Move? Never! A Story of Eldercare Challenges

**jeastridge**, BSN, RN

I rang the doorbell a second time-holding it just a fraction of a second longer than usual. I could hear the chiming inside and I knew the elderly couple were at home. But the dog barked loudly and I suspected that they had trouble hearing. After several more minutes, Mr. P cracked open the door, smiling widely when he recognized me as the Parish Nurse from his church.

"Hello, Mr. P! How are you? How is Millie* doing? Do you mind if I come in a visit a little while?" I had come to visit after a church member called to say that Mr. and Mrs. P had stopped attending Sunday School and seemed confused the few times they came. Previously very active, the couple seemed unkempt and unable to answer basic questions.

"Oh, she's right in here. Come this way. I'm so glad you are here. We are just in here watching TV."

I stepped over a pile of feces and noticed the dog penned in the kitchen, barking frantically. He did not looked pleased with my intrusion and barred his teeth with a growl, so I made a point of staying clear and followed Mr. P into the family room where I was met with more dog waste odors, along with piles of newspapers scattered on the floor, and leftover paper plates, smeared with the remains of forgotten dinners, piled up on a coffee table.

I sat down beside Millie and introduced myself, gently taking her hand. She looked over vacantly at me. I told her I had brought a casserole from the church and chatted a little while with them before getting up to put the food in the refrigerator. Mr. P held the dog while I placed the dish beside a nearly empty gallon milk jug. Besides condiments and a small bag of wrinkled carrots, there was little else.

I asked Mr. P about his son and how to contact him. While Millie was initially quiet, she warmed up and began telling me about her job and how she planned to go back to work, though I knew she had retired many years prior. Mr. P smiled. He answered questions that let me know he was still aware of date, time and general information but before I said any more he volunteered, "We are having a hard time. Millie can't remember much of anything at all and I'm not much better off myself." I asked permission to call their son and he said that would be fine. "But," Mr. P added, "he's so busy with his job. He don't come around much. And he lives away off."

I called the son from my car. He lived several hours away and had not been to visit in six months. Meanwhile, he talked with them on the phone every Sunday. I could tell that he really had no idea how much things had deteriorated in that interval. I told him a little of what was going on and he assured me he would come in that week-end and take care of their needs.

"So what do you think I should do? Is it time to move them out of the house? You know, Daddy built that place and he has told me that he won't move out until the hearse comes by to get him."

As a Parish Nurse or a nurse that is working with a family like this, what do you do?

Of course each situation is different, but there are some general principles that help us help families who face this type of situation:

Making a financial assessment when possible helps to determine direction. Without having too many specifics, a nurse can help . Financial resources do play a considerable role in options for elder care.
Empowering the family to work together to make decisions that make sense to them. They know their family culture, values, circumstances.
Providing as many feasible options as possible and let people make decisions as long as they can.
Keeping in mind that while safety and cleanliness are worthwhile goals, there are many ways to achieve these goals where people can still maintain some autonomy.
State assistance programs vary widely from state to state and location to location so it is important to know how to access and refer to available social service programs.
If families are unable or unwilling to provide eldercare then Adult Protective Services must be notified.

As nurses, we are often called into difficult family, neighborhood and professional situations simply because we are medical and in a helping profession. Helping families through these difficult times of adjustment can be a real gift to them so it's important for us to know how to prioritize and plan. In a situation such as the one I described, it is so tempting to want to pull them out of their setting and into a more "safe" environment. As nurses we can lean toward wanting to "fix" things for them, but studies show that people are happier longer staying in their familiar surroundings (nia.nih.gov).

In this particular case, the son came and was horrified at what he found. He was able to pay for a professional cleaning service to come in; he gated the back yard for the dog and provided some outside shelter; and he hired a neighbor to come in three times a week to cook a meal and do some grocery shopping. These simple interventions put Mr. and Mrs. P back on a path to well-being and better coping. They still continued to decline and experienced repeated hospital and ER visits, but with the neighbor there, the son was able to monitor things from a distance and make adjustments as needed. I also stayed in touch with all of them and provided assistance from time to time.

In this setting, the son had limited financial resources, but he was able to obtain legal power of attorney and function as a supervisory caregiver for his parents. They owned their home, so even though they did not have a lot of savings, their social security income was adequate to keep them aging in place. But what if the son had not been willing or able to help out? When that is the case, the care becomes much more complicated.

Generally, the levels of care include the following in order from least care to most: At home, independent, able to do all ADL's.

At home but requiring cues and reminders, assistance with meals, ADL's appointments. Sometimes a maid or an occasional companion.
At home with regular care coming in for several hours a week. Dependent for ADL's, meals, all medication management and transportation.
Facility for independent living with meals provided but little assistance in the individual apartments.
Facility with assisted living. Private pay. Must be able to transfer and do some ADL's but some assistance provided with all needs.
Nursing home facility. Paid for on a limited basis when for rehabilitative services. Otherwise, private pay. Maximum assistance provided. Higher level of complexity cared for.

I visited Mr. and Mrs. P again several months later. Mr. P opened the door and told me the Meals on Wheels volunteer had just left. He pointed toward the kitchen where two styrofoam containers sat side-by-side. The house was still cluttered but now leaned toward "homey" instead of hazardous.

What about you? Have you had some eldercare successes and some not so successful outcomes?

*Name and some facts changed to protect privacy.

needlesmcgeeRN, ASN, RN · Dec 13, 2016

There are organizations in place to assist seniors with staying in their homes safely - Area Agency on Aging and Council on Aging. Did you attempt a referral? Are you unfamiliar with this resource? You may educate yourself and others within your church so that next time people are aware of the resources to help their aging neighbours, family, and friends. The AAA and COA will come to a person's home to do an assessment (at no cost), in order to determine eligibility for their programs.

Libby1987 · Dec 13, 2016

It sounds like you facilitated a lot of improvements and resource utilization with a good outcome but why didn't you ask the husband and/or son to request a referral to home health? Though I would have thought a referral would have been generated from one of their many ED visits or hospitalizations.

taivin · Dec 13, 2016

There's lots of help out there to keep elderly people and couples in their homes. As a nurse who does home visits, you should have all the resources available in your community known to you. Networking with them, knowing who can do what...etc. You need to educate yourself with what's available in your area for situations like this. You are their advocate to keep them home. The help out there is sincere and great. The churches, volunteers, home health, family, etc... Also, did they have their papers in order? Advance directives, etc...?

The last person I helped; I went into the rehab they had been put into after a fall post ER visit. I gave the facility 5 days and then we were going to take her out at the request of a family member (she had been in the rehab for 27 days). The "rehab" was telling the family that they couldn't take her home...ok, please show me the documents that has deemed her with no capacity or the POA saying she must stay...none. We left 5 days later and the family and their mother were able to go home where she passed away a month later (we had discharge orders and hospice on board). She just wanted to go home.

Sadly, there are situations where it is not possible, but every attempt to keep them at home (if they want) should be made.

**tnbutterfly - Mary, BSN, RN** · Dec 13, 2016

Thanks for this great article which gives us a glimpse of some life's struggles of the elderly outside the hospital. This family was lucky to have you in their health care circle.

As a seasoned Parish Nurse (stated in your profile) I'm sure you shared only a portion of what you did in this referral. Parish Nurses are very familiar with multiple local referral agencies for transitioning the elderly and others who need additional care with ADLs, etc. Thank you for your on-going care for this couple and others.

**jeastridge, BSN, RN** · Dec 19, 2016

There are organizations in place to assist seniors with staying in their homes safely - Area Agency on Aging and Council on Aging. Did you attempt a referral? Are you unfamiliar with this resource? You may educate yourself and others within your church so that next time people are aware of the resources to help their aging neighbours, family, and friends. The AAA and COA will come to a person's home to do an assessment (at no cost), in order to determine eligibility for their programs.

Thank you for your comment. You are so right. the AAAD in our area does a great job. Thank you for sharing your insight and ideas!

**jeastridge, BSN, RN** · Dec 19, 2016

It sounds like you facilitated a lot of improvements and resource utilization with a good outcome but why didn't you ask the husband and/or son to request a referral to home health? Though I would have thought a referral would have been generated from one of their many ED visits or hospitalizations.

Hi Libby, Thank you for suggesting home health as part of the picture for this story. As you point out, they are a great resource for some aging in place situations. Joy

**jeastridge, BSN, RN** · Dec 19, 2016

There's lots of help out there to keep elderly people and couples in their homes. As a nurse who does home visits, you should have all the resources available in your community known to you. Networking with them, knowing who can do what...etc. You need to educate yourself with what's available in your area for situations like this. You are their advocate to keep them home. The help out there is sincere and great. The churches, volunteers, home health, family, etc... Also, did they have their papers in order? Advance directives, etc...?
The last person I helped; I went into the rehab they had been put into after a fall post ER visit. I gave the facility 5 days and then we were going to take her out at the request of a family member (she had been in the rehab for 27 days). The "rehab" was telling the family that they couldn't take her home...ok, please show me the documents that has deemed her with no capacity or the POA saying she must stay...none. We left 5 days later and the family and their mother were able to go home where she passed away a month later (we had discharge orders and hospice on board). She just wanted to go home.
Sadly, there are situations where it is not possible, but every attempt to keep them at home (if they want) should be made.

Thank you so much for sharing your insights and experience. It sounds like you did some good, compassionate work helping the person who wanted to go die at home. Joy

**jeastridge, BSN, RN** · Dec 19, 2016

Thanks for this great article which gives us a glimpse of some life's struggles of the elderly outside the hospital. This family was lucky to have you in their health care circle.
As a seasoned Parish Nurse (stated in your profile) I'm sure you shared only a portion of what you did in this referral. Parish Nurses are very familiar with multiple local referral agencies for transitioning the elderly and others who need additional care with ADLs, etc. Thank you for your on-going care for this couple and others.

Thank you for your kind comment. You are right. I did not share all the "ins and outs" of this case, just enough to help transmit the basic story. As you point out, Parish Nurses work together with all sorts of community resources to help families cope with aging in place as well as end of life care. Have a great day! Joy

Move? Never! A Story of Eldercare Challenges

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