Dols

[hjor20]

Advice please.
Elderly grandparent in hospital. Deemed medically fit but unsafe for discharge due to needing carers x4 a day. Admitted 2 weeks ago for chest infection and vomiting blood. During this admission no investigations have been done to identify route course of the bleeding.
Social worker, physio and OT now demanding best interest meeting due to her not engaging in physio and refusing hospital bed and carers. She's accepted and agreed to full care and hospital bed, she just isn't happy about physio in the hospital due to having torn tendons in feet and in a lot of pain, and the fact she is blind. Happy for physio to attend at home in a familiar safe environment.

I feel like they're not listening to my grandmothers wishes and pushing for best interest meeting so they can put a DoLs in place. They have mentioned dols a few times.

What can I do? The nurse yesterday offered to get her a book to read because she's that bored- she's blind for god sake!

Where has patient centred care gone??

Isn't that a good thing to put a Dols in place
That would mean she has someone fighting her corner
Has anyone got POA

Thanks. I've actually probably got my knickers in a. Twist about this 🤦🏻‍♀️
She's agreed to respite whilst carers are put in place and hospital bed organised etc. I just don't understand the need to do these meetings if she's consenting to the original plan?
The biggest thing to me is to wait until she's home for physio assessment. Due to her sight loss and being in an unfamiliar environment whilst in pain with her feet

Has a capacity assessment been completed? Best interest meeting would happen if capacity lacking.

ask for copy of capacity assessment and if one not done then in law capacity is always assumed so grandmothers wishes followed.

does anyone have power of attorney?

Yes doctors have completed capacity assessment and she's deemed to have capacity. It's the nurses and physio contesting it.

No unfortunately no POA of health, only finance.

She's always been very awkward and doesn't accept other people's opinions, but I truly believe it's her personality.

If the doctors have deemed her to have capacity then they cannot put her on a DOL ..they also can't have a 'best interests' decision if she's deemed to have mental capacity. Your GM is free to leave hospital and refuse the physio if she so pleases.Please advocate for her -just because someones old doesn't mean decisions can or should be taken away .

Thank you. I feel way out of depth right now but want to go armed with facts.
I just want her home and then we can work on physio etc when she's in her own surrounding. I don't think they're respecting the fact she's blind either and expecting her to do all sorts.

I am a best interest assessor and complete DoLS assessments. The other posters are correct that she needs to have been formally assessed as lacking mental capacity for a bi meeting to take place and they cannot apply for a DoLS.

She might benefit from a hospital physio assessment so they can put any adaptations or equipment at home, waiting for a home assessment just delays things. Her foot pain will be the same in hospital or at home, the doctors and physio should help with footwear, equipment, exercises and pain control. The won't work her hard, probably just assess her getting in and out of bed and chair, weight bearing and balance, once home she may refuse a community physio which may concern them. Did she have carers before she went into hospital. If she initially refused carers, hospital bed and physio and has now changed her mind they might worry she'll change her mind again but if she's got capacity and understands the risks she shouldn't need a dols. Are they insisting or suggesting a meeting, maybe they just want joined up care so everyone including nan are in agreement. If she's a big difficult is there a chance she'll refuse everything again and blame the hospital.

What are they expecting her to do, how was she managing before.

She had carers morning and evening before being admitted, and she's agreed to 4 calls a day. She lives with my auntie who does everything except personal care. Her bedroom is downstairs, she's agreed to a hospital bed with a view that she will try and get some mobility back to transfer to commode and onto sofa. She was walking up until 4 weeks ago.
They say she's making unwise decisions but she's agreed to everything except to engaging with physio in hospital. But they're just not listening to her when she's got pain in her feet and want her to try stand, when she cannot see and does not feel safe.

They're insisting on a meeting but nothing seems to be happening. A meeting was suggested Wednesday when she was medically fit for discharge, but nothing planned as of yet.
I'm probably being impatient but when she's ringing every evening crying she wants to be back home, it's heart breaking.the doctors have told her she can go home, and she's clinging onto that.

You could argue that the unwise decision that they deem she is making is not unwise to her and they are being judgemental.

Health are known for being risk aversive.

Poor thing, how did she tear her tendons if she was walking 4 weeks ago, is she having any treatment or ssurgery.they can't force her to have physio but it may be safer in hospital because they may have 2 staff with her but it's entirely her choice, if they don't know if she can stand or not when she goes home they will have to assess for a hoist or standing aid, what sort of respite are they offering,

Thank you, this is what I believe, they're not listening to how she feels.

What is the specific decision that they're contesting the capacity? Having physio? A hospital bed?

She fell in may last year and they passed it off as a sprained ankle, she then developed gout so her mobility deteriorated, which caused a few more falls. She had an mri on her feet in December and only just has got the results this week in hospital after pestering them.
When I say she was mobilising 4 weeks ago, it was literally 4/5 steps with a walking frame from her bed to sofa. But she was managing it.

She needs to be assessed by physio in hospital to see what she's able to do. That's what they're saying

Doesn't surprise me. I always think of the quote from Mumby about what is the point of making someone safe it is makes them miserable. If she has capacity they have no jurisdiction to keep her there and could be seen as unlawful.

Ok so the doctors feel she has capacity to make the decision regarding physio but the nurses and physios think she doesn't.

If a best interest meeting does happen make sure you are able to go and remind them that even if they make a decision in her best interest it needs to be the least restrictive. They shouldn't be forcing a physio assessment on her at all, capacity or not. That can be done in the community if needed.

I would ask the physio or nurse who completed the capacity assessment to explain which area they felt made her lack capacity (understanding, retention, weighing up or communicating). I'd bed they didn't do one at all.

It sounds like she's had mobility problems for a while now and frequent falls so they might just be trying to assess and minimise the risks, the doctors may have also said fit for discharge when therapists happy. If she can't walk at all now then 4 carers a day might not be enough, what about overnight care with continence, change of position, pressure area care too. They can't keep her in hospital if she wants to go home but advise against it. I have known patients being taken home by ambulance then the community therapists either go with them or a few hours later which might be an option.

She can move around in her bed, has great upper body strength and can lift her legs, she just cannot bear weight through her feet because of the pain in them.

She just rang crying that it's affecting her mental health, doctor tells her she can go home and nurses say otherwise 🤦🏻‍♀️

Oh dear, if she can't weight bear she'll be bedbound without the use of some form of hoist which may need more organising at home than just a hospital bed, maybe that's what they need to assess and confirm so she gets the right care and equipment put in place. The doctors also need to try and help with decent painkillers, the community nurses will have to monitor that. It sounds like she'll need more than just 4 short visits a day, she'll need continence care, pressure care, it can all be organised. You can contact pals on her behalf who can visit her on the ward and also the doctor who deemed her medically fit. I imagine though the doctor isn't interested in potentially unsafe discharges and will hand it back to the nurses and therapists. What treatment is she getting for the torn tendon.

the most helpful thing you can do here is to tell her she needs to chip on and have the physio assessment done in hospital. without it any care planning will be on incomplete information and probably not right for her.

Really can understand your frustration, especially when your grandparent is able to express their wishes. Agree with other posts that pain control is a must and if someone has capacity they can make decisions even if deemed unwise.
Physio’s are not all about standing and causing pain. Physios and occupational therapists will assess and try and optimise what a person can/ can’t do as part of identifying care needs at home.
it is not uncommon for people to think they will be fine at home when they have been in bed with 24hour ward care.
Physio’s can make a difference between fully bed bound ( weeing and pooing in bed, risk of bed sores, being flat with increased risk of chest infections ) and being able to stand and step with a zimmer frame or standing transferring aid (to get into a commode or chair/ help with dressing lower half.).Hoists can be an option but there needs to be suitable space for them and need 2 carers and planning.
Yes- there can be risk aversion but often they are trying to avert a crisis once someone has gone home ( who has underestimated what going home bed bound means in reality).
Older people who spend long periods of time in bed loose their strength very quickly and sometimes may not fully recover.
I would suggest you/ next of kin attend any discharge/ best interests meeting so you can understanding any concerns there are but also so you can be an advocate for your relatives.
Many many times when ability is reduced and dependency increases, and when people are discharged home with some carers (but with large gaps during the day), it falls to family/ friends to increase their support. This has to be considered and not underestimated.