Eldery Care

[2023forme]

I don’t really know what the point of my post is but I am feeling quite upset by some things in my working life that I need to get it off my chest. It’s a long one so you have been warned.

I have been a nurse for 30 years.
The first half of my career was working in cancer and palliative care and the second was in nurse education, mainly supporting student nurses on clinical placement. Got offered voluntary early release from the university so took it – but I wasn’t ready (or financially able) to stop working completely so I took a job at a lovely care home just round the corner from me.
A friend’s mum was a resident not too long ago and she rated it highly plus it meant a short walk to work and no commute, so I was really looking forward to doing clinical care again. But OMG – what an eye opener it has been.

I just was not prepared for how bad staffing is in the care home sector, the lack of resources and the level of waste has appalled me.
I enjoy the job itself but it has really made me think about my own future and that I need to make an advance directive now as I don’t want to end up living in a care home and just existing.

Staffing levels are dire. On a good shift, we will have a ratio of one staff member to five residents. There is one nurse and one nursing assistant on a shift and the rest of the staff are carers. Out of 32 residents, 27 need two staff members for personal care, continence care and moving/transferring/mobilising. Only 2 residents can feed themselves/take a drink independently. There is at least one agency nurse or carer per shift – often more. This means they don’t know the residents well and don’t understand their needs and preferences. There are also a high percentage of male carers who do agency and most of the female residents have specified in their care plans for only females to provide personal care. Given that women live longer than men, the residents are about 70% female to male. This means that often the male agency carers have very little to do whilst the female staff are run ragged. It also means that residents have to wait longer for care because the female staff are tied up meeting other residents’ needs. Sometimes we have no option but to ask the male carers to attend to a female resident’s care if the resident has dementia and is unable to say no to the male carer input, which feels really wrong to me. We are in the middle of a huge debate about trans women getting access to female spaces yet the issues of males having ‘access’ to some of our most vulnerable female members of society is not really considered.

The level of waste is truly shocking. An example is that last week we received a 3 month supply of high fluoride toothpaste – around 120 tubes. Since the toothpaste is prescribed, it is labelled with an individual resident’s name, meaning it cannot be given to another resident and if it is not used, it will be returned to the pharmacy and destroyed. I would estimate that about 90% of the residents who are prescribed this toothpaste cannot have their teeth brushed because they don’t consent to it (evidenced through spitting at you, hitting you and spitting it out) they choke when you try to do it or they are simply too weak to have it done to them/ can’t open their mouth etc.

The amount of medicines the residents are on is also eye opening. We have 95 year olds who are very frail and have less than 6 months to live still getting anti-cholesterol medications, folic acid and iron supplements and the like. A lot of the time, and I mean a lot, the medications are not tolerated by the residents (tablets too big even when halved and if effervescent is available, too big a volume to drink). Those with dementia just spit the tablets out. Last week we returned about 200 high protein drinks to the pharmacy for destruction as they hadn’t been used and were out of date.

But you cannot get a GP to stop prescribing as they don’t want to look like they are not treating the resident well. No one seems brave enough to say ….”look, this person is not going to benefit from cholesterol lowering drugs so lets just stop them”. In my palliative care practice, someone at the end of life had their medications stopped and were only on end of life meds to palliate symptoms.
I’m not talking about meds that help such as pain killers – but those that are just not going to add anything to the quality of the resident’s life. So we have all this money being spent on meds, high energy drinks, toothpaste etc but we can’t buy enough pressure relieving mattresses or employ more staff, both of which would do more to help provide better care.

We have one lady at the moment (aged 98) who is very frail and cognitively impaired. She has contractures, her skin is like tissue paper and is constantly tearing, she is doubly incontinent, unable to swallow much and is in a lot of pain.
But the GP won’t prescribe her morphine as he feels it is too strong for her frail state – if she had terminal cancer, no-one would think twice. She screams out all night, asking to be ‘put to sleep’, upsetting other residents and keeping them awake. We cannot sedate her – she is prescribed a medication for agitation, but she refuses to swallow it. In her lucid moments, she describes how her life is a living hell, she feels trapped in a decaying body and just wants to die.

I truly think we have lost our way when it comes to care of the elderly. People aren’t allowed to just get old and die anymore – its like we want to keep them living but for what? I’m not talking about treating reversible things which cause distress like urine infections – but really, what is the point in giving vitamin D tablets or iron supplements to someone who will likely die in a few weeks.

I don’t know what to do with regards to my employment – I want to remain and do the best I can for the residents but I am getting more depressed and frustrated at work. I spend around two hours of a 12 hour shift writing about care rather than actually providing the care. This is how long it takes to update the residents daily care plans – so I will be writing things like “Betty enjoys sitting in the garden and reminiscing about her time as a teacher” – but I can’t actually find the time to sit and talk with her and we can’t spare anyone to take her to the garden.

So AIBU to leave my job because I am finding it upsetting?
YABU – you have taken a role with vulnerable people and you need to stay and help provide care for them.
YANBU – you need to protect your own mental health and leave the work to those who can cope better with it.

I totally agree with you that people should be allowed to die. My beloved uncle was about 90 and he just wanted to die because of his quality of life. I agree there is an argument for allowing people to do make thus decision.
Cost to the state? My mum worked. She pays her own fees. She takes statins, aspirin, memantine and an anti depressant. That's a lot less than many people in their 40s and 50s take.
I understand the intention behind what you said, I just objected to the blanket statement. Lol!

Yes! Nobody understands how hard it is to navigate through the social care,system. How someone on their own in their 80s is,supposed to do it, I just don't know. Even when they've gone in a home, you still can't relax because you're constantly wary that they're being cared for correctly.
And you have all this learned knowledge but you're so exhausted and downtrodden by what you've gone through, you never want to think about it again!!! 😁 It's hard learned, solid, informative, useful information and it's just lost.

My mum is 87 and physically fit. But she has dementia otherwise she'd be fine at home. She has a DNR but if she, as someone said upthread, got pneumonia, I'd expect her to be treated. Despite her dementia, she still enjoys her life.

@MarshaMelrose when you say you would expect her to be treated for pneumonia, do you mean hospitalisation with all the downsides that brings for someone elderly and living with dementia or a more watchful waiting with oral antibiotics ?

As an ex carer (who left after a breakdown because I just couldn't provide the care they deserved with the staffing levels we had)

Actually I don't even know what I want to say. But I hear you. It's dire.

Regardless of your AIBU you write very well and raise and argue some very interesting points. You should consider writing a piece for a journal/newspaper or nursing press.

I am a nurse (20 years) based in a hospital and I am frequently made to feel like I am trying to just 'finish people off' by many of my medical colleagues who seem to have a different life-view to me and want to treat patients until the bitter end and leave no intervention un-done. Even if this seems cruel, unnecessary and futile...CT scans or cardiac monitoring on frail 95 year olds.

I agree, it does make you think about your own care and what you can do to prepare and make your wishes known.

That gave me shivers down my spine because, word for word, that was me, until last February. I was a senior care assistant, responsible for 30 residents and with 5 other staff each shift. As you said op, male staff make up much of the team and, as kind and gentle as most if them are, many female residents literally scream if they enter their room.Just no time to really care. I became terribly anxious about work because it made me feel so guilty, sad, frustrated, weary and certain something really bad would happen because we were too busy to do anything properly. When I started trembling and holding back tears at handovers, I knew it was time to leave.

Whatever the doctor thought would be best to cure her. She was in hospital last year. She didn't want to go because she thought she wouldn't come out. (Significant likelihood of that being true with our trust!) But she loved it. Now, I don't know if she'd cope as well. However, I certainly wouldn't want her deprived of all treatment because she's old. She still enjoys her life. Loves to see me, chats away (I haven't the foggiest idea about what half the time 😅), walks round the park with me to check out the ducks and squirrels, loves to have coffee and cake out, loves listening to me chatting with strangers. Just to withdraw treatment and let her die because she's 87 would make me most unhappy.

Is like to make a couples of points:

• A number of posters have commented that "people are living too long". In my view the only person who can /should determine what is "too long" is the individual themselves. Once others start having a say in the matter, then I think it gets dangerous. On the other hand, I'm an advocate of assisted suicide. If I decide I've had enough and my life is no longer sort living them I believe I should have the right to choose death.

• Re prescription waste, I'd like to share a very recent experience. I have eight different drugs prescribed, every 28 days. Some are to be taken "as required" some are boxed in 30 days supply. So I've built up a bit of a stokepile. I rang the pharmacy and asked that five of the drugs not be supplied for the foreseeable future. fine, the pharmacy said, but the surgery may prescribe them anyway, just b ring them back. About a week later the pharmacy delivered my drugs, my daughter's partner took them (they were doing my gardening at the time), brought them in, and there were the five I'd asked not to be sent. Daughters partner took them straight back, and the pharmacy said they'd have to bin them.

@MarshaMelrose you sound like a lovely person. I suppose as someone else has already said it's about assessing each individual isn't it ?, if someone is enjoying the majority of their life, even if it is one we wouldn't choose for ourselves, we should respect that ?.

Unless they want it. A friend of my mum's is 90 and he is having cancer treatment. But he is otherwise fit and well, lives at home, still drives a bit.

But if someone is lying in bed with advanced dementia - what on earth is the point.

Well he absolutely should not be driving as a 90 year old with serious health issues!

Thank you, @Dymaxion, that means a lot. You've made me a bit tearful really. Just the whole business of navigating her through the NHS and care systems is so very hard.

I've learned a lot on these threads from people like you and it has changed my outlook. I was reluctant to get a DNR because I wanted to keep her going forever. But I read posts on here, written very honestly, by nurses, particularly over covid, of how brutal resuscitation can be. I would really like to thank nurses who take time to write about their professional experiences in medical issues. It's a totally invaluable source of knowledge and support that you can't get in real life.

It's so hard to let go. So I am always trying to forget what's right for me to think what's right for her. I hope I'll make the right decision when the time comes. But at the moment, she's still capable of putting my sunglasses on and pretending to be a celebrity in front of a crowd. It's not her time yet! 😄

Personally I would like to see a move away from the big institutionalised type care facility that is currently the majority of elderly care, no matter how snazzy their decor.
I think lots of smaller home sized settings of 4-6 residents would be better and allow more inclusion into the community, trips out everyday to the shops, the park, cafe etc. A lot of the places I visit, whilst doing their upmost, are essentially holding pens. Once in them, the residents have no contact with the outside world unless via relatives, they are doomed to walk the plush corridors looking for the exit until no longer able to.

Reading your post OP has really made me appreciate how wonderful the care home I work at !
Yes we do have a lot of drug wastage but that is the fault of the system..bloody eye watering TBH ..probably dispose of £1000 meds monthly!
Our staffing levels are 2RNs plus 9-10 carers daytime and 1-2RNs at night plus 4 carers for approximately 30 residents!
All residents are reviewed monthly by GP who definitely doesn’t over prescribe meds and will stop anything that is not necessary. Pain relief is 100% priority and we have JIC meds prescribed for any resident we are concerned about !
Absolutely everything we do for our residents is with their or relatives consent.We review all care plans monthly and discuss with residents or their relatives.
Yes paperwork is a PITA and not always completely up to date but we try .
I would definitely contact CQC with your concerns.
We get paid for all training and RNs are paid for 15 min handover . If we get off duty late we claim on our timesheets.Our manager thanks the staff regularly and are treated respectfully . In fact the staff all got chocolates on V Day !
We feel appreciated and it reflects in the care that our lovely residents receive.

It's so hard to let go. So I am always trying to forget what's right for me to think what's right for her. I hope I'll make the right decision when the time comes. But at the moment, she's still capable of putting my sunglasses on and pretending to be a celebrity in front of a crowd. It's not her time yet!

She is lucky to have you and you her by the sounds of it ! Long may that continue for you both

Was the high fluoride toothpaste Duraphat, OP? Now and then I buy a small tube from the dentist - it’s £14!

Especially when dementia is involved with the very elderly, I do agree that life-prolonging meds should not be given. What on earth is the point? Let alone any life-saving treatment.

I’ve seen far too much of advanced dementia, with its attendant double incontinence, etc., and to me, it’s a fate far worse than death.

I think your post explains the problems well. DD is a carer, she gave up her job to care for her grandmother who had Alzheimer's. Her main complaint was that too many staff pop out for a smoke when there's work to be done. She found one home that she's happy working in and they've all held her job open for her.

I'm saddened and a little surprised to hear this. This sounds like care homes 10 years ago. Nowadays almost all areas have specialised care home GPs and services, who actively manage deprescribing, ACP, and end of life care. Its a strong government mandate.
However as evidence by a number of posts on here families are often the problem. Wanting everything done refusing to stop meds and engendering a fear of managing old age as a terminal disease like cancer. 92 yrs olds 94 Yr old may have good quality of life of course but sadly it doesn't take a lot to destabilise them and in this current climate there is always someone looking to blame.

Especially when dementia is involved with the very elderly, I do agree that life-prolonging meds should not be given.

My mum is 87 with dementia. She had an elective triple bypass at 81. She takes statins and aspirin to keep her heart going. Would you take her off those? She also has an iron infusion twice a year. Would you stop that?
Where is the line of what you would and wouldn't give to a dementia sufferer? And at what stage of dementia?

I am a very experienced care assistant in a high rated, high quality private home.

I can relate to so much of what you have said. The care sector is not taken seriously enough, and society has became out of touch with death because medical advancement and living sta standards has us living much longer. Families often only see their family member looking neat and tidy for their visit, but don't often fully see or appreciate just how poor their quality of life is for the 23 other hours in the day.

We really need to look at more hospice style palliative care for more people, instead of pushing for physio and medical intervention for 90 year olds with advanced dementia who have fractured yet another hip for example.

Person centered care should really be ensuring a person lives the rest of their life as comfortable as possible.

I love my role and working in the care sector, but there simply aren't enough dedicated nurses (you sound incredible and I would love to work with you!) or care staff who truly want to make a difference. Staffing issues mean people are often hired for numbers rather than the qualities to do the job. Many nurses have came in looking for an easy ride after the NHS/To Lord it up rather than be a true, hands on and challenging issues type of nurses. Agency carers are often forgein students who simply can't be arsed and just need money.

I guess it fully depends on the extend of her dementia and general prognosis/how quickly her dementia is progressing and what quality of life she has.

I am a carer not a nurse, but being comfortable and passing younger trumps living longer with a poor quality of life, often with extreme confusion,and inability to so even basic tasks is preferable and what I want for myself.

But we are all different, and it's much easier to see things from a non-family side than when it's family. It's very very difficult.

i see where you’re coming from OP, I work in community nursing as a HCA and am also doing my training. Far too much emphasis is put on quantity rather than quality and it isn’t right. The waste is unreal as you’ve pointed out, I’ve had people continually remove libre sensors, cut compression stockings etc which I’m sure they wouldn’t do if paid for from their own pockets, then there is non compliance particularly in those with leg ulcers who need to elevate etc but don’t do end up with twice weekly visits for years for bandaging

I too will be doing advance directives, I do not want treatments for every infection going, surgeries for thing etc if i get dementia and if I get cancer after the age of 75 I do not want treatments or invasive procedures but to be honest I think the generations before mine may be the last to live long lives with our current lifestyles

@MarshaMelrose everyone is different but I personally wouldn’t have had a big op like that and all of the associated recovery and meds in my 80s

However as evidence by a number of posts on here families are often the problem. Wanting everything done refusing to stop meds and engendering a fear of managing old age as a terminal disease like cancer. 92 yrs olds 94 Yr old may have good quality of life of course but sadly it doesn't take a lot to destabilise them and in this current climate there is always someone looking to blame.

I don't know if this refers to me, I think it does.

I understand about the frailty of old age. My mum pulled her back a few months ago. She got better but it's had a long term effect on her more mentally than anything. I understand every time a blow, mental or physical, happens, there is a toll and there's no bouncing back like she did at 70.

I don't want them to keep her alive at all costs. I want her to be given a fair chance to try and recover. She enjoys her life. I don't think she should be stopped taking statins and aspirin in order to hasten her death. I honestly don't believe you do either. She's mobile, continent, can dress herself, feed herself, have opinions, laugh at jokes, make jokes. I'm just asking not to write her off because she's falls outside a pre-set idea of how life should be lived.

@memorial absolutely, more education is needed. I have done ACPs with my elderly patients, some want resuscitated which shocks me but they do not realise the chances of survival are slim and even if they are their quality of life won’t be good, they think it’ll be like casualty. Then there’s the ones who do not want resuscitated but then the family call furious wanting it changed or guilt trip family into changing their mind