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.

@HedwigIsMyDemon many do not want to face up to their own mortality, working in this job makes me more keenly aware of mine and therefore I am not afraid, I prefer to be realistic

@AlaskaThunderfuckHiiiiiiiii its so incredibly sad. And with dementia even more complex of course because no permission can be given. It’s not life - it’s just existing 😢.

It's soul-destroying just reading about these people, let alone having to care for them. You have been doing a wonderful job, OP, but I do understand it must take an awful toll on your mental health.

Re Advance Care Directives - how do you know what to rule in and rule out? Since we don't have a crystal ball, it's very hard to know what you may or may not want in any future scenario. The only thing I am clear on is that I would want a DNR, and not to be ventilated. The thought of being in a care home horrifies me, and probably does for most people.

Social worker here.

Lately I feel like all I do is place people in residential and nursing homes over all else because families can't cope and they're unsafe and I honestly feel like I'm just sending them to die,

Unsafe in own home and left to fester in care home due to lack of staff etc. Staff are run ragged.

OP I salute you for doing the job you do.

There's nothing wrong with sending someone to a care home "to die". That's really what the point is. What we must do is normalise frailty of old age and dementia as terminal diseases (and other progressive chronic diseases) equally deserving of proper end of life care as cancer not prolonging life at all costs.

My dad is 83 and was fully able and active until just before the pandemic when he had a massive stroke. I was the one that was told he would be unlikely to survive without the thrombotic 'magic' drug and I had to make the decision of whether or not it should be administered. It was a 5 minute conversation and I had to make a split decision. I chose for him to have it and he lived, but has absolutely no quality of life.

The stroke left him with parkinsonian symptoms. He is unable to speak with clarity, doubly incontinent, immobile, needs help to eat and has thickeners for drinks. He lies in bed all day watching TV. He is dependent for everything and recently been diagnosed with moderate to severe vascular dementia. He frequently asks to be taken home to die. He is a miserable, depressed, a shell of his former mighty self and has no dignity whatsoever.

I have no qualms with the medical profession; I was given choices and I made the wrong one. Nobody should have to live this way. I've asked once if he could be sedated to make him unaware of his misery. I'll have to live with that too.

I'm so sorry. Its not your fault. You did what you thought was best at the time. I think as medics we need to be clearer on likely outcomes.

Thank you, that's a kind thing to say. I don't blame the doctors though. Everyone did their best in the time available. Its just such a great shame.

:(

I fully understand this. Post stroke is awful.

Yip, I worked in care homes as a qualified nurse for over two decades. It was awful, particularly the last few years. Nobody is permitted to die and the things we had to do to keep people going were barbaric and felt akin to torture. I burned out three years ago and left nursing completely. I still have bad dreams. I also have an Advance Directive.

The case that did it for me was a middle aged, end stage neurodegenerative resident whom the GPs wouldn't stop prescribing antibiotics for. They were kept going with PEG feeds, back to back courses of antibiotics and subcut hyoscine to dry their chest out. They were in constant pain, nauseous and full of thrush. Invasive suctioning every hour or so. Eventually, they couldn't tolerate the PEG feeds and basically starved to death over the course of five weeks, developing pressure damage as they lost weight. All because a pathetic, gutless GP was covering their arse by prescribing all these antibiotics. They could easily have contacted the hospital consultant and stopped it all. I did all I could to stop it happening, but they weren't interested. It left me with tremendous guilt and I couldn't go on. I'd never been involved in anything so horrendous in all my career.

Did you speak to the family and discuss all the pros and cons with them? Did you understand their and the patients express wishes. Do you pay many thousands a year to your defense union because you know "no blame no gain". Did you shoulder all the responsibilities and knowledge of management and prescribing? Until so how dare you act like you know what it's like to be in that position. I will also guess this was some time ago. Care home medicine has changed hugely over the last 10 years!

I use to work in adult social care and have worked with dementia residents and adults with LD. I left 7 weeks ago its absolutely dire. No support low wages very long hours, constant calls and messages to ask if you can come in on days off..Endless training. I've been attacked many times at work I've been spat at and the most recent was hit by a man with challenging behaviour while I was about to give him insulin. He's even put a Friend of mine in hospital twice and nothing is done by management who sit in the office doing nothing and not supporting staff.
I've made a report and went straight to the ceo of the company and said this has got to stop and staff need support and not the door shut on there face. The wages are dire and government don't give a dam. I'm glad I'm out of it and never going back.

It was four years ago and there was no family.

What the GPs do is totally inexcusable, I don't give a damn about how much litigation insurance they have to pay. A letter to the hospital consultant costs nothing but a little time.

What does community care have to do with the consultant?? We don't work for them you know? You have no idea what you are talking about. Some of us are still here trying to improve things for this group of patients. Your disdain is aimed in wrong place.

Um, the neurodegenerative patient can be referred to the neurologist for management. Or perhaps a palliative care consultant.

A GP who doesn't give a damn about providing appropriate palliative care and management to a dying patient deserves all the condemnation out there. I'm glad I don't have to witness this lazy, half witted behaviour any longer.

I'm sure they are very glad they don't have to deal with your appalling lack of professionalism and teamwork. Good riddance.

@memorial GPs need to be having conversations with family, the nursing home and the consultant to ensure the persons needs and best interests are met. In this case it sounds like they weren't.

I will fight for care home residents all that long, but there are many GPs who for some reason keep on prescribing rather than open the discussions for proper palliative care.

stbrandonsboat. Sorry to hear about your experience. It sounds horrendous. I hope that you are working and in a better place now.

I'm sure they are very glad they don't have to deal with your appalling lack of professionalism and teamwork. Good riddance

Were you the gp in this instance? I can think of no other reason for your bizarrely aggressive responses. Defending the indefensible.

Who's saying 90 year olds aren't mentally sharp enough to drive? My father stopped driving at 90, but he had Parkinson's. If he hadn't, I am sure he would have gone on longer.

I think we are led into thinking that every elderly person has dementia. They don't. Many are mentally sharp. I've been in the car with my mum's friend and I can assure you his reaction times are better than some much younger people's.

Agree @stbrandonsboat ..our GP attached to our care home listens to the residents,their families and the staff . Cannot speak highly enough where this practice are concerned! Mutual respect from all the team and family is the way forward and definitely works in the best interests of the residents.

I've not read all these posts - much of it is at odds with my experience via my mother in seven Surrey care homes. Many of them, it seemed they couldn't wait to get rid of her - via dehydration, a variation of the then illegal Liverpool Care Pathway. Seemed she'd been placed on end-of-life care without the family's permission, so we couldn't figure out why we had to attend daily at the care home to give her drink while all appeals fell on deaf ears.

She'd been put on the free NHS Continuing Care Pathway scheme and put in a Reigate care home. When that was initiated, from then on we couldn't get anyone to give her drink, it became very odd. We were allowed to, but not the staff. Then they tried to have us barred too!

Completely at odds with the OP's experience though I don't say that to invalidate it. Basically, one is dealing with the State and the State is nuts. It will do the opposite of what any family wants, it seems to me, because that is the only way it can demonstrate its power.

Social Services wholly complicit of course, and go after and harass any family that raises legitimate concerns. MPs too cowardly to intervene.

@2023forme

Hi so I talked earlier about what your statutory responsibilities are

It's not insulated to have 4 staff in overnight shift with one nurse. It is unusual to have only one registered nurse on during day shifts for 32 NH (nursing home) residents of which you describe as high dependency 30 with feeding and 30 with double up care ie mobility and pressure sore risk. I would question you providers dependency assessments

Please don't work for asda, we need good nursing staff

I'm sorry if you think anything I said was unhelpful, I was trying to give you a social work perspective as we rely on whistleblowers , family's , reviews and inspections to flag up poor practice and unsafe care homes.

If you think you're inadequately staffed for the needs your residents have , then there will no worries neglect occurring and we find it, it's in the charts and obvious when charts have been falsified. I just wanted to come in here to say that I know so many wonderful nursing homes and residential care homes, that I feel very frustrated when people accept poor practice and poor service.

If there's not enough staff then people will be being neglected - you just need to whistleblow how.

I wouldn't stay at a carehome i whistleblew at because of I don't think it's a good home with good leadership, I wouldn't want to be associated with it or have my PIN put at risk.

Unusual not insulated - sorry!! Mistype