What can you do when they refuse to get out of bed and mobilise?

[BB49]

FIL is currently in a rehab hospital after a fall a few weeks ago when he fractured a few ribs. He is in no pain from that now and the hospital is trying to encourage him to do physiotherapy and move around using a walker and support, as well as sit in a chair for short periods, but he is pretty much refusing to do anything. He is meant to be discharged soon to go back home with carer support, but as he is barely walking and cannot get out of bed or a chair unaided I am not sure how this is going to go? He is more than likely going to fall again when back home.

He keeps saying he is most comfortable in bed. He sleeps a huge amount and we can't really reason with him very well to try and move around to strengthen his body as there is some short term memory loss.

You say he has short term memory problems, he's 88, it's likely he has some form of dementia. That means that he will tend to say 'yes' to whoever is asking. So if the nurse suggested a care home he'd say yes; if you suggest going back home, he'd say yes. He probably wouldn't remember either of these conversations afterwards. He has no concept of the practicalities, and it sounds impractical for him to go home with carer visits.

So the person with POA has to make the decision as to what is best for him. One option is to arrange for a few weeks' respite in a care home. Most care homes offer this. They will have all the kit he needs - wheelchair, hoists, hospital bed. And carers on tap to help him 24/7.

He may recover enough to return home after a few weeks. But more likely he'll end up staying. Is there a social worker involved? Or will he be self funding his own care?

I do know of someone who in a similar situation (after a fall without major injury) at a similar age just decided she was done with walking and opted for a care home (self funding). She was quite sure in her mind that was what she wanted and her family facilitated it - it's her money after all. No question about capacity , everyone agreed she had it. It was her active decision.

I do think sometimes people can eventuallly get to a point where they just can't be bothered any more

Pads and changed in bed.

catheters increase the risk if CAUTI and are not recommended for convenience

Hospital should use HOUDINI to decide

District nurses have criteria to meet for hospital bed - in this situation it would be social services that would provide the bed

@BB49 are you resistant to the idea of him going into a care home? What's his financial situation? It sounds like you could suggest anything and he will agree without too much argument.

FIL talked a lot about wanting to be 'looked after' when he came out of hospital. He meant a care home - either that or SIL visiting every day, at least 2-3 times a day. Or taking him to live with her. He basically didn't want to have to do everything for himself any more. He saw MIL being cared for 24/7 in her care home and that's what he wanted - being lifted and laid and brought a cup of tea and cake three times a day.

But he was mobile, didn't have any fractures to recover from and was only in the very early stages of dementia. He went home with carers 3X per day. It's been bumpy, but he no longer wants to go to a care home with quite the same conviction.

Realistically, if he wants to go home, he needs to engage with mobilising and toileting progress.

If he doesn’t, and he wants to go to a care home hes going the right way in not.

@rickyrickygrimes I just didn't think he was quite at the stage of needing a care home. It feels like he has given up. He will need to pay for his care himself. I suppose we will see how the discharge meeting goes next week.

If he goes to a care home we will obviously need a few days to get it sorted. If he goes home we will need the same. I am hoping the rehab hospital won't just boot him out.

He is 88, struggling with mobility and has had a fall. He may have a given up, maybe his decision or maybe his body’s or a bit of both. If you haven’t been around some one in the last years of life before it can come as a shock but sleeping lots and staging in bed all of the time is one of the first signs of being in the last year/s of life.

When I am 88 (or earlier) I fully intend be be put in a care home. I have told my family this, so they don't worry about it when the time comes.

Why are you so resistant to him being looked after in a care home OP?

Also, do you have a Health & Welfare LPA for him?

I think it's quite common to be in denial about the need for a care home, it seems such a final step. I felt the same when I moved my mother to a care home but actually she loved it and was happy there for several years.

Realistically, he isn't mobile. He will have to wear incontinence pads, or be helped to a bedside commode. So he needs a carer nearby at short notice. If he's at home and soils a pad 10 minutes after a carer leaves, he will be sitting in that for hours until the next carer arrives.

Even if you don't think he needs permanent residential care, what is the harm in moving him there for respite/rehab for a few weeks and seeing how he gets on? He may love it, it may become obvious it's the right thing. But there is no rule he can't then go home if able to.

I would look at options. I found my mother's care home on

https://www.carehome.co.uk/

The manager will come to hospital to assess his needs. He will be far more comfortable in a care home than in hospital.

Ask if the hospital do discharge to assess - this would mean the NHS/social care would fund a few weeks in a care home to help you all decide if that is where he needs to be long term or if he has the potential to return home.

I had similar with a friend of mine. He is now completely immobile and needs to be hoisted. Completely self inflicted. He also wears pads, although I don’t belive he’s actually incontint. He just can’t be bothered.

The physio gave up with my aunt because she just wouldn’t try to get out of bed. She had Parkinson's. The hospital discharged her to a care home. She spent the next 3 years in bed before she died.
When someone won’t/can't get out of bed it is better they go into a home otherwise they can end up sitting in their own excrement for hours, especially if one carer is late or doesn’t turn up.

We had the meeting with the discharge lady and physio at the rehab hospital a couple of days ago. They have said that as FIL is refusing mostly to engage with any exercises, walking, and sitting in a chair, preferring to stay in bed 90% of the time, that he would be unsafe to return home with 4 carer visits. They did not think he could manage to get out of bed or a chair to go the few steps to the toilet as he has lost so much mobility and strength. Therefore would be unsafe to be left in a chair for 4 hours in between carer visits. They have advised a residential or nursing home would be best for him. Then we spoke to the ward nurse and apparently he is now doubly incontinent (the hospital had put a catheter in when he arrived as there weren't the staff available to help him to the toilet) and now he is also fecally incontinent as well? Neither of which he was before he went into hospital 3 weeks ago!

It just seems like such a quick deterioration. Medically there are no real problems apart from the chronic ones of arthritis and mild heart failure. The ribs are healing from the fall and he is not in pain from them.

I guess my question now is - we have a residential home in mind (with a spiritual connection as that is his background). Will he require more of a nursing home given this new incontinence issue? Or can a residential home manage it? I know this is a question for the home itself when they do the assessment.

The home you have in mind will do their own assessment.

The home will do the assessment. TBH, if it is not a nursing home, I doubt they will accept him.

There’s nothing you can really do. I’ve been here. My family member wasn’t interested in any small amount of recovery they could have.

My relative was just done, she wanted to be gone. She didn’t want to do rehab or physio, just to continue to deteriorate and age. I didn’t blame her tbh, it would
only have been another couple years of pain and struggle and indignity.

She wanted a few sherries a day and to watch films, so that’s what we did. I respected her for it, I might do the same tbh.

If he won’t move, it’s not a surprise that he’s become doubly incontinent. Your bowels more so that your bladder need movement to function properly.

Sounds like talking to the home you’ve got in mind is the next step and see what their assessment says. That level of need won’t be something that all would accept.

A residential home can look after double incontinence but like pp says they will do their own assessment. I don't think they would have put a catheter in due to lack of staff, did they tell you that was the reason. They can try a convenient sheath which runs into a bag. Have they asked him if he knows when he needs the toilet.

Toileting is not a medical issue. Unless he has a medical condition that needs nursing care, a residential home should be fine for him. As PoA you have to make the decision based on what best meets their needs. It does sound like a home would be more suitable at this point.

You don't need to view it as a permanent move. My parent went into a care home whilst I had a break and it was a revelation. Whilst there, they got their zest back and really enjoyed it. Why not try the home you have in mind for 6-8 weeks so they have time to settle and then go from there?

I just feel so despairing that he went in to hospital fully continent and now is going to be discharged doubly incontinent and barely mobile. What is going on with the NHS?!

I know it’s frustrating, but on this point I don’t think the NHS can be at fault. The trauma of the fall and the hospital admission itself can precipitate a steep decline in condition of elderly folk. It’s shocking just how precarious our health is once we get to a certain age. One day you’re living your live happy and independent and one medical incident later you’re frail and dependent. With my dad it was a small stroke that set him on the slope - when I went to see him in hospital he was sitting in the chair next to the bed and it was shocking to see how tiny and frail he looked compared to the previous week when he was pottering around the garden and making bacon sandwiches for me.

He went into hospital after an issue.

He gets to decide how he responds to that. From what you’ve said it’s not that rehabilitation support isn’t being offered. You've said that physios and OTs have tried to engage with him and he’s not interested.

Some of the deterioration is a result of the original issue. A lot is how interested or otherwise he is in rehabilitation. It’s really tough to watch, but he gets to chose. Same as we get to choose whether we spend our evenings on the sofa, feet up watching tv or at the gym.

It sounds like he has given up which isn’t the NHSs fault 🤷‍♀️

If he isn’t mobilising and is doubly incontinent I’d think a NH would be more suitable.

Have there been end of life conversations had with him? Has he got a TEP form to make sure his wishes are considered if he does die?

this doesn't sound like anything to do with the state of the NHS. It sounds more like a not unpredictable result of a really serious injury. Older folk are much less likely to have the physiological reserve to recover well from this sort of injury and if he's decided that he doesn't have the energy to engage with rehab that's entirely his choice - you can't prevent many of the sequelae of the injury now but can support him in being comfortable and receiving the care he does want. It's not at all uncommon for older folk to be using every bit of energy and all the physiology they have just to live at their normal pace - when a big injury happens they often just don't have enough spare cells or energy to recover back to their previous normal, whereas someone 20/30/40 yrs younger will have more reserve and ability to recover (and perhaps a little more incentive to use their energy for rehab). It's also not that unusual for families to be a little bit in denial about how quickly the wheels can fall off and the limitations of geriatric physiology and blame the NHS for not being able to restore their relatives back to their pre-injury state.