Murder Suicide and Older PeopleWhat One Case Tells Us

The recent murder of an 80 year old woman by her 77 year old husband in Penticton raises some ongoing concerns about care planning, our care system in British Columbia, and probably more issues.

Briefly, they were a socially isolated couple with no family, or none in the area. He had recently been in hospital, then she was, and then it somehow got decided that she was not able to go home because he could not care for her anymore. She needed extended care, he had to look for assisted living. Soon after this plan was made, it appears, he came into the hospital and the rest....

So if you look at it, and I know hindsight is easy, you know these two people were at risk: declining health and social isolation. The risk was compounded by the upcoming separation: separation anxiety and disruption of minimal social system.

Our system did not allow for this couple to occupy two beds at the care level which the wife needed. Did he receive any counselling? Our hospital's have cut back Social Work positions enormously--these were the ones generally charged with the provision of social and emotional support, and helping people through process and transitions. The tasks have been turned over to discharge planning teams, most of which are apparently nurses. Discharge planning does not do counselling. They are more like processing for optimizing bed utilization. Psychosocial support has fallen by the wayside; the Social Workers who are left do not have time to do it.

Hospitals and health units need to address people as part of family units, and the treatments, policies, and procedures need to be geared to making a shift so that they are able to do this.

Would this have stopped the murder and suicide? Maybe not. But it sure would provide better care.

Clothes Make the Man

I was in a care conference for a client the other day. He is in his mid-nineties. His bald head sometimes looks like it is about a third the size of his body. He used to be a semi professional athlete. He is stooped when he walks. But he is not stupid.

He is also often incontinent. He refuses to wear any kind of incontinence product. So sometimes he ends up wetting himself. More important, in terms of safety (but not perhaps in dignity) is that his floor gets wet, and sometimes he then slips and falls. He is a future broken hip.

He dresses in the dress pants and nice shirts that he has worn throughout his life. He was a natty dresser, I guess you could say. His clothes made him who he was, to an extent and in his mind.

The staff has asked him in the past to wear the track suits and easy care and maneuverable clothes that you often see people in care facilities wearing. He won't.

They don't ask him anymore to wear incontinence products. They don't ask him to wear a different kind of clothes. They know, and he knows, that he will have to have his clothes cleaned more often and he is at risk for falls.

But what that staff acknowledges is that what is not at risk is his dignity and his sense of self. That is what they are helping him to preserve. The clothes will continue to make the man.

A Note About Choosing Care Facilities

There is a ton of advice out there (or here, depending , I suppose, on where you are) about choosing care or assisted living facilities. There are checklists, and comparative tables and so on blah blah blah.

But there are a number of items that don't appear on lists, and certainly if they do, don't make it too high on the important factors of those lists. I talk about them a little in my book, Nursing Homes: The Family's Journey ( www.nursinghomesbook.com). But even there, they don't have the prominence they could.

One of those items is the issue of ownership of the facility and where it fits in the corporate world. Many, many of these places are owned by chains, and many are some kind of investment tools. This has a direct affect on how they provide service. For example, the ones that are investment tools have a focus on making money for their investors. That doesn't rule out their providing good care, but it does create an inherent dichotomy in where their focus is. It can be a choice between care and the bottom line, care and profits. It can dictate the salaries that they pay (or don't) and therefore the quality of people that they hire and retain. Especially in Canada. This doesn't say that they do not have good and caring people, but it does say something about how that staff is treated. Just like any caregivers, in order to provide good care, they need support from somewhere. As staff, part of that support are the wages and benefits.

Almost more important is the fact that corporate facilities and chains have to be more bureacratic, and have policies that extend across the chain. They often have a corporate image that they are trying to portray across their systems. The problem is that when they are in different "market areas" their are different and unique factors which impact on care needs. The corporate issue lowers the flexibility that the individual units can provide. It also absolves them of having to do any problem solving. More than once I have run into attitudes of "We can't do this...'" which ends up meaning that their corporate parent doesn't allow it, and they are not going to make an effort. It also is a way for them to absolve themselves of having to make efforts or be responsive to the needs of individuals in varying communities.

Individually owned and operated facilities are not constrained by the same needs of a larger organization. They may not have some of the same resources, but they also don't have the same cost. They are free to develop their own policies and procedures, and their own culture which can be specific to their facility, their area, their state or province. Of course this means that they may not have the same standards. But it means they have the opportunity create a unique environment. It also means they have more ability to respond to the social, cultural, and political environment in which they are located.

To sum it up, think about "where the buck stops" if you were to compare locally owned and operated places and chains. Then think about what that means.

So make sure you ask about ownership and governance when you look at facilities. Go to the corporate website, buy some of their stock, and think about what you are buying. O'kay?

The Importance of Assessments

Last week I received a call from a man whose mother is in a nursing home. She has been there for several years. He told me that about a year ago the staff had asked him to hire a companion because his mother had been taking so long to eat in the dining room, and because she seemed to be alone much of the time. He hired a companion, and gradually the time he had her increased to six hours a day. That combined with the fees of the home were more than she could afford.

I went to see Mrs. L. a couple of times. The first time, I went in while she was in the dining room. She is a tiny little thing with silver gray hair and large violet eyes. The staff told me she is 94, but it turns out she is 97. She is mostly blind, and very hard of hearing. Her hired companion was there, trying to encourage her to eat.

The second time I went in, I saw her in her room. When I sat down with her, I asked her about her eating. She said she has no appetite. Later, she told me she did not feel much like doing things these days. Finally, I asked her about her mood. "Down in the dumps," she told me. How long had she been feeling like this? "Ever since my husband died." She couldn't remember how many years ago that had been. I asked her what year it is now. "1986," she told me.

"I shouldn't be feeling this way," she said, "I should want to do something, but I don't "

When I said I thought she is depressed, she agreed. I asked her if she was willing to take something for it, and she agreed.

Later, I read through the chart with the nurse. She has had recent blood work, so it doesn't appear that there is an acute medical problem. I talked to the pharmacist about her medications, who said that they are appropriate for her diagnosis, and shouldn't cause loss of appetite, or change in taste, as some do. She has lost 9 kg. over the past couple of years.

I flipped back in the chart. At the beginning, was an intial diagnosis of mild depression. The early pages of the chart were thinned, but looking at what was there, I could see no history of anti-depressants.

I understand that this woman has some major issues which would affect her mood--visual and hearing impairment. Moderate memory loss could also be affecting her. This makes it more difficult for her to be able to partake in anything or be with many people. And I know she is 97. But still, we can still do a further assessment and perhaps ask the physician for an order for some antidepressants. But because there are dietary, medical, recreational, social, and family concerns, the first thing we need to do is have a care conference. With all the players in the room, including Mrs. L. if she will attend, we can really try to figure out what is happening to her.

The point here is that Mrs. L.'s son had been asked to spend close to $2500.00 per month for added help for his mother, without having had an assessment of what the real problem is. Having a companion may be a wonderful adjunct to Mrs. L.'s life but she probably does not need someone to help her eat. A good assessment should have been done first.

Unfortunately, this kind of thing happens frequently in senior's housing and nursing homes. Easy solutions are chosen, without complete assessments.

So what can family members do? Always ask why--why is the problem occurring. Then ask what--what kind of assessment have they done t o figure out how they found the why?