Domain 12 is the additional place to put something that has not already been covered by the first 11 domains (as there is no double scoring). There is no information about what should be included and little guidance, as there is with the other domains. It does however have to be a healthcare need and something that has not yet been covered by the other domains.
Mostly I find that people are covered well by the first 11 domains and rarely score anything in Domain 12, but as with everything, there are exceptions.
The exceptions that I cover are addiction of some kind, but to the extent that is it a problem. I had a very interesting Panel meeting recently where we discussed addiction, in the case of this Panel meeting, it was in respect of alcohol. We discussed that lots of us have an unhealthy relationship with things; food is a good example in an obese western society. When the unhealthy relationship with anything begins to affect the person’s ability to function day-to-day, then the unhealthy relationship becomes a dependency.
I’ve had a number of clients who were addicts (although I appreciate that this is outdated terminology and dependent is the preferred terminology). I’ve had clients that had dependency on alcohol, tobacco and clients who were just looking for the next high, whatever it was, so if alcohol and tobacco were not available, then sex would do.
I also score excessive sleepiness in this domain, as it can become a barrier to intervention, so that, similar to a period of being unrousable, it is not possible to take food, drink or medication when asleep. It is not uncommon that toward the end of life, someone becomes ever increasingly sleepy, so it is a question of whether or not that impact on the provision of care. This sleepiness is something that they can be roused from, so is not an ASC, but just not easily roused and even when awake remain relatively sleepy, so if they are being fed for example, it will take a long time and they may have minimal appetite.
I’ve also scored an overall generic frailty, which can happen with the very elderly or at the very end of life. I’ve had a few clients in the 90s and 100s and they do appear to have this kind of fragility. It can be hard to describe, other than generic frailty, but they often do seem very fragile, as if they could easily “break” (which I appreciate is not a great description).
I’ve also had a client with non aggressive cancer, which would need monitoring to make sure that it did not become aggressive, as the treatment regime for aggressive cancer would be very different from non aggressive cancer, so the monitoring is for the potential change of care regime.
The things that would not be included and scored in this domain are the things that don’t score for Continuing Care, such as the requirement for 24hour care or that they would be unable to live alone.
The scoring of this domain is also very hard in the absence of any guidance. What I try to look at when scoring this domain is the skin and drug domains. The low and moderate scoring in skin covers the risk of pressure damage, with low scoring when the monitoring is daily or less frequently, so monitoring of non aggressive cancer would be daily or weekly and would score low. The skin domain for moderate is about the treatment or monitoring for pressure damage multiple times per day, so if the domain 12 issue requires basic treatment or monitoring multiple times per day then it would score moderate. The drug domain for high is about skilled monitoring for side effect or fluctuations, so any domain 12 issue that required more than just basic monitoring or treatment multiple times a day, but was effective would score high and if it was not effective, would score severe.
This is a hard domain to deal with and the PCTs are often reluctant to accept anything in relation to this domain, but if there really is an issue that is not covered by the other domains, then I will make the point to have it scored in this domain, even if the MDT disagrees with it being included in domain 12, it will be brought to the attention of the Panel.
NHS Continuing Health Care. DST , Medication & Drugs Therapy Domain. Use of Antipsychotic drug haloperidol (PRN) to reduce aggression and agitation. Would this be HIGH or LOW . I say HIGH because NICE recommends monitoring. Dudley CCG tells us that ‘monitoring’ means adjusting dosage therefore score LOW. Is there anyway to get a definitive answer for this?
I would argue that almost anything that is prescribed PRN should be HIGH. It takes skill to know when is the correct time to give PRN medications, as they are not just given regularly. NICE also recommends that it is anti-psychotics are only given for 12 weeks, although often they are given for longer and therefore anything outside of the NICE guideline should also be carefully monitored and HIGH.
If the CCG don’t agree with you, all you can do is ask them to record the difference of opinion and the reasons for it, that way if the dispute goes to NHS England or the Ombudsman, they can see your thought process and if they think that the CCG should have taken notice of what you have to say, this does not reflect well on the CCG.