Can I refuse Mum's discharge from Hospital

[LadyShmuck]

I was going to NC but I'm so tired I can't work out how to, so if you know me, hi!

Background to this issue.
Mum is 71 with undiagnosed dementia which has deteriorated rapidly over the last 2 years and she is now doubly incontinent, unable to care for herself, cannot communicate in any meaningful way and needs 24/7 supervision. She lives with my dad who can't walk and has significant mobility issues. He cannot meet her care needs at this point in my opinion. Up to now they have refused to get carers, instead stumbling from one issue to the next with frequent propping up by me and my siblings.

Over the past 3 days she has had 2 falls (collapses? Can't be sure) and also it has become apparent that she hasn't taken her blood pressure medication and her blood pressure was at 250/118 on Monday night. We have ended up in A&E on all 3 nights, finally this morning a doctor decided to admit her and said that we should expect her to be in for a while for her to be assessed and get things in place so that she can return home safely or go into residential care if that was more appropriate. I left my mum in the Early Assessment Unit at 8am this morning.

Around 12 the hospital called to say they would sort an outpatients physio appointment and for their 'interface' team to assess her with a view to discharging her today. I said this didn't align with what the doctor this morning had said on admission and that I wouldn't support a discharge today on the grounds that she clearly can't be kept safe at home. The nurse I spoke to repeated their plan and given that the call woke me up after being asleep for an hour for the first time in 36 hours I'll admit I wasn't at my sharpest when I took the call.

What can I do here? What should I be asking for, I cannot allow her to go home today, my dad has finally admitted he can't cope and doesn't want her to come home as he can't care for her or keep her safe.

Any wisdom appreciated, I'm panicking at the thought of her coming home today and spending another night with her in A&E to go through all this again.

From my own experience this could just be crossed wires. Hospital discharge Comms often seem DREADFUL.
But yes this is (magic phrase) "unsafe discharge".
Don't suppose you have the names of the doctor, nurse, or ward she's on?

Anyway, try the ward and then, if you get no sense out of them, PALS. Bottom line, anyway, what are they going to do in the face of your Dad not opening the door to them?!

Make sure they are aware that your dad is unable to care due to his own needs and there is zero family backup available. Be blunt, very blunt. Follow up with an email to the discharge team. Don't give any reasons for not being available just say it isn't possible.

Assuming that's the next step are you already looking into residential care homes?
There should be a care plan in place before discharge. Either carers going into the home or a temporary residential home until permanent arrangements are made.
As PP said though, unsafe discharge. You might try the hospital social worker who would normally be involved in a care plan.

You can absolutely refuse an unsafe discharge.

Insist that her needs cannot be met at home as things stand any longer. State that you are not available to manage her care (leave them no chink of light there at all). She needs a full assessment of her needs before even considering a discharge.

Occupational Therapy and Adult Social Services should make a full assessment of your parents and their needs (particularly your mother, but also your father). It should be done before she leaves hospital.

Ask to speak to the vulnerable adult team and explain the situation. Also ask about a package of care and an occupational therapist (OT) home review particularly as your mum is a known falls risk. They may provide some aids for her to use at home. If no one is listening to your concerns, contact PALS.

I would also contact your parents GP with your concerns as it sounds like you need all the support you can get. It may be that carers can be arranged to go in to help both your parents.

I should add, also drum into them in whatever way you can that not only is there no family support available, your father is simply unable to provide any care at all because of his own health issues. Be absolutely blunt there and say that an unsafe discharge will not be accepted.

Insist that any discharge is to an assessment unit that can assess her ongoing needs properly. Accept nothing less.

Unfortunately, these days the only way to get anything you need out of the system you have to tip it into crisis.

My elderly Dad was sent home as an unsafe (and ultimately failed) discharge a couple of years ago. It was traumatic both for him and for everyone else and didn't end well. I will never forget it. Don't allow yourself to be shoved down that route. It is in nobody's best interests.

In similar circumstances (though she lived alone) Adult Services arranged a 'respite' stay in a care home for my MIL. So give social services a call.

Absolutely, get in touch with the ward she is on and explain that your father cannot meet her care needs. They should also have done a falls and frailty assessment.
Can your parents afford respite care while longer term plans are made?

To add, she should also see the continence team and be assessed.

It seem as though they’ve bypassed the discharge team

every time my dad was in it was carer and home assessment to make sure everything was ok and they had any equipment they needed

yes refuse

Sorry it has come to this OP. You can re-iterate that you are unable to meet her care needs at home. Could anything have been done prior to prevent an acute admission? Refusing care? That's not a reason to be in an acute hospital bed unfortunately and people can't stay in an acute hospital until they accept care, is there a community or outlying hospital she could go to for assessment?

@hashbrownsandwich everyone in hospital has a falls assessment, most over 65's are at risk of falls. Simply being a falls risk isn't a reason to stay in hospital, if that was the case most elderly people would be watched day and night.
Continence assessments are done by the ward nurses or community nurses, they often rely on family to help with this as you need to keep a full fluid chart and document when wet/soiled. The continence specialists do not routinely see patients.

Put your foot down and say no, absolutely no way, and insist that the house is not safe for her to go home because there is nobody to care for her there. Tell them over and over again that your father is disabled and barely able to care for himself, let alone an incontinent wife with dementia.

If she has diagnosed dementia, then she does not have the capacity to decide whether or not she has carers coming into her home anyway.

in your situation I would absolutely refuse to accept discharge. Insist it is unsafe, nobody is able to care for her at home. Ask for an urgent referral to the hospital social worker. Repeat that the doctor said she needed proper assessment and that the likely outcome is a full care package or admission to nursing care.

Ask for her to be admitted to the geriatric or gerontology ward at the hospital for a full frailty and dementia assessment so that her needs can be identified and plans can be made.

The ‘undiagnosed’ dementia needs to be diagnosed asap, this should help you get the care your mother needs. I’m amazed you have managed to cope this far, reading the info you have given about your mother’s difficulties.

Thank you so much for all of your help and advice. I've got an urgent referral with adult social services, hospital social team won't take responsibility as she's not officially an admitted patient whilst she's on the assessment unit.

I feel a lot better prepared for the next phone call from the hospital.

@ferociouslychristmas we possibly could have avoided admission, although having carers come in a couple of times a day wouldn't have stopped her falling.
We have managed through the last few years without any hospital visits at all so I'd say we've managed until we've reached a crisis point which is where we are now. Obviously I now wish I'd forced the issue of care or assisted living or all of the other suggestions I've made over the last year but hindsight is 20/20 as they say.

Good luck OP 🤞

Have you spoken to the hospital team again? I wonder if the interface team means they could discharge her home with a temporary care package (normally 6 weeks ish) to assess her needs at home. If so, that would normally mean carers coming in 3/4 times a day to support with personal care, meals, medication etc and then having an assessment of needs at home with a physio / OT / social worker with view to having an agreed care package which would keep her (and your dad) safe.

For older people, especially those who have cognitive issues, being at home with a discharge / assessment care package means that they stay as well as they can as hospital admission often comes with a reduction in mobility / muscle wastage, increased confusion and a higher risk of getting an infection.

It may not mean that at all, but it would be worth asking the question if that's what they meant. There is a big push at the moment to discharge (with care) then assess because outcomes are often better than an extended admission to hospital.

But you also definitely need to make sure that it's clear that your dad cannot support with care and there is also no family support that can help on discharge.

@LadyShmuck it's almost impossible to know when is the best time to intervene.

My SIL really wanted my MIL to be in her home environment for as long as possible, and gave up her job in order to stay with her for half the week (she lived two hours away). She arranged carers coming in four times a day for the rest of the week, and MILs lovely neighbours also kept an eye and would take meals over for her.
It seemed to be working, until MIL was found wandering more than a mile from home, at 5am, by a passing police car. I dread to think what might have happened had they not seen her. They took her straight to the hospital, and it was from there that adult services arranged respite care, which turned into long term care.

We left it too long. But with the best of intentions. I think most of us do.

Hope you manage to get the help you need Op.

Has anyone POA?

I live abroad & remember staff at my Dad's local hospital being incredulous that no, I would not fly in & look after my dad for 2wks so that he could be discharged.

We left it too long. But with the best of intentions. I think most of us do.

I think that can be a "problem" when you are near enough to help.

You step in & gradually take on more & more I should imagine.

Also if the person is resistant to a care home.

Intervening often isn't simple either. MIL needed 24 hour care (profoundly disabled following a stroke) and FIL needed carers himself. It was obvious to everyone that MIL needed to go into a care home but FIL would fly into a venomous rage and even assaulted a couple of people if it was suggested. It's hard to insist when someone is screaming at you how vile you are just inches from your face.
My mother on the other hand smiles benignly, says she doesn't agree and sacks anyone who is engaged.

What is there financial situation? Who if anyone has power of attorney. If nobody has power of attorney and you do not believe she or your father have capacity to refuse care then you need to get from the court of protection the rights to force the situation. If they have funds this means seeking suitable placement, ideally together, otherwise you need to wait for a social services assessment as to what they will fund

Hi everyone,
Luckily my brother and I have power of attorney for health and finance for both Mum and Dad. Dad still has capacity so I'm not sure if we need to intervene yet.

Had a very positive update from hospital this afternoon, occupational health have assessed Mum and said she isn't capable of managing her own feeding, dressing, washing or toileting and they cannot safely release her home so it's a huge, huge relief that someone has seen sense this afternoon. They're arranging an assessment placement at a care home which I'm guessing is just their terminology for temporary/respite. So that gives us some breathing space in terms of getting her a suitable permanent care home. They do have some savings and a house owned outright but we'll need to navigate what we should be paying for etc over the next couple of weeks.

Thank you so much for all of your support today, it's been so valuable to me.

Well another update, my mum is still on the assessment unit but is just waiting for a bed so she can be admitted.

Her temperature was high earlier on and now they suspect she has pneumonia so I'm not sure if I should be preparing myself for the worst. She is on an antibiotic and waiting on chest x ray now.

Thanks for sticking with me.