Care Homes, Coronavirus and Shared Decision Making
Professor Iain Carpenter
Date: May 2020
One afternoon in January this year my very frail 89 year old father-in-law, Bob, fell in his care home room.
I saw him shortly after and was called again at 10pm to be told that he had been taken to hospital. I went straight to the hospital emergency department, where patients filled the beds, the waiting room and trolleys, crammed into the corridors. With the Emergency Medicine Physician, I asked Bob if he would like to go back to the care home – of course he said yes, so we went, arriving back at 11.15pm. His admission had been inappropriate. It brought to mind a quote from David Oliver, recent RCP Vice President : ‘’Few doctors working in acute medicine get through an on-take shift without seeing patients brought by ambulance from care homes. If it’s distressing for us to witness, it’s much more so for them.” (David Oliver in the BMJ).
The paramedics had followed their protocols based on NICE guidance. They hadn’t asked him if he wanted to be taken to hospital.
The Care Home context
The rationale for admission, was that he had hit his head and might be suffering from intracranial bleeding, a diagnosis that requires a CT head scan. However very frail very old people do very badly if they are treated aggressively in this situation. Had he been in hospital, he would have been observed overnight and the situation reviewed in the morning. Was there any reason why he couldn’t have been kept under observation in the care home and reviewed in the morning, by the GP if necessary?
So what does this story have to do with Coronavirus? There has been a lot of discussion about people’s wishes for their care during the pandemic, and differences of opinion about whether frail elderly people at the end of life should be admitted to hospital with coronavirus or made comfortable in their own room in a care home. We need to ensure that everyone feels safe, secure and comfortable with equal access to good care and that care reflects a person’s health, needs and wishes.
The issues here are about consent, now called shared decision making, the context in which the paramedics’ protocols and NICE guidance were being applied and finally the degree to which care homes are properly resourced to do the work that is demanded of them, by their residents and their relatives.
Shared decision making
The Supreme Court Montgomery Judgement clarified the importance of giving appropriate recognition to patients as decision makers . Bob should have been asked whether he wanted to go to hospital. There should have been no assumption that he would be unable to consent without a formal assessment of competence. And what of the older people with COVID-19? What was their choice, did they have one?
- Unless they want to be, very frail elderly people should not be put through the trauma of admission to a highly pressurised environment, especially when there is little chance of benefit.
- Care homes should be properly funded and social care workers should be recognised as the skilled professionals they are who do a vital job in the community for our most vulnerable members of society. It should be a matter of national shame that successive governments and the public have failed to value care of the elderly and vulnerable sufficiently to support increased funding and professional esteem for care homes and community care.
- Care plans and good information sharing should be accessible to everyone involved in a person’s care. That is why the PRSB has developed the digital care and support plan for people to manage long-term conditions with greater control. They are also currently working on developing standards for information sharing between social care and health. Ultimately better and more joined up services will enable people to get more personalised services.
- Whatever the situation, decisions about care must always be a decision shared by the patient (or their proxy) and the attending properly informed care professional.
 The PRSB are developing an evidence and consensus based care record standard for informing and supporting support shared decision making