Uncategorized

I want to take a short break from what at least one of my readers has called “depressing” reflections on nursing home conditions to dwell briefly on the suggestion that Harry Lewis made in response to my introduction many weeks ago:

Sometime you can parse the relation of respect to dignity. There is actually rather a lot of talk about DISrespect these days, so much so that the word has been turned into a verb. This thought is rather fuzzy in my mind, but it seems that people would be more likely to be treated with respect if they acted with dignity, and dignity is today considered inauthentic, like using the dessert spoon while eating the entree.

After some reading and reflection, I have come to consider dignity as an inherent quality of all human beings, what I will call “inherent dignity.” Respect, on the other hand, is a sentiment demonstrated through certain behaviors offered in response to perceived inherent dignity. Respect may also be earned by “worthy”, or as Harry would perhaps say, “dignified” behavior.

The notion of inherent dignity is, I think at root, a religious one. For example, Daniel Groody writes in “Globalization, Spirituality and Justice”, p.109:

Catholic social teaching believes that human beings, created in the image and likeness of God (Genesis 1:26-27), have by their very existence an inherent value, worth, and distinction. This means that God is present in every person, regardless of his or her race, nation, sex, origin, orientation, culture, or economic standing. Catholic Social Teaching asserts that all human beings must see within every person both a reflection of God and a mirror of themselves, and must honour and respect this dignity as a divine gift.

Apart from a creationist or religious belief, the notion that, as human beings, we share the same “essence” encourages us to believe in the worth and value of others as we believe in our own worth and value.

There is little about an elderly man or woman in a nursing home that would elicit a natural response of respect. Most are physically ravaged by age and illness, possibly scarred or handicapped, stooped, and weak; many are angry or resentful about their condition, tired, lonely, and hungry. Under these circumstances, some are incapable of acting with dignity. Whether we recognize these individuals as children of God or simply as fellow human beings, determines whether we acknowledge their inherent dignity and respond with respect.

As a society, I think we have come to value “productivity” in all its forms as the highest possible good, the most valued human quality. Those who are not “productive” for whatever reason—age, mental or physical disability, social or financial disadvantage—are considered of less value and are regarded as less deserving of respect. This, I believe, is why we allow the oldest members of our communities to live in conditions that, when we come face to face with them, appall us and make us afraid of our own end-of-life circumstances.

If you were to ask an elderly person, faced with entering a nursing home what he or she fears most, I believe (and research has shown) that the answer would amount to the inability to make one’s own decisions or the loss of control – control of one’s body, of one’s surroundings, of one’s schedule. It is extremely difficult to maintain a sense of personal dignity, and therefore an expectation that one deserves respect under these conditions. Some elders do so. They are the ones we consider dignified; the ones we admire and hope to emulate. The ones we may respect. But the others?

The way we treat the elderly, indeed, the way we treat all those who are more vulnerable than we imagine ourselves to be, says a great deal about who we are as a society.

For this reason, I am writing about the “depressing” conditions in nursing homes.

When Dorothy began to consider the possibility of spending her final days in a nursing home she asked me and her son, Robert, to gather information about the cost of such care. She hoped to leave an inheritance to her children so wanted to choose a care option that would meet her needs but not eat up all her resources. Because my friend had worked extremely hard, managed her finances carefully and lived frugally all her life, her income was above the poverty level. She had enough resources to qualify as a “private pay” patient in a nursing home, meaning that her care would not be subsidized in any way by Medicaid, the federal and state health insurance program for low income individuals.

She was convinced from the outset that care facilities in the Boston area would be more expensive than those further from the city, and of course the information we gathered confirmed that suspicion. What was shocking, however, was not the differences in price from one location to another or the specific types of care the different facilities offered, but rather, the total monthly cost for a semi-private room, regardless of locale or care. In and near Boston, the price per day ranged from $410-$490, or $12,300-$14,700 a month. Further afield, in the neighboring states of Maine and Vermont, the range was $260-$333 a day, or $7,800-$9,900 a month – a difference of almost $5,000 a month for the same basic, and perhaps even marginally, better care.

Assuming that Dorothy’s physical decline was serious enough for her to qualify for admittance to a nursing home, she was looking at the possibility of spending between $93,600 and $176,000 a year for care as long as she lived. Her modest savings that she wanted to pass on to her children would severely, and very quickly, diminish. Her children tried to convince her that it was most important for her to get the care she needed and deserved, and that she should not be guided by thoughts of their future, but she could not put these concerns from her mind.

For the poor and destitute, the financial decision to enter a nursing facility is, perhaps, a little easier. A nursing home will take almost the entire Social Security income of an impoverished individual and supplement that with Medicaid funding. I do not know the prices for “Medicaid” beds in nursing homes (that’s rather difficult for a lay person to find out, and my intent here is to speak from personal experience and to focus on the situations with which I am intimately familiar), but we can assume that the state and federal governments pay significantly less per bed than private paying patients. This means that private payers are subsidizing Medicaid patients not only through their lifelong payments to Medicare and Social Security but also through the payments they make for their own care (upwards of $176,000 a year). This should not trouble a socialist like me, or a liberal like Dorothy, but somehow, as part of the larger eldercare picture, it does seem a little disconcerting.

When Dorothy agreed to a week of respite care in a nearby nursing facility she paid approximately $400 a day, or $2800 for seven days. For that amount she received a bed in a semi-private room; three meals a day; assistance getting in and out of bed, bathing, dressing, and going to the toilet; medication dispensing; laundry service; a few physical therapy sessions and consultation with an admitting doctor/gerontologist. This may not seem like an outrageous amount of money to pay for such services, but consider that the meals were meager and of very poor nutritional quality; the assistance was infrequent, always slow in coming and often performed in a grudging and brusque manner; her medication regime was uncomplicated; and she did not use the laundry service because she had been warned that unlabeled clothing would be lost. Important information that she or her family communicated to one shift of caregivers would not be passed on or remembered by subsequent shifts. Once she had to wait for more than an hour to be taken to the bathroom despite repeated “calls” for an aide. “It was very painful,” she said. In other words, she received “custodial” care*, in no way customized or responsive to her needs or wishes. Dorothy’s conclusion, at the end of her week of “respite” in a nursing home was that she had not gotten her money’s worth.

Why does it cost so much to provide this kind of custodial care? The consumer is, of course, paying not just for the care but for the “overhead” of capital expenditures, building maintenance, employee salary, training and benefits, certification costs, advertising, record maintenance, reporting, etc. And, of course, all these expenses are higher closer to metropolitan areas.

I do not believe I would (and Dorothy might not) so much mind the expense, if it were to purchase the type of atmosphere that takes into consideration the trials of aging; an ambiance that generously dispenses kindness, attentiveness, gentleness and compassion; a tone of respect for the humanness of those of advanced age, the sick and the dying. But that is not what one is buying when one checks into most nursing homes.

*Custodial care is non-medical assistance with the activities of daily life (such as bathing, eating, dressing, using the toilet) for someone who’s unable to fully perform those activities without help.

Next Post Nursing Homes: The Caregivers

Dignity and Respect

Nursing Homes: Money, Money, Money