January 2000 Print

 

C. Bruce Carroll, M.D.

From its embryonic stages through full bloom until the petals fade and fall off, life has been a favorite subject of poets and scholars. Almighty God has deigned that this flower is best and most properly nourished in the context of a family. Many good Catholics today rightly think of family along these general lines of the Jesuit Fr. Cahill: "The family is a composite society, which may be composed, at least potentially, in all or any of three ways - the union, namely, of husband and wife, of parents and children, and of masters and servants."¹ Fr. Cahill was referring to what some today call the "two-decker family." I would like to shift that focus to include the elderly in this world. Let's call it the "three-­decker family," and let's examine how they should be treated among the flowers that are in full bloom.

In the course of normal life, each one of us is born into a family and needs the nurturing, sustenance, and love of our parents and of our family members. Eventually, we grow and mature to a station of independence, often leaving our parents to pursue our own vocations. Then, ever so gradually, the once independent adult begins to need help. Health problems develop and the sun begins to set on another human life. Near the end of their term, our parents will often need our aid.

In a normal and healthy family setting, the mature and currently independent adults will help their aging parents, irrespective the cost; however, in the deranged world in which we now live, this is the exception and not the rule. Today, when the "oldsters" can no longer care for themselves, instead of making them "the third deck" in the current family, they get farmed out to receive their care from a nursing home.

The modern nursing home can never take the place of the family. Mainly this is so because it has deficiencies in three areas which are fulfilled in the healthy family, that is, it is lacking in charity, justice, and sacrifice—­ the footings and foundation in every good home. I hope to touch on the most important deficiencies of the modern nursing home or "manor" and discuss briefly their roots and remedies.

The same basic elements missing in a nursing home are also missing in the homes of most of the families who place its elder members in such places. Charity, justice, and sacrifice are the hallmarks of the good families who refuse to put their eldest or sickest members into a "long-term care" facility and who properly render them the care they need. Why are these key ingredients lacking in a place that boasts how well it will care for your loved ones?

 

Charity

Charity is the virtue by which we love God above all things for His own sake, and our neighbors as ourselves for the love of God. This is most easily and readily accomplished amongst our family first and our friends second, although true charity isn't limited to them, but extends also to strangers and even to our enemies, for Christ's sake.

The intimate and personal environment of one's home, replete with the privacy which is helpful in the care of illness and essential for spiritual growth, is fertile soil for this theological virtue of charity. Just visit your average nursing home and the mere thought of personal privacy will automatically seem folly. It is just not possible! The disorder that is present in most long-term care facilities is intrinsically contrary to the recollection and intimacy needed. Furthermore, for those few who, with Christian ideals and motivation, have labored in modern nursing homes, the sheer weight of government bureaucracy will snuff out their daily efforts of true charity.

To foster charity, we must keep our elderly and sickly out of a modern nursing home. We must act upon our convictions and keep them in our homes where they belong. Why go looking for neighbors to be good Samaritans to when we are faced with the opportunities to live our faith? Our catechism teaches us that "we should love our parents, brothers, sisters, relatives, friends and benefactors best."² And we must put this love into action as taught by St. John: "My dear children, let us not love in word, neither with the tongue, but in deed and in truth."³

 

Justice

This is a cardinal moral virtue, resting on charity, that disposes us to give everyone what belongs to him; that is, it instructs us in the manner of giving what is due to God and to man. The Apostle to the Gentiles teaches us, "Render to all men whatever is their due; tribute to whom tribute is due; honor to whom honor is due."⁴ This moral virtue is easier to practice when we truly know the person for whom we are caring.

In a nursing home situation, where the residents exist in a quasi-vacuum, it is absolutely impossible to render them justice. In all fairness, how can staff members at a manor render what is due when the patient is unknown to them? They cannot. It's not their fault. The resident has no context, and without the setting of the family and the family's home, the patient has no past and certainly no future. Therefore, the only dues you can pay them are those which are monetary and humanitarian. In the rush-rush world of the understaffed manor, these dues are left unpaid.

At home, when caring for the ill or elderly, we are flesh of their flesh and blood of their blood. We know what is their due because we are their heritage and they are our progenitors. The practice of justice will come more easily to family members who care for their own under their own roofs. Visiting mom or grandfather or Aunt Martha at the manor for a few hours on Sunday afternoon is not serving them justice when they are relatively abandoned the rest of the week. If we abandon them to long-term care facilities, we are not satisfying the Divine call to practice justice in this life.

 

Sacrifice

Love is sacrifice. If you love someone then you will make sacrifices for them. What better proof of this than the sacrifice of our Lord Jesus Christ for sinful man? To sacrifice one's self for the love of God is the highest form and greatest proof of that supernatural charity to which we are all called. This sacrifice is most often a daily and bloodless one.

Today, society as a whole has no sense of this sort of sacrifice. Its only sense is selfish. Worldlings making sacrifices for themselves, often heroic albeit fruitless for eternity. The exercise campaigns, diet regimens, and athletic programs of today require extraordinary sacrifice on the part of their participants, and how they succeed in their offerings! However, this spirit of sacrifice is rarely extended to others and when these egocentric adults are your clock-punchers and wage-slaves at a for-profit nursing home, it is obvious that no Catholic ideal of sacrifice is possible.

In the family, the Christian ideal of sacrifice must be the norm. And when the adults make sacrifices for each other's sake and for their children's sake, the children sense it and almost unknowingly adopt that spirit themselves, to varying degrees. Then, when we take a family member into our home to care for them, the youth will especially notice the sacrifice and it will leave strong impressions on them. In extension, the current children are being prepared thereby to make true sacrifices in their later adult lives as priests, religious, or family members.

For the adults making the sacrifice on behalf of their elder kinsmen, it is an investment in their own future. Think about it. If you farm out your relatives to a long-­term care facility, this example for your children will make it that much more likely for them to do the same to you. However, if you willingly give your helpless family members shelter, clothing, food, comfort, care, and the consuming sacrifice that may be required of you, then your children will find it natural to do the same for you. Recall our Lord's teaching: "And even as you wish men to do to you, so also do you to them."⁵

 

Observations

Anyone who finds these statements too bold might claim that this is all just pious drivel which isn't really germane to the pragmatic world in which we live. For the doubting-Thomas who thinks this is all just theoretical whim from someone hasn't "been there," I would like to offer some of my observations based upon real-­life experiences with patients and their families.

 

Quality of Care

Now, I am not referring to some bureaucratic phrase which claims "quality assurance" but really means just another governmental regulation policed by a former registered nurse who grew tired of dealing with patients. My meaning here is real, bona fide quality.

When I reflect upon the care received by my patients at their homes versus that received at a long-term care facility, the family home is a hands-down winner. Family members are more motivated and proffer genuine charity and justice which just has not been matched by any nurse or nurse's aide who is working the floor. With the continuity of the same family taking care of the same member over time, the quality of medical care is actually better despite their relative lack of training. After all, how can a nurse or aide really grasp the depth and breadth of their patient from the shift-change report they've been given by the staffer going off duty? They can't! A family member can sense, almost intuitively (or is it God's grace?) when their "patient" has developed a new problem, one requiring the physician. The recognition is sooner and, hence, so is the intervention.

In this same vein, the inherent efficiency of home care would make the nursing home administrator green with envy. Maybe these two schematics will illustrate the difference:

When a problem arises in home care, the family caregiver notifies the physician; the appropriate instructions and services are rendered. A direct relationship.

            

When a problem arises in a nursing home, the nursing aide (who usually has at least another six or eight patients as well) must notify the charge nurse; the problem or concern is documented on the appropriate papers and the report is then called to the physician. Instructions are given to the nurse who then usually passes it on to the aide for final execution. The nurse also notifies the family and completes the forms. Later, the physician must sign the papers with his verbal orders. And all of this is scrutinized by governmental agents of regulatory bureaus.

               

The governmental agencies that control nursing homes have a litany of reasons to call the physician, many of them trivial but all of them mandatory to report and document. A family member as caregiver is at liberty to use his judgment, whereas the manor staff members, though medically trained, are shackled by regulations and not free to use their training and judgment. Besides the frustration this causes those who work the manors, it generates five to eight times as many phone calls as the patient at home does; and yet, true quality of care is not greater.

The amount of paperwork done in a nursing home is astounding. A registered nurse will spend approximately one-fourth to one-third of her shift doing paperwork! This distracts from care for the patient. Remember this point later when the issue of expense is examined; the nurse is still "on the clock" while grinding out the paperwork at an average rate of $15 to $20 per hour.

 

Longevity and Outcome:

All other things being equal, the patients who are kept in their own home or in their family's home—even if they are just elderly and not ill—fare much better, on average, than had they been put in the "rest home." Their mental, physical, and spiritual health remain stable longer and their own sense of well-being is better. Love buoys them up.

Contrariwise, when persons placed in a nursing home often begin a quicker decline and a sooner end. I have witnessed aged patients who were cared for at home and lived far longer and fared far better than I would have initially expected. Other similar patients put in the nursing home deteriorated more quickly. This is understandable in the general case because of the mentality that the modern nursing home fosters.

This "manor mindset" is first encountered during the admission process when all the necessary forms are completed and signed. Among these forms and usually right after the financial information, the would-be resident or the family is asked about their funeral home choice and about their desires to receive resuscitation in the event of emergency. There is usually little hope offered and most residents know that they have just been admitted to the place of their death—a place of strangers without family.

I had an elderly patient whose family I admired because it was absolutely heroic in their care for him with several months of constant attention and vigil and service. They fed him, bathed him, nurtured him, encouraged him, prayed with him and contacted the priests to bring him the sacraments, etc. Finally, however, this tired family made the unpleasant decision to place the dignified but sometimes cantankerous man in a nursing home. He died the same day of admission. I do not mean to blame the family nor do I intend to diminish its valor. The old man would never have lived as long as he did had he been placed there first. But, as a flower uprooted, a few hours after arrival, he gave up the ghost!

 

Environment

I make no claim nor have any delusion that every family has a model home with a perfect environment for someone's latter years or final days. But, in the average nursing home, the general atmosphere is very contrary to peace and tranquility. Noise is common and most rooms have a TV set pumping out the world, the flesh, and the devil at all hours. Though in some families the situation is no better, the well-intentioned family at least has control over the matter. In the nursing home, the place is theirs; you're just a visitor.

 

Expense

"Dr. Carroll, I just can't understand why Margaret doesn't get better care at the manor?"

"What do you mean, Jerry?"

"Well, sometimes when she needs to go to the bathroom, she can't seem to get a nurse to come help her. She'll yell for them but it takes a long time. If she weren't blind, I guess she'd ring the buzzer."

"Would that be better? A buzzer versus yelling."

"Oh, I don't know, Doc. It's just sad how little attention she gets down there. The nurses and everybody are just too busy."

"That's certainly true, Jerry."

"And it's so expensive, too. For $3,000 a month, you'd think they could hire more staff. It's a waste of a lot of money."

"Well, Jerry, why don't you bring her home?"

[He emits a nervous chuckle and shifts in his chair; he looks away, at the calendar hanging on the wall.]

"Oh, there's no way I could. She's too much for me to take care of."

"But you and Margaret have a lot of family here in town..."

"But they have their own lives and are too busy to help."

"I see. But you can't expect her to have personal attention like she'd get at home, can you?"

"For $3,000 a month, I can."

[A pause in the conversation.]

"When are you going down to visit Margaret again?"

"Sunday morning before the Chiefs' game."

Jerry is a typical living paradox, caught in the trap between personal sacrifice, possible financial evaporation and his feelings of guilt. Sadly, he doesn't seem to realize the dilemma nor can he be brought to face it. His family is selfish and he anguishes. The convenient "solution" has been a costly one.

Nursing home care is generally a financial ruin for most families who place their kin there. Whatever nest egg they may have accumulated is usually consumed and the rightful inheritance of their children is gone in exchange for not having to "hassle" with taking care of the elderly. In crass terms of monetary gain, the nursing home is a bad "investment." Despite the fact that they whine to the contrary, nursing homes generally have plenty of gravy on their plate. You lose and they win.

Listen to the newswire reports of this past autumn:

Medicare will bar 80 community mental health centers in nine states from serving the elderly and disabled after investigators found patients watching TV or playing bingo instead of getting expensive psychiatric care they were supposed to receive....New benefits offered in the 1990's, including home health care and the outpatient mental health treatment, have proven particularly vulnerable to profiteers....At some of the centers, as many as 90% of the patients do not have illness serious enough to qualify for special care....Now, 1,150 community centers nationwide serve Medicare beneficiaries. Most are independently owned and operated for profit.⁶

Whom are we kidding? If it weren't profitable to run a nursing home, would there be so many of them in existence? The Chicago-based SMG Marketing Group, Inc. has compiled the following statistics:

i) There are 15,323 long-term care facilities in the United States of which 73% are recognized as being for-profit.

ii) There is an average of 110 beds per facility.

iii) Forty-five percent of all nursing homes are part of a chain.

iv) These comprise 1.67 million beds with a 90% occupancy rate.

v) The average number of residents at any given time is 1.5 million.

In the last ten years the percentage of occupied beds is increasing and the number of chain-owned facilities has also increased, from 7,900 to 9,100.

But how much does it cost to operate a nursing home? Sit down for the answer. It costs a typical nursing facility $3.4 million per year.⁷ Divide this sum total by the average number of beds per facility and you'll see that Jerry was quite accurate in his estimate and his complaint of the monthly cost for Margaret.

How is it possible to spend almost $3,000 per resident per month, you might ask? This is the breakdown: 51% is spent on salaries, 30% is spent on "legal, accounting, and miscellaneous expenses," 8% is spent on administration, 5% on dietary, 3% on drugs, and 3% on medical supplies.⁸

Think about it. If you keep your family member at home, besides pleasing God Almighty and earning eternal merit and setting a good example for your children and having a clear conscience knowing you've finished "a job well done," you will have saved an enormous amount of money. That's crass maybe, but it's true! Only dietary, drugs and medical supplies will remain as your cost; the rest will simply not apply.

You might argue that the 51%— about $1,500 per month—is well-worth the cost in salaries. Consider this: Employee turnover in nursing homes is amongst the worst of any "industry" in the country, maybe surpassed by only fast-food restaurants and per-diem construction companies. Recent stats paint a gloomy picture for nursing home employee dependability:

i) Administrators turnover at 29.8% per year;

ii) The Director of Nursing position has turnover at 38.3% per year,

iii) Department Heads turnover at 30.2% per year;

iv) Nurses turnover at 52% per year; and,

v) Nurses' aides turnover at 106% per year.⁹ Nurses' aides—the main floor worker and the fodder of for-profit long-term care facilities—have a position turnover of over 100% per year, and nurses, the most highly trained personnel and upon whom doctors rely for clinical accuracy, have a turnover rate of 52% per year.

A person admitted for a long stay in any residence will quickly find his life's savings drained. This is so certain that one of the hottest offerings in the insurance industry is "Long Term Care Insurance." Even on the Internet, insurance companies are pushing this agenda. One site reads:

As you or other members of your family enter your 50's, 60's, 70's and beyond, part of retirement planning should include long-term care. Will your parents or loved ones need long-term care? Consider the following:

Over 50% of all people over 65 need "custodial" care at home, in an adult day care center, in a residential facility or nursing home.

For every 1,000 people, 5 will have a house fire (the average loss is $3,428), 70 will have an auto accident (the average loss is $3,000), 600 will need Long-Term Care (the average cost is $40,000 to $80,000 per year).¹⁰

You are prepared for just about everything except the coverage you're most likely to need—Long-Term Care Insurance. Contrary to common belief Medicare, Supplements, Health Insurance & HMO's don't cover long-term "custodial" care at all....How much will long-term care cost? Now it costs $40,000 to $80,000 a year or more for possibly many years—totalling HUNDREDS OF THOUSANDS OF YOUR HARD EARNED DOLLARS! Long-Term Care Insurance could be the answer [emphasis in the original].¹¹

Long-term care insurance isn't even close to the answer. The answer to the problems of long-term care is so simple that most will refuse to believe it. The answer is to take care of your own family, kin, and blood. Run from it if you will, but you'll find yourself ensnared in the "Jerry Syndrome" which will haunt you from your deepest conscience.

 

Disclaimer

I know that it is not possible for everyone to be cared for in the family home. Some have problems which are really too complex. Some have no family who can take care of them. These situations do exist and I have witnessed them. I do not mean to imply that nursing homes have absolutely no reason to exist or that they are intrinsically evil. In fact, I pray for the day we might have a few truly Catholic facilities.

That notwithstanding, my observation over the past decade is that 75% of the people who are in long-term care facilities could be readily cared for in a private home. This doesn't happen because their families are not willing to make the sacrifice necessary to do so. These adults who are currently in their late 40's through early 60's who have put their parents in manors have set a dangerous example for their own children, worse yet that they might decide to euthanize them because they have become too costly. The abundance of nursing homes is an escape from the responsibility of caring for the elderly. Their convenience is a disruptive force that attacks family cohesiveness.

 

Walk the Walk, Talk the Talk

There was a certain widowed man; let's call him "Don." Living alone at 70 years of age, Don was putting a couple of logs into his fireplace when he felt a sharp pain in his right hip. He passed it off as a pulled muscle. After a couple of weeks passed, the typically stoic Don went to see his physician because the hip still hurt, and actually hurt more despite resting it and a full bottle of ibuprofen.

The doctor ordered some X-rays which showed worrisome findings; then, a bone scan was ordered which suggested a cancer. Don was hospitalized for a series of tests. The final diagnosis was very bad. The pathologist read the slides and gave the verdict: "Metastatic Cancer of An Unknown Primary." Nobody survives this one for very long. A death sentence.

The pain rapidly increased as the cancer was aggressive and Don's ability to function and live alone quickly decreased. His mental and physical health declined rapidly. He hid it from his daughter.

Then, a few weeks later, Don's physician called his daughter and son-in-law on the phone. The well-intentioned internist told them that Don was no longer able to take care of himself, and that he had only one of two options: either go to the VA or to the local nursing home.

His crusty son-in-law said, "Like H- are you going to put him there. I'll come get him." They made prompt arrangements and the son-in-law went to get Don and brought him into his home with his daughter and her four youngsters.

Don, a "jack Mormon" who had rarely discussed religion with his Catholic daughter and had never once broached the subject with his son-in-law, lived with them for a couple of months. It was often difficult. Extremely difficult. There were numerous long drives for radiation therapy, several hospitalizations a half-hour away for blood transfusions, and great stress trying to put in order Don's worldly affairs. Don fell often, and at 6-foot, 4-inches and 250 pounds, he was very difficult to help. He almost burned their house down trying to make coffee, and once in confusion, he even accused his son-in-law of trying to poison him. At times, there was serious friction. Nonetheless, his daughter and her husband refused to even think about placing him in a nursing home. When it was "Big Don's" time to die then, by God, he'll die right here in our home, they said.

On a sunny but cool Sunday afternoon, March 19th, the Feast of St. Joseph, Don was sitting in his recliner talking to his son-in-law. It was a lucid and cordial conversation between one sick and dying man and his son-in-law who respected him. Then, without warning, completely unexpected, Don dropped a bomb on his son-in-law, when no one else was present.

"Why are you a Catholic?" Don asked in honesty and simplicity. His deceased wife and their only daughter had clung to a Faith he had never known. Now, at the end of his tether, he doesn't ask his flesh-and-blood but her husband.

"Well, Don," the son-in-law paused as he put down his beer and prayed that the Holy Ghost would inspire him to say the right words, "I'm a Roman Catholic because that's the only way for us to get into Heaven."

Big Don took a draw on his own beer while his son-in-law furtively watched him, anxious that he'd blown his only chance. Don looked up and over at his son-in-­law for the longest moment, he ran his right index finger around the perimeter of the beer can.

"Well, after we get Jeanne moved up here, I'd like to see a priest about getting myself made a Catholic."

The younger man swallowed hard.

"Don," he said, "I'm afraid that you'll be dead before we can get your wife's body moved up here."

"Then I guess you should call one of your priests tomorrow for me."

"I'd be glad to," responded the son-in-law who felt he needed something stronger than a beer.

The next day a priest was contacted who came over to the family's home. After talking with Don in private, the priest felt he possessed the kernels of the Catholic Faith. Big Don was then baptized, removing all of his iniquities. Three days later, one week after he asked for a priest, Don died in his daughter's home.

Big Don was my father-in-law and I was his godfather at his baptism. Tell me, would he have had the chance to convert in the VA or a nursing home?

 

Final Comments

It can be very difficult to take care of the elderly in your own home, and it is even more difficult to take care of the sick elderly. Although not all have been terminal, I have taken care of an untold number of patients in their homes. I have seen the difficulties and the joys which go with it. And not yet have I had a family who ever, ever regretted taking care of their own kin in their own domicile. Never. On the other side of the coin, I have seen the remorse and heard the spoken regret of those who wish they would have done more for their beloved. But there is no chance to turn back the hands of time and relive the past. Sometimes, the remorse is haunting.

During the difficulties, it is not uncommon for one or all of the helping family members to feel the weight of the cross and to pray that the chalice might depart from them. Some refuse to drink, to do their duty in serving justice to their family member. Later, they regret it. Those who suffer through the cross are invariably happy they did so.

We know from our catechism that one of the corporal works of mercy is to visit the sick. If there is a reward just to spend some moments with them where they may be, how much more reward shall be ours for taking the sick into our own home and being a help to him at all times? Keep in mind these words of our Lord, "Blessed are the merciful: for they shall obtain mercy."¹² God's grace will not be lacking in this world and His reward will be great in the next. To every degree possible, we must make the sacrifices necessary and find the physicians, nurses, and friends who will help us in our own via dolorosa. Let us meditate upon the death of St. Joseph. Can we imagine St. Joseph dying in a long-term care facility—neglected, lying in a bed at the end of the hall with the curtain pulled so others won't see death? Or, do you prefer to think about the fact that he was cared for by those who loved him most, and that the greatest male saint died in the arms of our Lord and our Lady? Do your difficult and sometimes painful duty. Treasure your family member as if they were St. Joseph, and our Lord and our Lady will help you in your final moments, too.

Dr. Bruce Carroll is a Family Physician in his eleventh year of private practice in St. Mary's, KS.

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Footnotes

1. E. Cahill, S. J., The Framework of a Christian State, 1932 (Fort Collins, Colo.: Roman Catholic Books, n.d.), p. 320.

2. L. L. Morrow, S. T. D., My Catholic Faith (1949; reprinted 1994 by Sangre De Cristo Products, Inc.), p. 177.

3. I Jn. 3:18.

4. Rom. 13:7.

5. Lk. 6:31.

6. Alice Ann Love, Associated Press, Fox News Online, 9/29/98.

7. Hoescht Marion Roussel, 1996 Institutional Digest Annual Issue, Kansas City, MO.

8. Ibid.

9. American Health Care Association, 1997.

10. Statistics Source: Society of American Actuaries, 1995, and HIAA, 1994.

11. Peter Daenzer, CLU, CPCU, Long Term Care Consultant, Los Angeles, CA.

12. Mt. 5:7.