Family Questions: The First Thirty Days

Emotional Issues: Introduction

I feel so relieved - and so guilty for feeling that way. Are my feelings normal?

Guilt. Resentment. Confusion. Relief. All of these and more are common and understandable reactions to a family member moving into a nursing facility. Whether the move was long overdue, or the result of a sudden illness or a drastic change in circumstance, such a major change in the life of a loved one resonates throughout a family, creating concern not only about the care their loved one will receive but also about the many emotionally-charged issues that the move does not seem to resolve.

Questions most frequently asked by relatives of new residents are answered simply and directly. Some questions reflect the emotional turmoil common to the adjustment phrase, Like, “Did I make this decision for selfish reasons?” Others will address more practical matters like laundry and special diets.

This information is provided to help guide you, as a family member of a new resident, through what can be like an emotional roller coaster in the first few weeks. Questions have been provided by people who have themselves admitted family members to nursing facilities. Answers have been provided by experienced social workers who assist families daily in dealing with this life change.

The importance of your role in the success of your relative's adjustment to nursing facility life cannot be stressed often enough. You are one of the most knowledgeable members of your family member's caregiving team - you cannot give the other team members too much information, or ask too many questions about your relative's care.

Finally, the nursing facility industry is currently undergoing a period of major transitions. What was once referred to as an “old folks home” is now a state-of-the-art health care facility sometimes combining short-term rehabilitation services with long-term skilled nursing care. For the purposes of this document, we refer to the people who use short-term services as “patients,” and long-term services as “residents.” For the families of both patients and residents, the emotional turmoil - and the questions it gives rise to - can be much the same. But for questions specific to short-term residency, refer to Issues Unique To Short-Term Patients.

Helping Your Loved Ones Adjust

How can I help Dad settle into his new home?

You might help your family member settle into life in the nursing facility best by remembering that he's not just moving into a home, but into his new home. Ask your father how he would like his home decorated and arranged. You can help him make that home as comfortable and personal as possible.

Although it's important that any decorative item not interfere with the caregiving mission or policies of the nursing facility, thoughtful decorating can help the nursing facility meet its goals of caring not just for the body, but for the mind and spirit of its residents as well.

Don't forget to discuss with staff members you and your father's decorating ideas. Some of the best ideas for brightening up a family member's room can come from the staff who see them every day.

Consider the following:

You can help restore some sense of a home environment by decorating your father's room with things brought from his home. In borrowing from the former home environment, try to go beyond just moving items from the old into the new. Instead, try also to capture and recreate the same mood, texture and tone.
Bring things your dad's made or collected. Bring items that have always been important to him, like a chair, picture, or coffee table.
Provide photos of yourself or your family. Get the children involved in creating handmade items for all occasions. Create collages of children's photos, and bring or send wall decorations to commemorate holidays. In most cases, the brighter and more cheerful, the better
Stimulate all the senses. Borrow decorating ideas from Mother Nature - nothing can be as refreshing as a bit of the outdoors brought indoors. Find flowers, colorful leaves, and other reminders of the seasons to help brighten his room.
Provide paintings or prints of his favorite subjects, or of religious or other familiar scenes.
If your father is able to enjoy them, supply magazines, books and newspapers for him; if not, bring tape-
recorded books or music. If he subscribed to the daily newspaper, keep it coming.
Provide a telephone or TV if his room can accommodate them.

Mother's still angry and keeps saying she wants to go home. Will she ever adjust to the move?

If you've ever moved yourself, especially out of town, you've already experienced a part of what your mother is going through. But add to that the stress she's experiencing from the loss of her cherished independence, from living in unfamiliar surroundings with scores of strangers, and from trying to accept you in the unnatural role of caregiver, and you'll begin to understand just how major a life change this can be.

Suffice it to say that the first 30 days may be uncomfortable for both of you. Don't be surprised if during the early days of your mother's residency, the whole family experiences some degree of guilt, tension, fear or fatigue.

Your mother is likely to do or say things that will upset you and make you feel guilty. She may express either verbally or non-verbally her dissatisfaction with the new arrangements and her desire to go home. She may act mad or hurt, or berate or ignore you.

Remember that these behaviors - and your reactions to them - are perfectly normal under the circumstances. Adjusting to their new living arrangements is a process that all residents go through in their own way, and at their own speed. The adjustment won't be accomplished overnight, but as the days turn into weeks, you'll find your mother talking less about her old home and more about her new. In the meantime, the staff is always there to help see you through the peaks and valleys of this very emotional experience. Don't be afraid to ask for a little moral support.

Coping With Guilt and Resentment

Mom and I chose this nursing facility because we thought it was the best thing for her, but she treats me like I'm abandoning her to pursue my own selfish pleasures. How can I remind her that we have her best interests at heart?

The decision to admit a family member to a nursing facility setting is never an easy one. But whenever you begin to doubt the decision, remember the many advantages a nursing facility offers your family member:

24-hour care, with medical assistance always available.
A roommate, with whom many residents form a deep and lasting bond that proves both invigorating and
supportive.
A sense of community and activity, which can encourage residents to get up, dress and get out to enjoy a community meal in the dining room or an organized activity in the recreation room.
Staff members who become attached to the people in their care, and work to make their lives as comfortable and interesting as possible.
Regular clergy visits and religious services.
Activities, educational programs, group discussions and outings.
Personalized physical, occupational, speech and restorative therapies.
Trained nurses who teach skills and promote self-care.
Medical staff that tracks the individual progress of each resident, as well as his medical needs, on a daily basis.
Tasty and nutritious hot meals on a regular schedule, with help for those who need it, and special attention for those whose diets need to be monitored.
Finally, more satisfying relationships with family members who, with the stress of routine daily care transferred to home staff, now have sufficient energy and time to devote to the emotional needs of their family member.

I know my mother should be here, but I promised her years ago that we'd never put her in a nursing home. I feel like I've gone back on my word.

One of the most difficult situations a person can face in life is having to move an elderly family member into a nursing facility after having promised - often years before - not to.

The decision can lead to guilt and self-doubt, and, if it's not resolved, even to depression. If you've had to break such a promise, whether it was expressed or only implied, it's important to take some time to separate what you feel about your decision from what you know. For example, even though you might feel as though keeping that kind of a promise is very important, you might know that it was no longer safe for your mother to live alone.

Remember:

As circumstances change in your life, so too, do your options. The “best” solution to a problem ten years ago might not be the best solution today. If you did make a promise not to institutionalize your family member, it was probably made at a time when home care and independent living were practical options. If they are no longer practical options, they should not be considered just because they seemed like good solutions years ago.
All you can give is your best. If you've considered all the options and made the best decision you can, you have nothing to feel guilty about. The guilt that often accompanies placing a family member in a nursing facility can actually debilitate you or drive you to give more than you can possibly give.
Doing the impossible to keep your family member at home is precisely that: impossible. Few people can provide the 24-hour care a nursing facility can provide. Your family member needs you for more than lodging, meals and medication. She needs your love, something that can be hard to provide when you're constantly drained, both physically and emotionally. Often the only way to do your primary job right is to turn your secondary over to another.
Try to listen to your head. It's very difficult to get over the emotional reaction of admitting a family member to a nursing facility. Remember though, that being relieved of the daily physical and emotional stress of a practically impossible home care situation can enable you to enjoy your relationship again. And the time it frees up can be used constructively with your own family or in taking an active role in nursing facility activities, both of which will provide support for your own adjustment.
You're not alone. At the heart of almost all guilt suffered from placing a family member in a nursing facility is the unspoken doubt that a promise has been broken. Talk to someone who has made a similar decision and share your conflicting emotions. Then ask them to share with you how they coped with the guilt, and how they feel about their decision in retrospect. If your nursing facility has a family council, visit with some of the members. See Family Councils.

Making Your Visits Count and Visiting By Mail

Dad and I never did talk much, and now conversations are even harder. What can I talk about that won't make us both uncomfortable?

Often relatives and friends find it painfully difficult to visit a family member during the early days of his residency. They may feel it their “duty” to keep the conversation light and to avoid any discussion topics that might make everyone uncomfortable.

But talking about the “uncomfortable” things can be therapeutic for nursing facility residents - and for their family members. And if he can't talk frankly with you, his family member, who will he be able to “talk it out” with?

Knowing that you won't flinch from difficult issues might help your dad grapple with them all the sooner. You can help make your conversations more productive in other ways as well:

Often conversations in the early days of residency revolve around the decision to admit the family member to the home. When discussing it, avoid loaded terms like “helpless” and “incompetent” - terms that strike at the heart of your family member's self-concept. Instead, stress the more objective side of your case: “Your condition requires that you have 24-hour nursing care.”
Use your conversation to lovingly motivate your family member. Saying, “You can't even get out of your wheelchair by yourself,” is in essence saying he might as well give up. But if you know he can do better and you say, “After you can transfer from your wheelchair to a chair maybe we can plan an outing in the car,” you're inspiring him to achieve.
Finally, remember that the most important part of any conversation is the time you spend listening. A relative who says, “I want to go home,” wants to feel that you care. Turning away from his honest expression of emotion because it makes you feel uncomfortable will only make further communication more difficult.

Instead, encourage him to talk about home and the things he misses. Then listen! Listen as you would to your boss or your spouse - carefully and patiently. Accept the fact that at first a lot of his conversation will cover the same ground over and over, but don't feel as though the conversation is pointless.

Realize, instead, that your family member is “working through” a major life change in the best way available to him, and he needs your help.

How can visits seem like they used to be at her home?

Geriatric care providers recognize that sometimes the best therapy in the world is a visit from a loved one. Unfortunately, visits can sometimes be an emotional challenge for family members - and instead of tackling the challenge, too often they give up altogether.

Successful visiting is like any other social skill - it can be improved upon with a little bit of work and some practice. The payoff will be more enjoyable visits for both you and your resident. Consider these tips for better visiting:

Plan ahead. You can help avoid the “duty” visit by remembering why you used to visit your relative before she became a resident. Then fill the visit with similar activities. If you shared a passion for jigsaw puzzles, bring one along and help her get it started. If you're both big readers, start a book aloud that you can read a chapter out of each time you visit.
Write letters for her, take her out to lunch, meet her new friends, or brag about the kids - with grade cards, photographs, school projects, and even videotapes to back you up! The possibilities are endless, but the point is to think ahead.
Remember this is a visit to your family member's new home, not a hospital room. Fill the visit with things you felt comfortable doing before she entered the home. Touch, if it feels natural to do so, and talk as you used to. Take her for lunch and to the mall, or out to get her hair done. Ask your family member for a tour of the home. Don't feel pressured to entertain; instead, if she's able, let her be hostess to you.
Don't fear reminiscing. Gerontologists are showing that such “life review” is an important adjustment mechanism that helps elderly people put their situation into perspective and deal with lingering conflicts.
Remember you're an important link to the outside world. If she wants to gossip, then gossip. Keep her involved in the family, the community, and the church. Don't be afraid to seek the same amount of advice and comfort from her as you did before she moved into the home.
Sometimes you'll have to let her vent her anger and frustration at the situation, and at her new limitations. But remember, you don't have to remedy the problem in order to be of some help, you just have to listen.
Get to know the staff. These care providers are part of the extended family that constantly works to improve the overall quality of life for your loved one. Fill them in on your family's favorite stories about your resident, and about her personal idiosyncrasies, to help them understand her individual needs. Volunteer to help in the facility's group activities to get better acquainted.

Visiting Policies and Trips Out of the Home

Can I take Mom out sometimes?

Of course. Residents are encouraged to go on outings as much as possible. Plan outings for your relative, especially on Sundays, holidays, and family birthdays and anniversaries. If overnight outings are planned, check with your facility regarding the policy on overnight stays.

If I take Mom out, does she need to be back by a certain time?

Not usually. However, the nursing staff needs to know when you are leaving and the estimated time of return. Medications may be given to you for your mom.

Complaints

How should I handle complaints?

If your family member complains, remember:

Never hastily dismiss a family member's complaint. Even if the complaint appears petty or simply a way to register dissatisfaction with his new limitations, ignoring complaints will only further damage your relative's morale.
In many cases, all the complainant wants is for you to listen, support and comfort him as he adjusts to his new environment.
Try to really listen to what he is trying to say. (See Helping your loved one adjust.) Don't prejudge the validity of the complaint, and pay particular attention to his verbal cues, body language, facial expressions, posture and gestures. All can help you determine the seriousness of his complaint.
Complaining is not limited to verbal expression. The onset of depression, an increase in anxiety, or the development of a tendency to withdraw into hostility and unresponsiveness can themselves be forms of complaint.
Always respond to complaints, whether they are well founded or not. Use facial expressions, gestures, statements, questions and comments to show you're listening. Don't get upset and don't be condescending or patronizing. Treat your family member as an equal in the conversation.
If you do feel a complaint could be warranted, bring it up to a staff member you're comfortable dealing with. Lingering or more serious complaints should be taken up with the home's administration. Most homes have a specific complaint procedure. If you're uncertain, ask.
Be sure your relative is kept informed that everyone is working on the complaint and give him status reports.
Although you should always bring complaints to the attention of the staff first, you should also be aware of the other avenues available to you for resolving problems. Amendments made in 1978 to the Federal Older Americans Act set up an ombudsman program in each state to help family members who have complaints about nursing facilities and long-term care facilities. Residents or relatives should be encouraged to report any unresolved complaints to this or similar programs in their area.