The talk I gave at the Alzheimer’s Show is available to listen to via their website but you need to pay (price includes all other talks) so for those who’d like instead to read what I had to say I have tidied up my scribbled notes and added the slides…
Hello everyone, thanks for joining me this afternoon. My name is Zoe Harris and I’m the founder of My Care Matters, a not-for-profit social enterprise with a mission to improve people’s experience of care in all care settings.
The project I am going to talk about today is our My Future Care service, supporting people to make plans for their later and end of life. I’d like to start by giving a bit of background as to how it came into being.
The inspiration for this work was my late husband Geoff who lived with dementia. I cared for Geoff for about 5 years until he had to move to a care home for what turned out to be the final 13 months of his life. During that time I saw how mistakes would happen because the people caring for him knew nothing about his needs and preferences, the things that mattered to him.
So I developed a wall chart, that went on to be called the Remember-I’m-Me Care Chart, to share the things that I knew Geoff would have talked about if he’d been able. All I was trying to do was help busy carers support Geoff, and to help them develop a relationship with him which would be impossible if they knew nothing about him. But when the care home manager saw that first chart and asked for some more for her other residents, and I realised this simple tool had the potential to help thousands of other people in a similar position to Geoff, unable to communicate and being cared for by people unaware of their needs and preferences.
Long story short, variations of that original chart have gone on to be adopted by over 1,400 care homes throughout the UK.
It also attracted the interest of hospitals but as much as I could see how vital it was to ensure a person’s needs and preferences were available to hospital staff, we needed to find a way to ensure that it was available immediately, not just when family members came in to provide the information to go on the chart.
So we developed an online tool, the Mycarematters Profile, where people can input information about themselves, or on behalf of someone they care for, and make it available to anyone with their unique Mycarematters code, name and date of birth. The reality is that printing it out has the best chance of it being seen for now, but at least if that goes missing the information can be viewed online and can of course be reprinted, also updated or amended whenever necessary.
We were trialling that concept with an NHS Trust in Cambridgeshire where they were also looking in to how to increase the number of patients with advance care plans and wanting to understand why those conversations weren’t happening. Because the two projects were running at the same time, it soon became clear that inviting someone to complete a Mycarematters Profile also helped kickstart the conversation about advance care planning. It also demonstrated that making plans for the future should not just be about preparing to die well but also how to live well. One of the questions on the Mycarematters Profile is about pets. Not knowing whether their pet is being looked after is one of the most frequent sources of stress for people who are in hospital. So it is an opportunity to ask people what plans they have in place to ensure pets are cared for during their stay in hospital. This can expand into a conversation about the other practical issues that need to be considered, for example in an emergency when the person is unable to communicate. Another question asks about the important people in a person’s life. So that is an opportunity to ask whether they might like one of those people to speak on their behalf, again if they are no longer able to communicate. In other words, would they be a suitable person to take on power of attorney.
But why does any of that matter? As one person said, when enquiring about the My Future Care service: I can just let my family decide about all those things. But is that fair? One of the most frequent reasons people come to us for support to make their later life and end of life plans is because they’ve been put in that position by family members being expected to make decisions on their behalf, when they felt unprepared to do so, even if they have power of attorney, and they don’t want to leave their family members in that position when the time comes.
That was confirmed by research done around advance Decisions. An advance decision, full name Advance Decision to Refuse Treatment, is a legal document setting out the treatments you would not want in certain circumstances. Even if decisions have been made, they may not have been discussed with family members. Plus this concentrates on a very narrow set of questions about the circumstances in which a person might choose to refuse treatment, when a much wider conversation is needed. We need to ensure that our family members know what our wishes are, even if that conversation can be a challenging one for some or all of those involved.
So it matters because we don’t want to increase the stress our family members are already under when we are unwell. And it also matters because it can give the individual some sense of control over their future and therefore lead to improved mental wellbeing. That is something we measured when evaluating the My Future Care Service, and I’ll say a bit more about that in a minute.
But first, when is the right time to start having these conversations? There is a saying, that it is always too soon, until it’s too late. We always think we have time to sort things out, until suddenly we don’t.
We have to remember that none of us knows what’s round the corner. I’m not sure you should be too worried about this particular scenario, but there is one thing that we can be absolutely sure of, and that is our life is going to come to an end. We may not know how or when but, as Benjamin Franklin said, “in this world, nothing is certain except death and taxes”.
There are other things we know: we know for example that we are extremely likely to have at least one hospital admission in the year before we die. But we shouldn’t be waiting for our last year of life to think about, write down and share the things that are important to us, and who’s to say whether or not we have entered that final year. You want to know that your wishes and any decisions you’ve made have been written down and discussed with the people closest to you, to avoid medical interventions you don’t want, to be cared for in your preferred place where possible, to ensure anything related to your religious beliefs is respected, and so on, so that it is there, ready for the time, temporarily or otherwise that you are unable to communicate your wishes. So whenever I am asked when is the right time to do these things there is only ever one answer I give, and that’s ‘Now’.
And yet some of us still find it incredibly difficult to make those plans, and after those trials in Cambridgeshire we went on to run some workshops and do some research to see why those conversations aren’t happening.
These were the barriers we identified:
- Lack of clarity about options available, what it is we should actually be doing, and that goes for healthcare professionals as much as the rest of us. That was a key factor behind the reluctance of staff to initiate the conversation.
- Confusion as to what document does what – one of the classics is understanding the difference between an advance statement and an advance decision.
- Reluctance to discuss death and dying. As we all know, it’s not true that talking about it makes it more likely to happen. But that reluctance might be on the part of the individual, or perhaps it comes from family members.
- The longer it’s left the more difficult it becomes, and by that I mean emotionally, it seems the closer we get to facing our own mortality the more difficult it is for some of us to acknowledge it and make plans.
The work we did with that Cambridgeshire Trust led on to a couple of years of further research on the topic of later life planning, understanding why it matters and the difference it can make.
During our research, we had found a lot of great materials both online and in printed form, but none that brought it all together.
So we produced the My Future Care Handbook, a one-stop-shop for all things related to later life. It has been described as a gentle walkthrough of the decisions we should all be thinking about, and the intention is to encourage people to think about and make decisions around their future care and end-of-life much earlier than tends to be the case.
The approach we have taken is to make it relevant even to those people who may not feel that they are ready or need to discuss later life care, so we talk as much about living as we do dying.
You can write a bucket list of all those things you still want to do, produce a play list of the music you might like to listen to if you’re unwell, it explains how to do things like writing a will and sorting out power of attorney, it includes blank Mycarematters profiles for people who don’t want to complete one online, it prompts people to have a contingency plan to ensure, as I mentioned before, their pets are looked after if they have an unexpected stay in hospital.
We use colour coding to help prioritise the tasks that may be most appropriate or urgent according to a person’s situation.
And then there’s a variety of Factsheets with tips on healthy living, the different kinds of housing and care that’s available for people in later life and we touch on financial planning as well.
By making it relevant even to those of us who have yet to recognise and face our own mortality, it encourages us to start thinking about these issues, as I say, much earlier than is normal practice.
It is deliberately a printed document as opposed to being online, which is not to say we shan’t take it online in the future, but we get lots of feedback that it’s a pleasure to have a tangible document to hold and work through. People talk about getting drawn in almost without thinking about it, we provide a pen with each Handbook, so you can just open it up and make a start. For those willing and able to use the internet we also include QR codes which take you straight to various online resources.
And then of course, just as important as the conversation itself, is recording and sharing your decisions.
My late mother had COPD and as it started to get worse she made plans. How detailed some of those plans were I wasn’t aware of until after she died, and I shall forever be grateful that she left a full list of people to inform and their contact details, and the kind of funeral she wanted, including her choice of hymns and readings and what she wanted us to do with her ashes.
The only thing she could have done better was leave those instructions in a more obvious place. She had told me she’d written it all down so I searched high and low in her flat until I finally came across some scrappy bits of paper in the back of her previous year’s diary.
So it’s really important that people not only think about these things and write down their preferences, but that they are accessible when needed! – the Handbook is full of forms and planners to help record someone’s wishes and decisions and also has advice on where documents can be stored.
But, as user friendly and easy to use as the Handbook is, even that isn’t enough to get some people to shift from a position of thinking about it to doing something about it. Lots of us are expert procrastinators, finding convincing reasons for not getting on with it, and we need a nudge.
I learned a great word for this recently: what we are doing is quiddling, busying ourselves with trivial tasks as a way of avoiding the important ones. We are all such good quiddlers!
There were lots of people who were very generous with their time and did some in-depth reviewing of the first version of the Handbook in 2020, but I noticed that many of them only made a start once we had a date in the diary to speak about it. Then there was an urgency, a deadline, that meant they needed to get on with it. They admitted they needed that nudge to open up the book and make a start. Sometimes they’d get stuck at a particular point, and I’d need to give them permission to move on, do something else, maybe come back to that later.
So that’s what inspired our Buddy Service, offering people an opportunity to have a friendly chat, via Zoom or on the phone, with a trained volunteer Buddy. We use a coaching style to help people think through plans for later life, perhaps give you the gentle nudge you need to put your thoughts into action.
Thanks to some grant funding we’re able to offer it as a free service and that includes a free copy of the Handbook. If you don’t need or want the Buddy Service you can always choose to buy a copy of the Handbook (they’re available on our website), but the funding is all about providing that extra support.
We offer up to 4 sessions by phone or video call to give the Buddy and their client an opportunity to agree an action plan and then time to see it through.
The Buddy is there to support you to identify and meet goals. Think of it as a bit like working with a personal fitness trainer. They’re not going to do the work for you, but having an appointment in the diary means it would be rude not to show up, and if you and your Buddy agree a set of actions that are going to be done before your next conversation, it’s more likely you’re going to do them!
We don’t offer advice but we can signpost to services as appropriate, when a greater level of support and advice might be necessary.
So a couple of quick case studies…
Working with John started out as a bit of a challenge. He was persuaded by his wife to have an introductory session with a Buddy but his first words were along the lines of “What’s the point?” During the session he came to realise that this wasn’t just about him but the impact it would have on his wife if he didn’t make plans and he was proud to share with his Buddy two weeks later how much he had achieved.
Yvonne lives alone and isn’t in touch with any of her family so just being able to chat about the various issues with her Buddy, as she says, took a weight off her mind.
Chris attended sessions with her husband and they were initially quite anxious about having the conversation with each other. By having a Buddy in the room so-to-speak it took the pressure off and it sounds like they had a thoroughly enjoyable time!
So we’ve had some good anecdotal feedback, but because we ask everyone to complete a questionnaire before and after using the service we have been able to measure the number of documents people have produced and also any change in their wellbeing.
Unsurprisingly, virtually everyone ends up with more decisions made and documents created than they had before using the service. You may not be able to see these so from left to right they are… funeral plans seems to be one of the topics that people are able to engage in most enthusiastically. I’m not sure we’ve worked out why that is.
The percentage of people saying they had a poor quality of life before using the Buddy service was 57% and reduced to zero after. And the percentage saying their quality of life was good increased from 7% to 43%.
And from the questions we asked that enabled us to measure people’s wellbeing, the average score went up from 48 to 78.
Good mental wellbeing is not just some fluffy nice to have outcome. Positive feelings bolster the immune system and lead to fewer cardiovascular problems, whereas anxiety and depression are linked to poorer health behaviours and other conditions such as inflammation.
But we can only support a limited number of people that way, and an online service doesn’t suit everyone. So we are working with organisations, training their staff or volunteers as My Future Care Buddies so they can support their clients themselves. The Handbook means they don’t have to become advance care planning experts, and they’re free to provide that support in whatever way suits them best, whether that is running group sessions, drop-ins or 121 meetings.
So we currently have funding to provide free online training, free Handbooks and free access to our ongoing Buddy Support Programme to small organisations and groups, and we ask larger organisations to buy the Handbooks and we have the option of more in-depth face-to-face training as well.
They say knowledge is power. Informing ourselves of the options available to us and making some decisions can give us power and a sense of control over events in the future when we may have lost the capacity to speak for ourselves.
We’re also going to enable the professionals caring for us to do their best to give us the kind of end of life we want, and reduce some of the stress our family members might otherwise feel, not knowing what we would have wanted.
I’d like to leave the last word to Dr Lucy Pollock who has written a book I highly recommend, called The Book About Getting Older. This is just one of the pearls of wisdom to be found in the book: “When these questions are kept locked away they weigh us down with unhappiness, anxiety and anger. Bring them into the light instead, and we can discover reassurance and new-found confidence.”