“Consider your loved one's wishes for independence at home. What do they want?”
Your decisions and actions may be well intentioned but stop to ask your ageing loved one how they want to live their life.
Recently I was asked by a GP to ‘help’ him with a potentially challenging conversation he was going to be having with one of his older patients and the elderly gent’s family.
The GP informed me that the family (adult children) of the older gentleman had decided they wanted to "put Dad in a nursing home" and they were seeking to enlist the GP to "break the news" to this unsuspecting gentleman.
There had been many phone calls from different family members to the GP, with each family member stating their reasons why they felt it was time for their father to move into a nursing home.
Courageous conversations.
I’ve been involved with these kinds of conversations before. They are not easy conversations. I agreed to ‘help’.
I attended a home visit at the gentleman's place. I had been there before as I had assessed him previously. I spent two and a half hours at the gentleman’s home, assessing, looking for any signs that circumstances had changed and if there was in fact a need for this man to move out of his home.
The older gent has a mild impairment of his cognition, but he manages well in his own familiar environment and keeps to his routine well.
I was thorough in my assessment and wrote a detailed report for the GP and forwarded my summary the following day.
At the Family Meeting
The following week a family meeting was scheduled at the GP’s office, and I attended, ready to discuss my review assessment with the GP and the family.
I was pleasantly surprised that the gentleman's children had brought him along to participate in the conversation.
The GP took the lead in the discussion and the children then stated their reasons for believing their father should move into a nursing home.
The reasons were…
1. “You could have a fall.”
2. “You haven’t been taking your medication properly.” and
3. “You aren’t eating properly.”
This is interesting, I thought, and I waited for the opportunity to discuss what I had done to mitigate the falls concern and what I had observed in my review.
The gent said, “But I haven’t had a fall” and the GP said, “Ah, not yet”.
This gent said he was taking his medications as he was supposed to (corroborated by me) and the GP said, “Ah but as your eyesight fails you won’t be able to see well enough to take them.”
And the children and the GP all argued, “But you refused Meals on Wheels.” and the old gent said, “Yes. Those meals were bland and it was the same food most days.”
At this point I was beginning to realise the ‘help’ I had been asked to offer was not to demonstrate this elderly man's ability to manage well in his own home. The ‘help’ I was anticipated to offer was to align with the GP and the adult children to coerce this relatively capable gentleman to move out of his home and into an aged care facility.
‘Facility A’ is the home of a resident who is overweight. The managers know that choice and self-determination is important. They understand that forcing a person to diet against their will is as absurd as hearing the teenager at the MacDonald’s drive-through suggest that it might be better if you have a salad, because of your weight.
Realising what was happening
The gentleman realised what was happening at this point, too, and understandably became quite distressed and defensive.
The GP went on to say how nursing homes were very different these days; that there were lots of younger people in the homes and there were plenty of activities to do.
“But I like my own company and I am happy living here by myself!” was the reply.
Everyone started talking at the same time. The GP was talking to one son, two other sons were talking to each other and occasionally trying to include me in their conversation, and this distressed old man and I were looking from one person to another trying to make sense of what was unravelling before us.
I asked the GP, “Have you read my report?” because I really believed he must not have, by the way he was talking.
The realisation that I was not presenting the evidence he wanted was still dawning on my bewildered brain.
He replied “Yes”.
So I started talking about my assessment and how this gent was in fact managing his medications ok. He was having his medications delivered to him by the pharmacy and they were preparing Webster packs for him. I advised everyone that the elderly gent correctly told me how many tablets he takes in the morning and the evening.
And I advised everyone that their father was now going to decant the tablets from the blisters of his Webster pack into a small dish so they wouldn’t roll off the table and would also allow their father to count the tablets to make sure they had all been expelled from the blisters.
The GP cut me off and changed the subject. I had no words. I realised I wasn’t supposed to say anything else.
But the gentleman was sitting there trying to assert himself while the people he trusted most became increasingly animated and coercive in portraying their appraisal of his situation.
Redirecting the conversation
I knew how much this gentleman enjoyed my visits and he would happily chat for ages whenever I visited to complete a review assessment. So I facilitated a conversational detour.
I jumped into this deteriorating dialogue and suggested we increase the community services the gentleman was receiving. And everyone stopped and listened.
This gentleman was receiving domestic (cleaning) support only. Cleaning support ONLY. From such minimal support to entering an aged care facility is one huge leap.
So I talked about daily visits as a way of social support (for their father) but in doing so, the carer could monitor medication administration, check on the gentleman and ensure there was adequate food in the house and possibly help their father prepare a meal (reassurance for the children).
Everyone thought this was a good idea, though one son who kept shaking his head and who was bouncing around in his seat kept telling me his father would forget and refuse the support we were to put in place. I gently reminded him that we had made progress with the medications, and with someone coming to the house each day, it was likely his father would come to look forward to the visits and begin to trust and accept ‘formal support’.
I gave the family some tips for accessing the best community care support in our area and reassured them I would follow up next week.
Given that this gentleman still retains decision making capacity and is managing ok in his own environment, the right thing to do, as I saw it, was to advocate for him. Coercing him into packing up his memories, decluttering his lifetime of living in his home of 50 years and moving into accommodation which would deny him independence, choice in his diet and accessibility to his friends and the community would be heart breaking.
Yes, there will come a time for this move to happen, as my client graciously acknowledged during the family meeting, but the time is not now.
You can fall in an aged care facility. Medications can be missed or doubled up by overworked and time poor staff in aged care facilities. And quality and selection of food in residential aged care facilities has been questionable as exposed by the Royal Commission. This gentleman is currently enjoying his balanced dietary intake.
Would I adopt my recommendations for my own parents? Absolutely! I did with my father, and I am likely to with my mother also.
I understand that it's not always possible to support ageing parents to continue to live in their own homes. There comes a time where community support and services just aren't enough, but transitioning a loved one into residential care should be undertaken with honesty, compassion and patience, and not for convenience.