This is a fictitious case that has been designed for educative purposes.

Social work report

Mrs Beryl Brown URN102030
20 Hume Road, Melbourne, 3000
DOB: 01/11/30

Date of application: 20 August 2016

Background

Mrs Beryl Brown (01/11/30) is an 85 year old woman who was admitted to the Hume Hospital by ambulance after being found by her youngest daughter lying in front of her toilet. Her daughter estimates that she may have been on the ground overnight. On admission, Mrs Brown was diagnosed with a right sided stroke, which has left her with moderate weakness in her left arm and leg. A diagnosis of vascular dementia was also made, which is overlaid on a pre-existing diagnosis of Alzheimer’s disease (2013). Please refer to the attached medical report for further details.

Social history

I understand that Mrs Brown has been residing in her own home, a two story terrace house, in Melbourne for almost 60 years. She has lived alone since her husband died two years ago following a cardiac arrest. She has two daughters. The youngest daughter Jean has lived with her for the past year, after she lost her job. The eldest daughter Catherine lives on the Gold Coast with her family. Mrs Brown is a retired school teacher and she and both daughters describe her as a very private woman who has never enjoyed having visitors in her home. Mrs Brown took much encouragement to accept cleaning and shopping assistance once a week after her most recent admission; however, she does not agree to increase service provision. Jean has Enduring Power of Attorney (EPOA) Financial paperwork that indicates that Mrs Brown appointed her under an EPOA Financial two years ago. She does not appear to have initiated an Enduring Power of Guardianship (prior to September 2015) or an Enduring Power of Attorney (medical treatment).

I also understand from conversations with her daughters that Jean and Mrs Brown have always been very close and that there is a history of long-standing conflict between Catherine and Jean. This was exacerbated by the death of their father. Both daughters state they understand the impact of the stroke on their mother’s physical and cognitive functioning, but they do not agree on a discharge destination. Mrs Brown lacks insight into her care needs and says she will be fine once she gets back into her own home. Repeated attempts to discuss options with all parties in the same room have not resulted in a decision that is agreeable to all parties.

Current function

Mrs Brown has a history of Alzheimer’s disease; type II diabetes – insulin dependent; hypertension; high cholesterol and osteoarthritis. She has had two recent admissions to hospital for a urinary tract infection and a fall in the context of low blood sugars. She is currently requiring one to two people to assist her into and out of bed and one person with managing tasks associated with post-toilet hygiene. She can walk slowly for short distances with a four-wheel frame with one person to supervise. She benefits from prompting to use her frame; she needs someone to cut her food and to set her up to eat and drink regularly and to manage her medication routine. She requires one person to assist her to manage her insulin twice daily.

The team believe that Mrs Browns’ capacity for functional improvement has plateaued in the last ten days. They recommend that it is in her best interests to be discharged to a residential care setting due to her need for one to two people to provide assistance with the core tasks associated with daily living. Mrs Brown is adamant that she wants to return home to live with Jean who she states can look after her. Jean, who has a history of chronic back pain, has required several admissions to hospital over the past five years, and states she wants to be able to care for her mother at home. Jean states she is reluctant to agree to extra services as her mother would not want this. Her sister Catherine is concerned that Jean has not been coping and states that given this is the third admission to hospital in a period of few months, believes it is now time for her mother to enter residential care. Catherine states that she is very opposed to her mother being discharged home.

The current risks

Mrs Brown is at high risk of experiencing falls. She has reduced awareness of the left side of her body and her ability to plan and process information has been affected by her stroke.  She is now requiring one to two people to assist with all her tasks of daily living and she lacks insight into these deficits. Mrs Brown is also at risk of further significant functional decline which may exacerbate Jean’s back pain. Jean has stated she is very worried about where she will live if her mother is to enter residential care.

Attempts to trial least restrictive options

We have convened two family meetings with Mrs Brown, both her daughters and several members of the multi-disciplinary team. The outcome of the first meeting saw all parties agree for the ward to provide personalised carer training to Jean with the aim of trialling a discharge home. During this training Jean reported significant pain when transferring her mother from the bed and stated she would prefer to leave her mother in bed until she was well enough to get out with less support. 

The team provided education to both Jean and Catherine about the progressive impact of their mother’s multiple conditions on her functioning. The occupational therapist completed a home visit and recommended that the downstairs shower be modified so that a commode can be placed in it safely and the existing dining room be converted into a bedroom for Mrs Brown. Mrs Brown stated she would not pay for these modifications and Jean stated she did not wish to go against her mother’s wishes. The team encouraged Mrs Brown to consider developing a back-up plan and explore residential care options close to her home so that Jean could visit often if the discharge home failed. Mrs Brown and Jean refused to consent to proceed with an Aged Care Assessment that would enable Catherine to waitlist her mother’s name at suitable aged care facilities. We proceeded with organising a trial overnight visit. Unfortunately this visit was not successful as Jean and Catherine, who remained in Melbourne to provide assistance, found it very difficult to provide care without the use of an accessible bathroom. Mrs Brown remains adamant that she will remain at home. The team is continuing to work with the family to maximise Mrs Brown’s independence but they believe that it is unlikely this will improve. I have spent time with Jean to explore her adjustment to the situation, provided her with information on community support services and residential care services. I have provided her with information on the Transition Care Program which can assist families to work through all the logistics. I have provided her with more information on where she could access further counselling to explore her concerns. I have sought advice on the process and legislative requirements from the Office of the Public Advocate’s Advice Service. I discussed this process with the treating team and we decided that it was time to lodge an application for guardianship to VCAT.

Recommendation

The treating team believe they have exhausted all least restrictive alternatives and that a guardianship order is required to make a decision on Mrs Brown’s discharge destination and access to services. The team recommend that the Public Advocate be appointed as Mrs Brown’s guardian of last resort. We believe that this is the most suitable arrangement as her daughters are not in agreement about what is in their mother’s best interests.  We also believe that there is a potential conflict of interest as Jean has expressed significant concern that her mother’s relocation to residential care will have an impact on her own living arrangements.

Medical report

Mrs Beryl Brown URN102030
20 Hume Road, Melbourne, 3000
DOB: 01/11/30

Background information

Mrs Brown’s medical history includes Alzheimer’s disease; type II diabetes; hypertension; high cholesterol and osteoarthritis. She was admitted to Hume Hospital on 3 March 2016 following a stroke that resulted in moderate left arm and leg weakness. This admission was the third hospital admission in the past year. Other admissions have been for a urinary tract infection, and a fall in the context hypoglycaemia (low blood sugars), both of which were complicated by episodes of delirium.

She was transferred to the subacute site under my care, a week post her admission, for slow-stream rehabilitation, cognitive assessment and discharge planning.

Mrs Brown was diagnosed with Alzheimer’s disease by Dr Joanne Winters, Geriatrician, in April 2013. At that time, Mrs Brown scored 21/30 on the Standardised Mini-Mental State Examination (SMMSE). During this admission, Mrs Brown scored 15/30. I have undertaken cognitive assessment and agree with the diagnosis; further cognitive decline has occurred in the context of the recent stroke. There are global cognitive deficits, but primarily affecting memory, attention and executive function (planning, problem solving, mental flexibility and abstract reasoning). The most recent CT-Brain scan shows generalised atrophy along with evidence of the new stroke affecting the right frontal lobe. My assessments suggest moderate to severe mixed Alzheimer’s and vascular dementia.

Financial and legal affairs

While able to recall some key aspects of her financial affairs, including the general monetary value of her pension and regular expenses, Mrs Brown was unable to account for recent expenditure (for repairs to her home) or provide an estimate of its value, and had difficulty describing her investments. In addition, I consider that she would be unable to make complex financial decisions due to her level of cognitive impairment. Accordingly, I am of the view that Mrs Brown now lacks capacity to make financial decisions.

Mrs Brown states that she previously made an Enduring Power of Attorney (EPOA) but could no longer recall aspects of the EPOA, such as when it would commence and the nature of the attorney’s powers. Moreover, she confused the EPOA with her will. Her understanding of these matters did not improve with education, and therefore I consider that she no longer has capacity to execute or revoke an EPOA.

General living circumstances

Mrs Brown acknowledges that she needs some assistance but lacks insight into the type of assistance that she requires, apart from home help for cleaning and shopping. She does not appreciate her risk of falling. She is unable to get in and out of bed without at least one person assisting her. She frequently forgets to use her gait aid when mobilising and is not able to describe how she would seek help in the event of falling. She is not able to identify or describe how she would manage her blood sugar levels and this has not improved with education. Accordingly, I consider that she lacks capacity to make decisions about accommodation arrangements and services.

Mrs Brown does not agree with the treating team’s recommendation to move into residential care and maintains her preference to return home. This is in spite of a failed overnight trial at home with both her daughters assisting her. Unfortunately she was unable to get out of bed to get to the toilet and required two people to assist her to do so in the morning. In light of these matters, and in the context of family disagreement regarding the matter, the team recommends that the Office of the Public Advocate be appointed as a guardian of last resort.