Not always an easy decision

Caring families want the best for their loved ones. Sometimes, however, in the quest to provide what is thought to be the most suitable and safest care, they can forget that the person they care about has to be part of the decision-making process.

By Dr. Michael Gordon

Family members often assume that if there is any degree of cognitive impairment or if there has been a serious fall, the best solution is a “protective environment.” This usually gets translated into a retirement or nursing home solution, depending on the loved one’s level of function. It is easy to forget that decisions related to where one should live cannot be based solely on issues of safety.

Sadly, I periodically see conflicts between children, siblings or parents as to what is “best.” Some time ago a daughter came to see me with her mother, who had mild cognitive impairment and a history of repeated falls. The cause of the falls appeared to have been discovered after a recent visit to an emergency department, when an adverse reaction to new medications had resulted in an excessive fall in blood pressure on standing, combined with excessive slowness of the heart. The mother was already on a medication for cognitive impairment, which alone could also cause a slowing of the heart.

Now the mother’s blood pressure and heart rate were controlled and her mild cognitive impairment was such that she would not necessarily be considered unsafe. She had not had any further falls since the change in medication. The mother had given up her apartment and was happily living with her daughter, who was quite pleased to have her. The mother had an emergency alarm system, which she knew how to use, as she was alone during the day.

Following the fall, however, the patient’s two other children became adamant that their mother needed to move into a retirement home and an emergency admission was arranged. After three days, the patient was begging her daughter to take her home. She explained to me that she didn’t like living with so many people around or eating in a dining room with others. While discussing her experience at the long-term care home, she said quietly, “I would prefer to return to my own apartment but if that is not possible, I am quite happy to live with my daughter as long as she is willing to have me. I feel safe. Everything I need is on one floor and I wear that bracelet all the time, which I know that I can push if I have a problem.”

It was a conflict indeed, and an obvious case where an older adult’s wishes needed to be considered. I suggested to the daughter that she and her siblings meet with our social worker for help with exploring the process of their decision-making, so that her mother’s wishes could become the proper and central focus of their actions.

Dr. Michael Gordon is Medical Program Director of Palliative Care at Baycrest Geriatric Health Care System and co-author of Parenting Your Parents: Straight Talk About Aging in the Family.