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Americans live in a society in which youth is highly valued and many people become uncomfortable when asked to think about or discuss the aging process.  News stories about nursing homes generate greater public interest when an unfortunate event related to patient care has occurred or some type of conflict exists regarding long-term care services.  These types of stories may generate a discussion among family members which could include a statement such as “Promise me that you will never put me in a nursing home.”  The implications which may accompany this promise are probably not given full consideration until actual care needs arise.

This type of promise may appear to be very logical.  Over the years, our elder law firm has asked hundreds of people at long-term planning seminars “Who has it as one of your life goals to spend your final days in a nursing home?”  The answer is often nervous laughter and disbelief.  Since most people agree that one’s own home most desirable, a promise to never admit a loved one to a nursing facility is easy to make when the discussion is taking place between generally healthy individuals.  Although it may be easy to verbalize, following through on this promise can prove to be more challenging than one might imagine.

An individual’s mental and/or physical health might decline as the result of chronic disease, a sudden catastrophic event, or a general slowing down due to age-related changes. This need for assistance with the tasks of daily life will require someone else to be a caregiver. Caregiving can range from providing help with a single task every once in a while to a monthly, weekly, daily, or 24/7 commitment.  Caregiving can include a multitude of tasks such as household chores, transportation, scheduling of appointments and activities, medical monitoring, and hands-on personal care.  Are you ready to sign up yet?  Paying bills or driving a loved one to the store or doctor’s office may sound manageable. But how many of us would feel comfortable if asked to bathe a parent, or assist them with toileting?  Since we do not possess the ability to see into the future, this type of scenario could happen.  Caregiving often starts out as help with a few tasks here and there, but over time the number of tasks and their complexity gradually increases.  Some people may be emotionally, physically, and socially equipped to provide intense and intimate care for a loved one, but others are not.  Factors such as family relationships and structure, stage of life of the care recipient and caregivers, economics, geography, and the actual care tasks are all factors which impact whether or not home is a safe place to stay, either with or without the help of paid services.  Therefore, making a promise to avoid a nursing home or other care facility before having the understanding and experience of how life will unfold is highly unrealistic.

Couples may view “the promise” as an extension of their vows.  After all, didn’t they say “…for better or for worse; in sickness and in health…”?  The intent behind these vows is to remain committed to each other.  Sometimes this commitment involves recognizing one’s limitations and being responsible to utilize available resources to make sure the partner’s needs are met.  When one partner promises never to place the other in a nursing home, it is often made with the belief that care at home will always be available, high quality, and safe.  The intent behind the promise is to provide the best care possible for the partner. But what if the healthy spouse must continue to work?  Or the “healthier” spouse uses a walker and has a heart condition?  The stress of caregiving for another adult 24 hours/day every day can be overwhelming and precipitate a health crisis for the higher functioning caregiver.  Suddenly, there are two people who require care instead of one.

Sometimes, the best care is care outside of the home.  When the responsibility for caregiving tasks is shared, caregivers will be more likely to have the time and energy to care for themselves, as well as be a partner, child, or other loved one in the life of the care recipient. The stability and routines of care in a facility, as well as increased opportunities for socialization, can lead to improvements in functioning for the care recipient.  While the recipient of care may not understand the decision, it is important for the healthier partner to keep these factors in mind when feelings of guilt for not being able to fulfill the technical wording of  “the promise” are experienced.

Karen Kaslow, RN, BSN

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Long Term Care Guide