Yesterday one of my patients, who should long since have moved on from the hospital, told me hopefully that he “might as well stay” until his next outpatient appointment (in 6 weeks time). At £350 a day, that’s about £14,700 to the tax payer. Seems a strange calculation that this might be a better bet than a £20 taxi ride either way from home into outpatients. Clearly, it was time for THE meeting.
So I called in the family, social services managers and every nurse and therapist I could find lurking in a dusty corner to squeeze into a tiny room (the so-called Multi-Faith room was the only empty one available – if ever we needed faith it was now) and drive home the bad news. It was one of those difficult discussions that go something like “You are medically stable and don’t need to be in hospital but you are now far too crumbly to live alone on your own as you were. Its not safe and you need someone around 24 hours a day to help you. I know you are happy here but this is a hospital and you can’t stay here any longer. We must help you make a plan.”
(loose interpretation : You’re not going to get any better now, its time to face the last phase of your life. We need your bed for much sicker people who can gain some improvement from our highly trained and expensive team of therapists.)
Several times a week we repeat this mantra, and the reaction is often the same.
The patient wavers. They know that if only they could get home, everything will return to normal, just as it always was. They will put the kettle on, build the fire, tuck up in their cosy armchair, watch their favorite TV programme and enjoy the ghostly company of their long-deceased partner in the empty chair next to them. All will be sunny.
The family waver. They’ve known for a while, perhaps subconciously, that Dad needs more help. But their lives are busy, they have jobs that consume all their energy and mental resources, and their stylish homes lack the space for an older person with their commodes, their favorite chair, their zimmer frame, their catheter trailing a bag full of urine, and their slow rambling chatter. Of course, Dad needs to go into a residential home. He wasn’t really coping even before this last illness, and his bungalow had become a squalid scene of self neglect, the fridge packed with out-of-date ready meals, kindly supplied but rarely eaten while the occupant takes the path of least resistance and lives on biscuits and jam sandwiches. The bath went unused, too slippery to climb into, and the fusty smell in the air when they visited told them that even a quick rub down with a damp flannel was too much for him. Often the bed was not slept in as their elderly father remained planted in his armchair through the night, risking pressure sores and dependent leg ulcers to avoid the effort of moving. Of course, Dad needs to be in a nice home where kindly staff can keep an eye on him, cook him nice meals, make sure he takes the right medicines and tuck him up in bed at night.
But they have already spoken to the Social Services Care Manager (few bring themselves to use the term social worker, with all its connotations of despair and deprivation) who has told them that Dad, with his little bungalow, is way above the threshold for social services funding. He must sell his house to buy into a new type of home – a residential care home, costing hundreds of pounds a week. In a blink their inheritance is to dissapear. If only Dad could get home, things would be alright – wouldn’t they ?
We don’t waver. Of course, we would send them home if it was safe and feasible. Most people are happier and do better in their own home, surrounded by familiar objects and a familiar routine. Carers can pop in up to 4 times a day to sort out the getting up, washing, toileting, meals, medicines and getting back to bed. But this gentleman, one of my favorite patients, is fiercely independent. Everyday on the ward he tried to get himself up – and falls over – despite the nurses calls to him to wait – they’ll be with him as soon as they can deal with all the other dozens of urgent calls on their time.
We know that if he goes home, and is left on his own for any time, he will likely be on the floor in a blink of an eye, smashed head, cracked pelvis or delicate elderly skin degloved and haemorraghing whisking him under the piercing flash of a blue light back into the District General Hospital before you can say Meals on Wheels. If anyone finds him. Otherwise its long hours on a cold kitchen floor. We’ve seen it all before. So many times. He needs to live with someone. But although he owns his bungalow, he has little cash in the bank. He couldn’t afford to pay the roughly £100/day for a live-in carer unless he sold his property.
Moving in to a residential home is his only option.
His family stare bleakly as this dawns on them. “But what am I going to do ?” laments his son (who has already referred several times to his important job, which involves long hours packed with resposnibilities that leaves him unable to care for Dad at home, but which must surely mean he is well rewarded and comfortably off. “What about my future ?” he says referring to the inheritance nest egg he had pinned his hopes on for a sundrenched retirement in the Costa del Sol . “3 years for him in a retirement home and it will all be gone. What about me ?” he starts to rant, anger rising, taking to task the government, the social services, the miserable society we live in, the lack of free care for an elderly man who proudly suffered the privations of war in Burma for the love of his country…….
Don’t shoot me. I’m only the messenger. And I’m growing weary of delivering the message.
