General practitioner, Alleghany County, N.Y.Read the extended interview »
… I think people who don't have family are more likely actually to be in the nursing home; and that if you have good family support, you can stay out of the nursing home longer or stay out of it entirely. I have many patients that I know that if we put them in a nursing home -- and this isn't to say anything bad about nursing homes -- [but] even [at] the best nursing homes they would get bedsores; they would be unhappy and probably die much [more quickly]. I don't think there's any question about that.
Sometimes, though, people come to nursing homes after families have done their best to keep them at home, but the family can no longer provide all of the care needed, right?
... [A] lot of times … people have given up -- basic caregiver burnout or whatever you call it -- and [the family member] winds up in the hospital because they get sick, … They go to the nursing home for a short period of time and then go home again. Then family members are able to cope for a while longer with health aides and a visiting nurse, [but] then often they burn out again. They go through the cycle again, and then some people just reach the end of their rope, and they've had it, and they don't even want to try again. But I would say that's the exception.
Do you help families make the decision on the nursing home? Is it tough?
It is. Sometimes they turn to me. But I usually try and take that one step ahead and tell them that it's time to do that. I think sometimes that's better because it's not their decision; it's kind of doctor's orders. ... I try and explain it like, if you had appendicitis, you'd go to a surgeon because that's who you need, and for some people, nursing home care is just what they need.
I tell people all the time that they should never tell their children, "Don't ever put me in a nursing home," or vice versa: "Mom, we'll never put you in the nursing home." ... That's the wrong thing to say, ... because sometimes that's the best place for a person to be. It really is. Unless you have an overabundance of money and can hire shifts of two or three people to be there constantly, some people just need the environment of a nursing home.
You're relieving them of responsibility and guilt?
You are. People feel terribly guilty about putting somebody in the nursing home: They let them down, and if they tried harder, this wouldn't happen.
Do you see an older and sicker population in nursing homes here?
There certainly are sicker patients in the nursing home, partially because they're the ones that get booted out of the hospital after your five-day stay, or minimum three-day stay, and continue treatment at the nursing home. That aspect of it has become much more intense. They can do ultrasounds, echocardiograms, X-rays, blood tests. For some things, I can get them done faster in the nursing home than I can in the hospital. There's no question that there's that group of patients that are sicker. ...
Geriatrician, Mt. Sinai Hospital, New York CityRead the extended interview »
… If people want to stay at home, ... they're going to need help, and that help costs money. There are huge costs associated with trying to stay home. But sometimes [the funds are] just not there. Lots of times family steps up, and I see tons of people that have family caregivers that have moved in. ...
There's a lot of what we call noncompensated care for older adults, which means using family members and people that don't get paid to [provide care] because it's not obtainable from other sources.
More commonly, what I see here is [that] people really do care; they want to help, but they're just not around. The son is in Florida and the daughter's in California and the patient is in New York. People are busy. They've got their own lives; they've got their own families; they've got their work. They can't just pick up and move. And Mom also may not want to move in with one of them and leave all of her friends and everything she knows to move in with a daughter and feel like a burden. ... And there may not be so much room in that home to accommodate other people. It's a big responsibility, and I don't think most people realize what a major responsibility that is. ...
A lot of caregivers get, quite frankly, depressed, frustrated, burnt out, and leave or move on or just can't do it. I see a lot of families that try or start, and say: "Look, we don't have the wherewithal to do this. Can't we have her in a nursing home?" ...
[What is your impression of nursing homes?]
The nursing home where I [started working and training a few years ago] is fantastic. I think it's one of the best ones out there. The staff is great. The physicians are really wonderful and dedicated. But it is an institution, and people do lose their personal identity and give up a lot of their individualism to join the system and get cared for in a group setting, where things happen at certain times, and schedules are adhered to, and you have your room, or you're with your roommate, and you have the nursing station in the middle and the long hall. It feels like a hospital. It is a hospital.
They all are places where there are a lot of older, debilitated people, coming toward the end of their lives. A lot of people die there. One person I visit on a regular basis in the nursing home calls it "the waiting room," and she views it as "this is where we all come to wait to die." And in some perspective, she's right. That's what happens.
I've seen people who thrive there. I've had patients that were at home and then went to a nursing home, and they're much better off. The socialization -- they're participating in groups, having all these people around for meals -- is tremendous. They live off of it and thrive from it. So it's not always a downturn for some people. ...
Visiting Nurse Service of New YorkRead the extended interview »
Can you talk about most people's visceral response to the idea of going into a nursing home?
Well, I've worked in nursing homes. I don't ever want to be in a nursing home as a patient -- not that they're all bad, but the personal care and touch is lost in a nursing home or a hospital or someplace outside of your own home.
The thing that I hear most from people is, it's a place you go to die. That's the stigma that's attached to nursing homes most often, is that if you don't have anybody and your family doesn't care about you, you're going to end up in a nursing home. That's not always true. A lot of people have to put their loved one into the nursing home because they just really can't manage them at home. There are some very, very good places that take care of patients, but generally speaking, I don't want my patients to go to the nursing home. I try not to have them go there at all.
For many, it is usually the last stop?
It often is, yeah, because once they go there, all kinds of things can happen. If they go there for a fall, they can have another fall while they're in there. Or if they're left in the bed too long and no one changes them, they can end up getting a bedsore or pressure ulcer, and then that could lead to an infection, and then that could be the end. These are the worst case scenarios. This doesn't happen all the time, but it happens pretty frequently that people get new problems when they go to a nursing home.
... There's that institutional feeling, the feeling that everything is kind of homogenized and just based on the bottom-line tasks of what have to be done, instead of the comfort stuff that's around when you go into someone's apartment. You see the pictures of them and pictures of their family and the various stuff that they've collected in their lives. It's a much different feeling than you get in a nursing home.
Then there are all these strange noises and strange people, and it's very hard to feel comfortable in a place like that, especially if you're older. You may not be able to hear well, or you might not be able to see well, and noises and confusion upset you. These things can be traumatizing to an older person.
Dean of medical education, Mt. Sinai Hospital, New York CityRead the extended interview »
The iconic image of what we don't want: The nursing home fills us with dread.
And why is that? Why is there that dread and horror? I guess I wonder out loud whether there isn't something else about nursing homes, being there alone and having people taking care of you who don't really know anything about where you've been or what you've done or what you stand for or how much you've fought for -- just all the places you've been in your life. And to have that disembodied care, even if the nurses are great, even if the staff-to-patient ratio is phenomenal, maybe it's perceived as a little bit cold and distant, and that's what makes people a little bit afraid of the whole experience -- and the fact that a lot of them just are really not nice places to be, and the care is not fantastic.
But I feel like there's something more to not wanting to be in the nursing home. There's a sense of being marginalized and, as you said, being stored away somewhere, out of everyone's sight, even if it is a relatively nice place.
It's interesting that you mentioned it, because I realize as I think about it that I spend at least half my time, when we have students with us or residents, at least half the time on every visit, before we walk in, preparing the trainee by telling them the story of the patient. The story, of course, includes their medical diagnoses and the surgeries they've had and the medications, but also some precious little pearls about who they are or where they've been and what they've done, and they're an artist, and World War II -- just all these little stories that help create a context for the student walking in and seeing someone for the first time.
It doesn't exist at all in nursing homes. It doesn't exist at all in hospitals. Who the hell has time to ask those kinds of questions? I think a lot of patients are willing to trade off some cutting-edge medical care for the sake of that human contact.
Are you disturbed when you go in nursing homes?
It was probably 10 years ago, the year I was chief resident, I did some moonlighting work in several nursing homes around New York City. I did it for about six months, and then I just couldn't take it anymore. I mean, the system is not set up for you to be able to spend any kind of reasonable time. The more patients you see, the more boxes you tick off, the more money you get. It was so dehumanizing to have to go from room to room to room, and even the patients who didn't have problems that the nurses wanted you to address. After three years of residency, it was more than I could bear.