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When You are Faced with the Nursing Home Decision

Placing a relative in a nursing home may be one of the most difficult and traumatic decisions a family member can make. Families may be forced to make a sudden nursing home placement because of a drastic change in the person's health condition, such as following a stroke or major illness. Or the placement may be a planned move that includes the older person in the decision making and selection process.

The Decision
Families agonize over the decision after the placement is made for weeks, months and sometimes years, asking themselves was it the right decision? The right time? Could they have made it a little longer at home? Acceptance of the placement is eased sometimes if everyone involved feels that it was the last step in a process where many other alternatives were already tried. The family may have provided a high level of care in the home, utilized formal services, or tried residential care arrangements, but the elder still had unmet needs or questionable safety. The physical and/or emotionalelderly man and woman working on a puzzle health of the caregiver may also have been at risk. Every family has its own threshold at which they feel they can no longer continue to give adequate care. The problems that most frequently lead families to decide on nursing home placement are the ones that require 24-hour care, such as severe memory loss, incontinence, inability to transfer himself or herself, and unsafe behavior such as inability to take medications properly, wandering, or leaving the stove on.

Caregiver Emotions
Although there are benefits to nursing home placement, and "one might expect that nursing home placement would immediately reduce the stress on the family caregiver, sometimes family caregivers experience no less and sometimes increased stress following nursing home placement. This may include depression, a loss of purpose in life, psychosomatic illness or frank medical illnesses on the part of the caregiver." (Eric Pfeiffer, MD)

Families feel a wide range of emotions when making this difficult decision. They often feel others will judge them, thinking they have abandoned their loved one. They experience guilt because they may have promised the elder never to place them in a nursing home. They may feel angry that there are no other options. They may experience grief over the physical or mental deterioration of their loved one. Spouses may feel a sense of loss and depression about being separated from their partner. At a time of such intense change, the caregiver may experience anxiety and confusion. At the time of placement, they are constantly being asked to make unfamiliar and complicated decisions for another person's well-being. Financial concerns are universal at the time of nursing home placement, and can be another source of anxiety.

Nursing Home Myths
There is a myth that families don't care about their loved ones and "dump" elders into nursing homes because they don't want to be burdened. Nothing could be further from the truth. Families provide 80 percent of the care required by older adults, and nationally only five percent of people 65+ reside in a long-term care facility.

People often have impressions of nursing homes as cruel, impersonal, uncaring places where elders are taken because no one in the family wants to bother with them any longer. In reality, nursing home residents are older, more frail, and more often without close relatives than other older people in the community. Today's nursing homes are greatly improved, carefully regulated, and more accommodating to the needs of individuals than those in the past.

On the positive side, once the older person and their family get through the adjustment phase, the nursing home can be a good experience for both. The caregiver may experience some relief from no longer being solely responsible for meeting the older person's multiple needs. They may have their own health needs to attend, which may have been aggravated by the demands of caring for an infirm elder. The older person may become stronger, healthier and happier with better nutrition, medical attention, exercise, stimulation, and more social opportunities. The older person's relationship with the family may improve as the day to day caregiving demands decrease.

Caregiving in the Nursing Home
Caregiving doesn't end when the older person is in the nursing home, but it changes. Some of the stress of 24-hour caregiving is relieved, but the sense of responsibility does not go away. The quality of care in an institution can never be what it is in a person's own home. Many caregivers continue to question the placement decision long after their family member is in the home. Many caregivers visit frequently and provide a good deal of care. Caregiving becomes a partnership between the family and the nursing home staff. Ideally, this partnership can support the caregiver. Selecting a Nursing Home
If your loved one is not entering a home during a crisis situation, you will have time to research and visit several nursing homes. You can get names of homes from the LIFE (Lincoln Information For the Elderly) office, the telephone book, your doctor, or friends. Your choice of homes may be limited by waiting lists, location, or cost, but carefully exploring the options will allow you to make a wise and informed decision. Make sure you visit the home, and take the older person with you, if possible. Some things to look for and ask about:

  • What levels of care are offered? Intermediate care offers nursing supervision and assistance with personal care. Skilled care provides skilled nursing, medical and rehabilitation services. Does the home have an Alzheimer's unit?
  • What are the fees and charges? Does the home take Medicare and Medicaid? Are there additional charges for special services?
  • Are there special services offered, such as physical therapy, occupational therapy, accommodations for special dietary needs?
  • Does the home look and smell clean? Is the atmosphere pleasant?
  • Are safety measures apparent-fire doors, sprinklers, call lights, grab bars in hallways and bathrooms?
  • Do the residents look clean, well-groomed? Do you see positive interactions between the staff and residents?
  • Is the diet appealing?
  • Are call lights answered promptly?
  • Is there a range of activities?
  • Any provision to match roommates for compatibility?
  • Are there support groups for residents and families?

Spend some time in the facility to get a sense of the atmosphere. Inspection reports are available through the State Health Department.

Once you have chosen the nursing home, make sure that you understand the contract. The home may have policies that their residents must have advanced directives regarding health care decisions, or have someone designated with a durable or health care power of attorney. You may want to consult with an attorney if you have questions about the contract or power of attorney. Every nursing home resident has a "Bill of Rights" that protects their civil rights in the institution.

Transition to the Nursing Home
Moving to a nursing home will have a significant impact on the older person and their caregiver. The process of adapting to the new environment can take several months, with the first 4-6 weeks being the most intense time. Remember that people go through many changes in life, and will utilize their strengths at coping with change when they go to the home.

  • Bring personal things to individualize the room.
  • Emphasize the continuity of your relationship, that you are not abandoning them. Plan to visit frequently, especially at first. Once settled in, take them out for visits, drives, or meals.
  • Expect there to be some sadness, anger, confusion. Also, new residents are more at risk of falling, as they are unsure of their new environment.
  • Get to know the routines, the shift changes, the best times to call.
  • Share information about the older person with the staff. Attend case conferences, get to know the plan of care, and contribute helpful information.
  • Support the staff and show appreciation for their work.
  • If you have concerns or complaints, try to complain to the right person.


Suggestions for Visiting
Express your concerns privately, in a non-threatening manner. Your positive attitude will build a good relationship with the staff.

Often, when a person is first admitted to a nursing home, family and friends come to visit but may feel awkward. Over time the frequency of visits may begin to dwindle. Keep in mind that even if the older person may not remember you, they are aware of your care and concern. A friend's visit is often a great show of support for the family, helping to show that this special person has not been forgotten.

Some ideas to keep in mind if you plan to make a visit include: (Material from Annie Sharp, The Nursing Home Connection)

  • Introduce yourself at the beginning of your visit.
  • Bring a gift as a reminder of your visit, something small, such as a box of tissues, a plant, lotion, a card, a calendar.
  • Label everything.
  • Touch your loved one, touch is a message from the heart.
  • Listen, be patient, pay attention to what she tells you.
  • Bring books and magazines. Large print editions may be especially appreciated.
  • Play cards or board games if they enjoy them.
  • Show photographs.
  • Reminisce.
  • If the nursing home allows, bring the family pet.
  • Be observant. Take note of your loved one's appearance, health, fit of glasses and dentures, complaints. If some thing seems wrong, tell someone and then follow-up.
  • Don't feel you have to stay a long time.
  • Don't bring money, jewelry, or other valuables.

Visits to a memory impaired person can be a bit more challenging, but the above suggestions can be helpful. Your presence is the most important thing.

Nursing home placement can be one more step in the continuum of caregiving. The older person moves from the community to the institution, and the caregiver provides less of the hands on care, but your love and concern remain constant. The LIFE (Lincoln Information For the Elderly) office is available to help you with both the emotional and practical aspects of nursing home placement. Written by the Lincoln Life Office.

For Nebraskan's who are currently living in a Nursing Facility and are in need of assistance in finding the resources to move back into a community setting, please call (888) 585-8778 toll-free. This phone number will automatically route the caller from any county in Nebraska to their appropriate AAA.

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