they're not as good. Not even in the same league. Their unqualified carers are, rightly, directed by the nurses. They're a mixed crowd but, typically, have time and interest and common sense in their delivery of care. But if nurses aren't directing them to undertake appropriate care, then appropriate care's not undertaken. Less superb.

Back to a different patient, stuck in Limbo, and a different experience. My CMHT colleague (a social worker) returned from Limbo where they'd had a meeting with 3 nursing staff. Three, on one shift, for one meeting?! The home's not that well staffed. Folk had axes to grind and had come in to make themselves clear. The social worker was concerned that no medication had been given for weeks. The nurses explained that the patient had declined medication offered. The social worker explained that, indeed, this was known and expected, because the patient was severely demented and didn't appreciate their illnesses, the impact of their illnesses, the consequent effects of this on their health and wellbeing, and the desire/need for medication to help manage this. My social worker described how the nurses in Limbo shook their heads and tutted a lot, saying they could only give medication to the patient, including his insulin, when he was unconscious.

This patient is an incapacitated adult, unable to either give or to withhold consent. The nurses just couldn't (or wouldn't) get that.

My social worker sadly didn't know the NMC guidance on covert medication so had to accept the 3 nurses telling him that they couldn't provide appropriate medication for the patient. He quoted the relevant bits of the Mental Capacity Act 2005 to them. They were having none of it. If that patient says no, the patient gets no treatment. All this is becoming much less than superb.

Worse, on review, the patient was in a state. Sitting in urine sodden clothes. Not moist, but apparently soaked. The social worker was astonished, since the urine was even dripping down the chair. He backed out of the room so staff could attend to the patient with dignity, undressing and attending to him without the social worker present. The staff left the room too. They left the patient. They wouldn't change him. He told them he'd not been incontinent and didn't need to change his clothes. The social worker questioned if, being diabetic, leaving him sat in urine was okay for his skin. Nurses said it was his choice. If that's how he wanted to live, they wouldn't and couldn't force anything on him.

Nothing polite can convey what I was thinking, feeling and expressing to my social worker at this point. Suffice to say, I was animated and more than a little vexed.

A nurse and I'm meeting with their manager tomorrow.


The Girl said...

That is tragic. I hope you give them an (entirely appropriate) piece of your mind.

IMHO, they are using the patient's non-compliance/adherence as an excuse for their own laziness.

Does the poor patient have any family?

Elaine said...

Disgraceful, utterly disgraceful.

They should be hauled up before a disciplinary hearing of the GNC.

Kathryn said...

I am so glad you are there to get angry, Shrink. Seems that anger is possibly overdue

Disillusioned said...

Like K, am glad you are there and prepared to intervene.
Hope you manage to get at least some changes made.

Maggie said...

that is horrible. I'm so glad that you are there for this poor man.

My Mum was sent to an EMI home when she became demented. She absolutely hated it. At the time it seemed an OK-ish place (as so called "care homes" go) and had reasonable CSCI reports. But I went back to look again at newer reports around a month ago, and it seems to have gone downhill badly since Mum died in 2007. The report was OK just after Mum died, but the latest one is appalling.

It's such a shame that our parents have to live out their last days in these places. BTW I am disabled, so wasn't able to look after my parents myself. I still feel bad about that.

Your blog is amazing - I am always glad when I see it has a new entry in my News Reader. Thank you so much for writing on these very important topics.

Best wishes from sunny Liverpool

Cat said...

Thanks for the kind words. I would be horrified if I were in that situation. I'm not as good as I should be at professionalism in those kinds of situations. I hope you and/or those involved (social worker) called CSCI too. You can tip off anonymously if necessary. Often they haven't got a clue what is actually happening in residential homes (and nursing homes) - especially as they have moved to 'desk' inspections now - but I won't start on that as I can feel my blood pressure rising as I type.

XE said...

To me, that seems like a perfectly acceptable reason to get angry.

The Girl said what I was going to say, in that they seem to be turning patient autonomy on its head, and using it to be as lazy as possible instead of using it to promote the patients' well being.

There needs to be some disciplinary actions here, so I'm glad you're there to shout a bit and get some things worked out.

Spirit of 1976 said...

Just abysmal practice. And not even bad practice that can be excused due to lack of staffing or resources, by the sound of it.

Milk and Two Sugars said...

Do the Consultant-thing for as long as it takes to satisfy you. I can only imagine how livid you are.

Nurse Anne said...

Have any of you actually tried to get medication into someone with dementia who is refusing?

I get many patients with dementia on my hospital ward.

If the "crush the pills and put it in food" doesn't work then you are screwed basically.

Many pills are modified release so they cannot be crushed. Some do not come in syrup form. Some are huge and cannot be crushed nor do they come in syrup form or dispersable.

Many medications are impossible to safely get into the refusing patient with dementia without harming them or choking them.

If it is pain medication you can get it in a patch form...but other than that it is impossible. Impossible.

Now if someone like this is my only patient then I can spend the day trouble shooting and coaxing him. There are a million different strategies I can try.

But if I have 20 people due to have their medications at the same time and only a short window to administer how much time can I spend arguing, coaxing, and forcing without harming my other patients even more?

The incontinance situation is just bad however. It doesn't matter how aggressive a patient with dementia is or how hard they hit us. They get attended to and remain as clean as possible.

I often have patients with dementia who are full of pressure ulcers but they scream and hit and say no when repositioned every 2 hours. It still gets done as pressure ulcers are horrible and get even more nasty if positional changes and hygiene needs are not met.

But the medication things stumps me. Sometimes it really is completely impossible. The nurse should still try at every opportunity. But if they try and fail and have other patients to attend to.....